PPE II / [CASE STUDY AND EVALUATION]

University Of Sulaymaniayah

School Of Pharmacy

4th Year Students

Pharmacy Practice Experience II 79

“CASE STUDY AND EVALUATION”

Prepared By;

Kozhin Jamal

Hunar Baxtyar

Azhy Hawraman

Nvar Jabar
Subjective

This is the medical case of a 65 years old male who is admitted to the General Internal Hospital with signs of repeated bloody vomiting, epigastric pain, and severe abdominal pain.

He has a history of previous hepatitis and hypertension.

Objective

The patient is received in ICU and kept under observation for 2 days straight. Monitoring HR, BP, and spO2 until stabilized.

The following tests are carried out;

CBC:

Test / Result / Normal Range
WBC / 22.3 X 107 / L / 3.5-10 X 107 / L
LYM% / 14.9 % / 15-50 %
GRAN / 17.1 X 107 / L / 1.2-8 X 107 / L
RBC / 5.69 X1012 / L / 3.5-5.5 X 1012 / L
HGB / 7.5 g/dl / 11.5-16.5 g/dl
PLT / 235 X 109 / L / 100-400 X 107 / L

Erythrocyte Sedimentation Rate:

Test / Result / Normal Range
E.S.R / 17 mm/hr / 1-10 mm/hr

Liver Function Test:

Test / Result / Normal Range
Serum Total Bilirubin / 6.9 mg/100ml / 0.2-1.2 mg/100ml
Serum Alkaline Phosphatase / 172 IU/L / 40-130 IU/L
Aspartate Transaminase (AST) / 110 IU/L / 3-40 IU/L
Alanine Transaminase (ALT) / 118 IU/L / 3-40 IU/L

Coagulation test:

Test / Result / Normal Range
Prothrombin Time (PT) / 19 sec / 11-13 sec
INR / 1.8 / 0.8-1.2

Abdominal Ultra Sound (U/S) Scan:

  • Prominent liver of homogenous texture with evidence of hepatization of GB (gall bladder), suggestive of hepatitis.
  • An enlarge infiltrative liver mass seen measuring 13 cm occupying both left and right lobe of liver with feature suspect of hepatocellular carcinoma (HCC).
  • Mild Splenomegaly.

Esophago-Gastro-Duodenoscopy (OGD):

  • A case of fundal and esophageal varix, present with hematochezia.

Assessment

According to the vital signs, symptoms and the laboratory test results, this patient is suffering from a severe known case of liver dysfunction and hepatitis that has probably advanced into hepatocellular carcinoma.

The coagulation tests indicate that there is depletion in the coagulating factors that are synthesized in the liver, this combined with the fact that the patient has high blood pressure, has led to fundus as well as esophageal varix and hemorrhage.

He has high levels of white blood cells (WBC) and elevated erythrocyte sedimentation rate (ESR) that indicates the large inflammatory condition.

There is also elevated level of bilirubin and jaundice, abnormal results of liver function tests represented by increased levels of both aspartate aminotransferase (AST) and alanine aminotransferase (ALT) which also confirm the hepatic damage or tumor.

In our opinion, this patient has not been treated appropriately at early stages of the disease for that reason disease severely progressed, since he had lifelong hypertension in each attack lead to rupturing of varix and internal hemorrhage with the risk of death by 35%.

However, he is now not suffering from one disease but from several serious diseases of the liver. Therefor medications that metabolize in liver should not be given otherwise will result in life threatening toxicities.

Planning

The patient has been taking the following medications;

Medication / Regimen
Cannula
Metoclopramide (Plasil®) / 1X3 ; Ampule
Vitamin K1 / 1X1 ; Slow IV infusion
Glucose/Saline / 1500 ml over 24 hr
Aspirin / 1X1 ; 100 mg
Ranitidine (Zantac®) / 1X1 ; Ampule
Omeprazole (Losec®) / 1X2 ; 20 mg cap
Ceftriaxone / 1X2 ; 1g dissolved in 100 ml Normal Saline
Lisinopril / 1X1 ; 10 mg, tab
Amlodipine / 1X1 ; 5 mg, tab
Packed RBC / 1 Unit
Octreotide / 2 Ampules ; Subcutaneous
Octreotide / 5 Ampules ; IV in 500 ml Normal Saline / 24 hr

Initial treatment has started with Glucose/Saline for rehydration of body and packed RBC because of bleeding that he had which led to blood loss and decreased hemoglobin level.

The Dopamine receptor antagonist, Metoclopramide, is used for its antiemetic effect by acting on chemoreceptor trigger zone in the brain. But its metabolic site is liver and since there is no acceptable antiemetic that is not metabolize by liver so regular monitoring of liver function tests are necessary.

Using vitamin K1, is due to liver problem which raised prothrombin time and to reduce risk of bleeding, vitamin k has risk of producing severe allergic reaction(like anaphylaxis) for this reason it should be administered by slow IV infusion and it is advisable to do regular follow ups.

Giving Aspirin, at dose of antiplatelet activity for cardio protection is harmful for this patient since he is admitted with epigastric pain and vomiting so by this gastric state it will be worse while also metabolize by liver, despite that concomitant administration of NSAID with ACEI (like Lisinopril) increase risk of renal impairment and damage.

At the beginning, Ranitidine is given then Omeprazole added because of the presence of ulcer and aspirin which deteriorates it, but the problem with both drugs is not only there hepatic metabolism but also they will damage liver by themselves and increase liver function tests with increase toxicity of other drugs (like metoclopramide) mean they make liver condition more deleterious, Antacids is a useful alternative because they are simple compounds, with faster onset and have no metabolism.

Ceftriaxone is the best drug in the case from others, having broad spectrum and excreted by kidneys in unchanged form.

As we mentioned above, Lisinopril with NSAIDs makes interaction, besides, ACEIs have adverse effect of dry cough which we saw during takingthe case, he also had Amlodipine which is CCB for his hypertension, they made dose adjustment by given 5 mg cause of his liver. But the best choice that we prefer is giving more potent drug alone without undergoing metabolism mean to be water soluble and readily excrete by kidneys like Beta blockers especially selective beta 1 blockers (Atenolol) more powerful.

And Octreotide, analog of somatostatin which inhibit growth hormone, given as infusion for management of acute hemorrhage from esophageal varices on basis that it reduces portal venous pressure and splanchnic blood flow so risk of bleeding decrease but effect is transient and not improve survival so this only until applying bands (Endoscopic Band Ligation) for him.

Follow up

As presented above, this patient has got a complicated case and is taking multiple drugs daily.

So naturally it would be necessary to follow up on both the disease state and the medications by measuring their specific markers including;

- Renal Function Tests; S. creatinine and S. Urea

- Liver Function Tests; AST, ALT, and Alkaline Phosphatase

- Blood Pressure and Heart Rate

- Respiratory Rate and pO2, spO2