NYU Medical Grand Rounds
Clinical Vignette
Jeffrey Mayne, MD
Third Year Resident Internal Medicine
1/17/2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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).
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• Abdomen: shifting dullness, large volume
ascites
• Extremities: no lower extremity edema
• Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• CBC: White Blood Cell Count 19.1*109/L,
Hemoglobin 9.3 mg/dL, Hematocrit 26.2, Platelets
152*109/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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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 mm3,
Nucleated Cells 920 mm3, 12% Polynuclear
cells, Albumin 0.9 g/dL
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• MRI Abdomen: Mild to moderate iron
deposition
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Alcoholic liver disease with superimposed
iron overload
– Child-Pugh Score 12
– MELD Score 30
• Hematemesis secondary to esophageal
variceal bleed
• Renal failure
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 8:
– Patient extubated.
– Encephalopathy managed with lactulose and
rifaximin.
• Hospital Day 12:
– Patient transferred to regular room.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 25:
– Patient developed spontaneous bacterial
peritonitis (SBP) requiring antibiotic treatment.
• Hospital Day 50:
– Discharged home with subsequent
progressive clinical and biochemical
improvement
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Day 450:
– Patient working full-time, ascites wellcontrolled, hepatic encephalopathy wellcontrolled.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Hematemesis secondary to esophageal
variceal bleed
• Cirrhosis secondary to alcohol and iron
overload
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS