1. Case presentation
경희의료원 내과
R2 조창현

2. 장 O 남 F/50 admission :
C.C. ) drowsy mentality, jaundice ( onset: 내원 당일 오전 )
P.I. ) 여자 50세 3년전 부터 매일 소주 2병이상 마시던 자로 특별히 입원하거나 medication 받은 병력은 없었다. 내원 2일전 jaundice 나타나고 식사량 저하되며 내원 일 오전 부터 사람을 잘 못 알아보는 confusion 양상 보이고 시간 경과 하며 크게 부르는 소리에 눈을 뜨는 정도의 drowsy mentality 나타나 응급실 통하여 내원하였다.
PMHx : DM /HTN/ TB / Hepatitis ( - / - / - / - )
Op Hx (-) medication Hx (-)
Personal Hx
Alcohol : 매일 소주 2병, 3년간
Smoking : none
Family Hx : n / s

3. Review of system
General fever(-) chill(-) fatique(+) poor oral intakes (+)
Skin itching(-) rash(-) jaundice(+)
Head & Neck headache(-) stiffness(-)
E & ENT visual disturbance(-) sore throat(-)
Respiratory cough(-) sputum(-) hemoptysis(-) dyspnea(-)
Cardiac chest pain (-) palpitation (-) exertional dyspnea(-)
G-I A/N/V/D/C (+/+/+/-/-) abdominal pain(-)
hematemesis (-) melena(-)
Renal oligurina(-) dysuria (-) hematuria (-) nocturia(-)
Others arthhralgia(-) syncope(-) confusion(+) Seizure (-)

4. Physical examination General drowsy
Skin no rash, yellow skin ,spider angioma (-)
Head & neck no neck vein engorgement, no palpable neck mass
no neck stiffness
E / ENT Pinkish conjunctivae, icteric sclera
Chest clear Breathing Sound without rale & crackle
regular heart beat without murmur
Abdomen soft & flat abdomen, no hepatosplenomegaly
no tenderness or rebound tenderness
normoactive bowel sound
caput medusa (-)
Back/extremity CVA tenderness(-/-), pretibial pitting edema (-/-)
DTR : symmetric, Babinski sign (-/-)
130/80mmHg–100/min–18/min–36.7 ℃ Bwt 60kg, Height 159cm

5. Initial laboratory finding
CBC/DC
13060/mm3-13.6g/dL–39.6%-124X103/㎣ (Seg %) MCV 97 ( 81~98 )
aPTT 60.5sec /34, PT 101.7sec/13.3 ( INR : 11.5 )
Chemistry
T/ D-bilirubin 5.12/ 3.0 mg/dL( mg/dL)
AST/ALT / 6200 U/L (<40/<40 U/L)
ALP/rGT / 274U/L (39-117/<50 U/L)
Prot/ALB /2.8g/dL( / g/dL)
T-cholesterol 80mg/dL(<200) Glucose 111mg/dl
BUN/Cr / 1.7 mg/dL (8-23/ mg/dL)
Na/K/Cl /4.1/88 ( / / mmol/L)
Ca/P 8.2 /2.9 mg/dL(8.4~10.2/2.5~5.5 mg/dl) Mg 2.0mg/dl(1.9~2.5 mg/dl)
CRP < 0.5 mg/dL

6. Urinalysis
RBC 0~1 , WBC 10~29HPF
Occult Blood -, Protein - , Bilir 3+, Urobilinogen 0.1 mg/dl
Nitrate+, Glucose -, pH 5.5, ketone -
Specific Gravity 1.025, Leucocytes +
ABGA
pH pCO2 32.1mmHg – pO2 75.2mmHg- HCO3 22mmol/L

7. Chest PA

8. Brain CT

9. Problem lists #1. drowsy mentality #2. jaundice, nausea
#3. coagulopathy
#4. renal failure
#5. isolated pyuria

10. Initial assessment
#1. fulminant hepatic failure ,hepatic encephaopathy Gr 4
alcoholic liver disease ( severe alcoholic hepatitis likely )
discriminatory factor = 404 ( > 32 )
MELD score : 44 ( 90 day motaliry ratio = 94% )
r/o viral hepatitis
r/o drug & toxin exposure
r/o Reye`s syndrome
Wilson disease
#2. ARF
#3. isolated pyuria

