Luminary Learning Gastrointestinal Disorder- Issue 1

2  • LUMINARY LEARNING: GASTROINTESTINAL DISORDERS total bilirubin of 28.6 mg/dL, direct bilirubin of 23.8 mg/dL, and International normalized ratio of 3.1. Urinalysis showed pyuria and urine culture showed Escherichia coli >100,000 cfu/mL. She was diagnosed with hepatic encephalopathy (HE), urinary tract infection, severe alcoholic hepatitis, and acute-on-chronic liver failure. Discussion This patient had hepatic encephalopathy in a setting of acute-on-chronic liver failure (ACLF) given that she had acute renal injury as an extrahepatic organ failure. Patients with HE in the context of ACLF had a heightened risk of mortality compared to isolated HE. Thus, early detec- tion of extrahepatic organ failure was vital for risk stratification purposes and to determine the need for organ support. Intensive care unit admission should be considered as she was likely to require renal replacement therapy. In addition, she would require treatment for severe alcoholic hepatitis and urinary tract infection, the precipitating factors for hepatic encephalopathy. Patient Scenario 2 A 66-year-old female with decompensated nonalcoholic steatohepatitis cirrhosis and chronic kidney disease presented with worsening altered mental status for 2 days. She had compliant with the maintenance lactulose regimen that had been started after one prior episode of precipitated HE. Her vital sign demonstrated slight tachycardia with heart are of 114/min with normal blood pres- sure of 145/77 mmHg. Her oxygen saturation is 95% on room air. She was awake but confused and not able to answer any questions. Asterixis was noted. The white blood cell count was 8.5 × 10 9 /L and the creatinine was at her baseline of 1.7 mg/dL. The microscopic urinalysis showed >50 white blood cells/high power field and the urine culture was positive for Escherichia coli . Discussion Because the patient did not have any other evidence of extrahepatic organ failure other than hepatic encephalopathy, she was diagnosed with isolated hepatic encephalopathy. Because she had recurrent episode of hepatic encephalopathy while on lactulose, rifaximin was added. In addition, the urinary tract infection which was the precipitating factor was treated. Patient Scenario 3 A 65-year-old male with decompensated nonalcoholic steatohepatitis cirrhosis, model for end- stage liver disease (MELD) score of 13, was admitted with persistent hepatic encephalopathy. He had multiple previous admissions for episodic overt hepatic encephalopathy and no precipitating factors were identified. His examination was consistent with the West Haven Criteria (WHC) Grade 3 HE. He did not respond to lactulose, rifaximin, and zinc therapy. Computed tomography of the abdomen with intravenous contrast demonstrated a large splenorenal shunt.