Summative assignment 1: Problem Solving
Introduction
This is a case study of a 45-year-old attorney, whose main symptoms were chronic gastric pain and diarrhoea with bulky and smelly stools. It is also mentioned that the patient had a 20-year history of alcohol abuse. Physical examination of the patient showed cirrhosis of the liver and his sclera – the white outer layer of the eyeball appeared yellow. The physical examination of the patient, showed that the temperature, blood pressure, pulse rate and respiratory rates were all within their normal ranges, however, the patient showed signs of malnutrition although the patient was eating frequently. This was probably due to his chronic diarrhoea combined with malabsorption, but the rest of the symptoms indicated that there was an underlying issue that was causing the patient to present other symptoms.
Laboratory results showed that the patient had an electrolyte imbalance which is seen by the low levels of potassium, serum calcium, serum triglycerides, hydrogen carbonate and a slightly below normal pH. It is also important to note that electrolyte disorders are a sign of an underlying disorder like chronic liver diseases. (Buzzetti et al., 2017)
Alcohol related liver disease – Cirrhosis
The patient showed signs of a severe form of Alcohol Liver Disease (ALD). According to the Journal of hepatology, early signs of ALD are not easily noticeable but the main symptoms of ALD include abdominal pain, weight loss, diarrhoea and yellowing of the sclera. The patient in this study showed signs of severe form of Alcohol Liver Disease, namely – cirrhosis. (Gustot et al.,2017). This is supported by the results of his physical examination that showed the liver appearing cirrhotic. A study by Bhattacharyya, Barman & Goswami (2016). showed that the main clinical features of alcoholic cirrhosis are losing weight, abdomen pains and jaundice. These were some of the symptoms the 45-year-old presented.
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Pancreatitis
Alcohol is known to be the most common cause of chronic pancreatitis although the manner at which excess alcohol consumption leads to pancreatitis is unknown. According to the British Medical Journal, alcohol consumption accounts for 60% of all cases of pancreatitis. Pancreatitis is diagnosed after carrying out clinical history, physical examinations and cross imaging the pancreas. (Ravindran, 2019). Chronic pancreatitis is suspected because of the epigastric pain and evidence of steatorrhea. (Mathurin & Michael, 2012). The physical examination for faecal analysis was positive for fat indicating steatorrhea – fatty stool which is a symptom of liver damage and pancreatitis. This was due to the destruction of the parenchyma (functional tissue in the pancreas) (Markowitz, 1999). Steatorrhea develops because of blockage of the pancreatic duct which prevents enzymes from reaching the duodenum. Fat soluble vitamins (K, A, D and E) are affected by malabsorption. (Apte et al.,1997).
Studies have shown that chronic alcohol consumption makes the acinar cells – (endocrine and exocrine cell in the pancreas that are responsible for storing, synthesizing and secreting enzymes) sensitive to injury by disrupting the processes in the acinar cell that protect against stress caused by the endoplasmic reticulum.
Symptoms of pancreatitis are not usually present initially but over varying time intervals, the patient will begin to develop chronic abdominal pain. According to Majumder & Chari (2016) severe cases lead to exocrine pancreatic insufficiency which is indicated by steatorrhea, loss of weight and malnutrition.
Available treatment options
Firstly, to treat the diarrhoea, taking over the counter medicines like loperamide and Imodium can be useful. (Robles-Medranda et al., 2006). The best way to prevent or treat malnutrition would be to provide the patient with food rich in carbohydrate, proteins and vitamins. Iron, zinc and vitamin and food supplements.
Cirrhosis of the liver cannot be reversed however prevention measures to stop further damage to the liver can be implemented to stop the production of scar tissue. (Schuppan & Afdhal, 2008)
Chronic pancreatitis is managed by treating the pain and modifying nutrition and making lifestyle changes. The use adjunctive pain medication, for example antidepressants and selective serotonin re-uptake inhibitors are combined with opioids and pancreatic enzyme therapy is usually recommneded. In the worst case, surgical interventions will be necessary. (Majumder & Chari, 2016) If the abdominal pain is too severe further investigations of the bile duct and duodenum would need to be carried out. (Lackner & Tiniakos, 2019).
