1. NYU Medical Grand Rounds Clinical Vignette Jeffrey Mayne, MD Third Year Resident Internal Medicine 1/17/2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 46 year-old man with a past medical history of alcoholic cirrhosis who was admitted to an outside hospital with hematemesis. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Presented to the outside hospital three weeks prior for alcoholic hepatitis, jaundice and ascites. Started on steroids and discharged on diuretics. Remained alcohol free following discharge. Re-presented 3 weeks after discharge with hematemesis. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Emergent endoscopy revealed extensive clots throughout the esophagus. Clots were removed, revealing actively bleeding varices. Attempt at endoscopic control with band ligation and sclerotherapy not successful. Developed massive hematemesis. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Transfused 7 units red blood cells, 2 units platelets, 2 units of fresh frozen plasma. A Blakemore tube was placed. The patient was intubated for airway protection, ceftriaxone, octreotide and protonix were started. The patient was transferred for evaluation for emergent transjugular intrahepatic portosystemic shunt (TIPS). History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Past Medical History: None Past Surgical History: None Social History: Head of hedge fund, regular heavy social alcohol use with increase following stock market collapse Family History: No liver disease Allergies: None Medications: Propofol Octreotide Vasopressin Ceftriaxone Imipenem U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination General: Obese, intubated, following commands Vital Signs: T: 97.6 BP:110/60 HR: 90 RR: 18 O2 sat: 96% 50% fiO2 Eyes: conjunctival icterus Skin: jaundiced, spider angiomata U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Physical Examination Abdomen: shifting dullness, large volume ascites Extremities: no lower extremity edema Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Laboratory Findings CBC: White Blood Cell Count 19.1*10 9 /L, Hemoglobin 9.3 mg/dL, Hematocrit 26.2, Platelets 152*10 9 /L Basic Metabolic panel: Sodium 117 mmol/L, Chloride 87 mmol/L, CO2 15 mmol/L, BUN 54 mg/dL, Creatinine 1.9 mg/dL, Calcium 6.6 mmol/L Hepatic panel: AST 1741 IU/L, ALT 595 IU/L, Total Bilirubin 17.4 mg/dL, Conjugated Bilirubin 11.0 mg/dL, Total Protein 4.5 g/L, Albumin 2.0 g/L INR 1.8, PTT 33.5 s, Ammonia 88 mcg/dL U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Laboratory Findings ABG: pH 7.42, pCO2 22 mmHg, pO2 122 mmHg, Bicarbonate 14.6 mmol/L, Lactate 7.2 mg/dL Paracentesis: Red Blood Cells 20,000 mm 3, Nucleated Cells 920 mm 3, 12% Polynuclear cells, Albumin 0.9 g/dL U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Other Studies Chest X-Ray: Small right pleural effusion CT Abdomen: Liver cirrhosis, portal hypertension, large volume pelvic and abdominal ascites, portal vein small but patent, patent hepatic veins. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Other Studies MRI Abdomen: Mild to moderate iron deposition U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Alcoholic liver disease with superimposed iron overload –Child-Pugh Score 12 –MELD Score 30 Hematemesis secondary to esophageal variceal bleed Renal failure Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Hospital Day 1: –Transjugular Intrahepatic Portosystemic Shunt (TIPS) was attempted unsuccessfully due to thrombus within distal right main portal vein and small caliber of portal veins. –Gastric and esophageal balloons were deflated without active bleeding. –4 liters ascites removed. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital Day 3: –Esophagogastroduodenoscopy (EGD) revealed grade II esophageal varices without stigmata of bleeding, gastric varices without bleeding. –Transjugular Intrahepatic Portosystemic Shunt (TIPS) performed with coil embolization of large coronary vein and large variceal cluster. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Hospital Day 4: –Due to worsening renal function and volume overload, patient was started on Continuous Veno-Venous Hemofiltration (CVVH). –Vasopressin stopped. Hospital Day 6: –CVVH stopped due to spontaneous improvement in renal function Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Hospital Day 8: –Patient extubated. –Encephalopathy managed with lactulose and rifaximin. Hospital Day 12: –Patient transferred to regular room. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

18. Hospital Day 15: –Melenic stool complicated by hypotension requiring blood transfusions and monitoring in ICU. Hospital Day 17: –Patient underwent TIPS revision, including embolization of coronary vein varix arising from the mid-splenic vein. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

19. Hospital Day 25: –Patient developed spontaneous bacterial peritonitis (SBP) requiring antibiotic treatment. Hospital Day 50: –Discharged home with subsequent progressive clinical and biochemical improvement Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

20. Day 450: –Patient working full-time, ascites well- controlled, hepatic encephalopathy well- controlled. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

21. Hematemesis secondary to esophageal variceal bleed Cirrhosis secondary to alcohol and iron overload Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS