Question

Gl case study Subjective Data: D.R. is a 44 year old male with a history of alcoholic cirrhosis and portal hypertension who has not been feeling well, also noting that his abdomen is larger than normal. The patient admitted with ascites and a paracentesis is performed. Unfortunately, though, his admission has become complicated as he has esophageal varices that have ruptured. He now has hematemesis is hypotensive and tachycardic. Objective Data: Vitals: BP = 88/45, Pulse =115, Respirations 24 breath/min, Oxygen saturation 92% on Room Air, Temp. = 98.7 *F and Pain 7/10 to his abdomen Neurologic: Alert and oriented to person place and time. Cardiovascular: Pulse is +2/0-3+. Identifiable S152. Pulmonary: All lung fields are clear to auscultation. Abdomen: distended with hepatomegaly Genitourinary: decreased urinary output in the last 24 hours where his urinary output has been 20 cc/hr for the last two hours Integument: warm, dry with jaundice and pt. complains of intermittent pruritis. Nurse also notes jaundiced sclera, Significant Laboratory Results: Creatinine 2.2 mg/dL Questions: 1. Please identify the clinical manifestations that support the diagnosis of esophageal varices. 2. Please discuss the diagnosis of esophageal varices are causing low blood pressure and increased heart rate. 3. Please discuss if you think this patient has developed an acute kidney injury and if so which type and by mechanisms this has developed.

Answer 1

ANSWER :

1) Clinical manifestations that support diagnosis of esophageal varices :

• Hematemesis - blood vomitings
• Hypotension and tachycardia (due to blood loss)

Hematemesis associated with alcoholic cirrhosis and portal hypertension indicates ruptured esophageal varices.

2)In the above scenario ;

Ruptured esophageal varices ------> hematemesis --------------------> blood loss ---------> hypovolemic shock -------------------------------> hypotension and tachycardia

Cause for increased blood pressure  :

• Ruptured varices ----> blood loss ---> decreased cardiac output ----> decreased peripheral vascular resistance -----> decreased blood pressure.

Cause for increased heart rate :

• Ruptured varices ----> blood loss ----> hypovolemia -----> reduced circulating blood volume ----> decreased venous return ----> decreased arterial pressure -----> compenstaory release of catecholamines ---------> peripheral vasoconstriction -----> increased cardiac contarcatility ---‐--> increased heart rate

3) Patient's urine output decreased in last 24 hours and serum creatinine level is 2.2 mg/dl which indicates acute kidney injury.

▪︎Type of acute kidney injury : Prerenal type

▪︎Mechanism :

• Blood loss -----> intravascular volume depletion -----> decreased renal perfusion ----------> decreased glomerular filtration rate ----------> acute kidney injury