According to Gupte et al., 2018). Malabsorption – exocrine insufficiency will require pancreatic enzyme replacement therapy PERT. PERT is taking a mixture of pancreatic the enzymes as a supplement. A pancreatic function test would need to be carried out to measure bicarbonate and enzyme concentrations in the pancreas.
The patient will have to be advised about abstaining from alcohol as alcohol will worsen his symptoms. According to Crabb et al. (2019).” Abstinence is the most important method in improving survival in ALD. This can be done through a psychological and behavioural approach whereby the patient can receive counselling as an individual or in group therapy sessions or alcoholic rehabilitation.” There are also relapse prevention medicines that have been approved by the FDA such as disulfiram, Naltrexone and Acamprosate. There are also non- FDA approved medicines that have been found beneficial in preventing relapse. Some of these medicines include pregabalin, gabapentin, baclofen, topiramate, varenicline and ondansetron. A 12-week course of baclofen with a dose of on tablet three times a day has been proven to improve rates of total abstinence and decreased relapse. pregabalin has been proven to reduce pain by 36% in 3 weeks compared to placebo.
Conclusion
Having looked at all the patient’s symptoms, the patient was most likely to be suffering from two conditions; an alcohol related liver disease (cirrhosis) and pancreatitis.
References
Apte, M. V., Wilson, J. S., & Korsten, M. A. (1997). Alcohol-related pancreatic damage: Mechanisms and treatment. Alcohol Health and Research World, 21(1), 13-20.
Bhattacharyya, M., Barman, N. N., & Goswami, B. (2016). Survey of alcohol-related cirrhosis at a tertiary care center in north east India. Indian Journal of Gastroenterology, 35(3), 167-172.
Crabb, D. W., Im, G. Y., Szabo, G., Mellinger, J. L., & Lucey, M. R. (2019). Diagnosis and treatment of alcohol-related liver diseases: 2019 practice guidance from the American association for the study of liver diseases. Hepatology (Baltimore, Md.), doi: 10.1002/hep.30866doi:10.1007/s12664-016-0651-2
Buzzetti, E., Kalafateli, M., Thorburn, D., Davidson, B. R., Thiele, M., Gluud, L. L.,Guruswamy, K. S. (2017). Pharmacological interventions for alcoholic liver disease (alcohol-related liver disease): An attempted network meta-analysis. Cochrane Database of Systematic Reviews, 2017(3) doi: 10.1002/14651858.CD011646.pub2
Gupte, A., Goede, D., Tuite, R., & Forsmark, C. E. (2018). Chronic pancreatitis. BMJ (Clinical Research Ed.), 361, k2126. doi:10.1136/bmj.k2126
Gustot, T., Fernandez, J., Szabo, G., Albillos, A., Louvet, A., Jalan, R., . . . Moreno, (2017). Sepsis in alcohol-related liver disease. Journal of Hepatology, 67(5), 1031-1050. doi: 10.1016/j.jhep.2017.06.013
Lackner, C., & Tiniakos, D. (2019). Fibrosis and alcohol-related liver disease. Journal of Hepatology, 70(2), 294-304. doi: 10.1016/j.jhep.2018.12.003
Majumder, S., MD, & Chari, S. T., Dr. (2016). Chronic pancreatitis. Lancet, the, 387(10031), 1957-1966. doi:10.1016/S0140-6736(16)00097-0
Markowitz, D. D. (1999). Handbook of liver disease. Gastrointestinal Endoscopy, 50(2), A1-A1. doi:10.1016/S0016-5107(99)70265-8
Mathurin Philippe, & Lucey Michael, R. (2012). Management of alcoholic hepatitis. Journal of Hepatology, , s39-s45.
Ravindran, R. (. (2019). Chronic pancreatitis. Surgery (Oxford), 37(6), 336-342. doi: 10.1016/j.mpsur.2019.03.002
Robles-Medranda, C., Lukashok, H. P., Novais, P., Biccas, B., & Fogaça, H. (2006). Chronic diarrhea as first manifestation of liver cirrhosis and hepatocarcinoma in a teenager: A case report and review of the literature. Journal of Paediatric Gastroenterology and Nutrition, 42(4), 434-436. doi: 10.1097/01.mpg.0000189342. 38634.ac
Schuppan, D., Dr, & Afdhal, N. H., MD. (2008). Liver cirrhosis. Lancet, the, 371(9615), 838-851. doi:10.1016/S0140-6736(08)60383-9
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