11. Diagnosis plan #1. fulminant hepatic failure hepatitis viral marker
serum ceruloplasmin & liver biopsy
imaging study ( abdominal sonography or CT )
#2. ARF & isolated pyuria
spot urine check, urine culture

12. Abdominal CT

13. HBsAg (-)
Anti-HBc IgM / IgG ( -/ - )
Anti-HBs Ab (+)
Anti HAV IgM (-)
Anti-HCV (-)
serum ceruloplasmin = 8.92 mg/dL ( < 20mg/dL )
BUN/Cr 13/1.7 mg/dL (8-23/ mg/dL)
serum Na =135 mmol/L
Spot urine Na =2 mmol/L
Spot urine Urea nitrogen = 75.6 mg/dL
Spot urine Creatinine =100 mg/dL
FeNa = 0.02 % FeUrea = 9.8 %
Urine culture = no growth

14. Therapeutic plan #1. ICU care abstinence from alcohol
nutrition support with thiamine supply
vitamine K & FFP
protein restriction & lactulose enema
broadspectrum antibiotics
#2. hydration
> 2L / day

15. Oliguria -> Hydration 1.5L
Clinical course
Oliguria -> Hydration 1.5L
HD:0 1 5 10 14 15
INR
11.59
1.87
3.85
3.36
3.62
Alb
2.8
2.3
2.2
1.8
2.0
AST
8200
2250
231
122
209
ALT
6200
2403
828
104 86
Bilir
5.12
4.7
16.1
25.6
27.4
24.6
BUN 13 21 42 65
124 Cr
1.7
1.5
1.1
0.9
1.6
3.7
U/O
1550
3070
1440
2100
255
470

16. Clinical course
HD #15
S & O ) Hourly urine output < 20cc/h , brown color urine

17. Clinical course HD #15 Plan ) prerenal failure hydration saline 1.5L
Acute tubular necrosis
spot urine check → FeNa
Infection induced renal failure
chest PA, urine analysis, urine, sputum, blood culture
Hepatorenal syndrome
vasopression ( terlipressin 1mg q6h) ,albumin ( 1mg/kg )
→ ECAD, TIPS, hemodialysis & liver transplantation

18. ? acute tubular necrosis
? prerenal ARF
Melena ( - ) vomiting & diarrhea ( - / - )
Cr 1.6 → 3.6 mg/dL after 1.5 L saline hydration
? acute tubular necrosis
BP 110/70mmHg
BUN/Cr 124/3.7 mg/dL (8-23/ mg/dL)
serum Na = 145 mmol/L
Spot urine Na =10 mmol/L
Spot urine Urea nitrogen = 492 mg/dL
Spot urine Creatinine =153 mg/dL
FeNa = 0.16 %
FeUrea = %

19. ? Infection induced renal failure
Body temperature = 37.0 ℃
WBC 12508/mm3, CRP 1.0 mg/dL
Chest PA = no active lung lesion
Urine analysis
RBC 5~9 HPF , WBC 0~1 HPF
Occult Blood 3+, Protein 100mg/dL ,
Bilir 3+, Urobilinogen 0.1 mg/dl
Nitrate-, Glucose -, pH 5.0, ketone -
Specific Gravity 1.025, Leucocytes ++
urine & blood culture : no growth

20. HD #15
Plan )
Hepatorenal syndrome
vasopression analogue ( terlipressin 1mg q6h) + albumin ( 1mg/kg )
→ ECAD, hemodialysis,TIPS, & liver transplantation

21. Clinical course death terlipressin 1mg q6h ,albumin 1mg/kg oliguria
Oliguria -> Hydration 1.5L 13 15 16 19 23
INR
3.36
3.62
3.17
2.38
3.43
Alb
1.8
2.0
2.2
1.7
AST
209
195
274
409
ALT 86
122
172
246
Bilir
27.4
24.6 32 31
BUN 65
124
139
203
244 Cr
1.6
3.7
3.2
4.0
4.6
U/O
255
470
1815
490
100

22. Final diagnosis #1. fulminant hepatic failure
alcoholic liver disease ( severe alcoholic hepatitis likely )
#2. hepatorenal syndrome