Pathophysiology II
Digestion/Hepatic Case Study
Worth 15 pts; July 15, 2014.
Name: ___________________________

Directions:
Please read the following scenarios and answer the questions that accompany each. Use complete sentences when answering your questions. You will likely need to use your textbook, the class BB site, additional web sites, and your own analytical skills to answers these questions in full. No two people should turn in word for word answers even if you are in the same group. Likewise, information found in resources other than your brain, should also not be copied word for word, but should be rephrased in your own word. Word for word copying in either case will count as plagiarism and no points will then be given for the assignment.

Please TYPE out your answers on a separate sheet of paper.

Case 1 (7.5 pts)

S.M., a young woman in her twenties arrives at your clinic complaining of feelings of pyrosis in her neck, shoulders and jaw. She has had difficulty swallowing her food lately. She self-reports as a smoker. She also reports that she has a low alcohol intake but does drink two or more cups of coffee a day. She is six months along in her first pregnancy. She has a BMI of 22, her BP is 145/90 and her temperature is 37.7oC. Her only reported medications are vitamin C and prenatal tablet supplements daily. Her reported occupation is as a waitress.

1. Give a possible diagnosis for S.M.’s clinical presentations, explaining which symptoms lead you to this diagnosis.

2. You send her home and suggest that she reduce the habits that may trigger her symptoms. Therefore ask her to no longer do, or reduce, what? 3. S.M. returns to your clinic in a month, still complaining of the same symptoms, this time you prescribe Zantac, a histamine blocker, which is safer than other higher level medications during pregnancy. Explain briefly, how Zantac works to reduce stomach acid, at the cell level. 4. You conclude that the strength of her LES has been reduced. Draw a picture showing where the LES is in the GI track. Why is reduction of LES strength a problem?

5. Despite the medication, S.M. returns still complaining of similar symptoms. This time you order and ultrasound and it shows that her LES and part of her stomach have shifted and moved up above the diaphragm. What underlying abnormality has been causing her symptoms? Be specific. Could her condition improve after S.M. delivers her child?

Case 2 (7.5 pts)
R. S., a 55-year-old man, has been admitted to the hospital for treatment of acute gastrointestinal bleed. He is well known to the medical community for his chronic alcohol abuse and encephalopathy.

Past History: R. S. has been hospitalized four times in the past 24 months; most recently he was discharged 12 weeks ago for treatment of upper gastrointestinal bleeding. He has a 40-year history of smoking and drinks an unknown quantity of liquor daily. On previous admissions he has been treated for pancreatitis, alcohol withdrawal seizures, cirrhosis and associated ascites, coagulopathy, esophageal varices, anemia, gastrointestinal bleed, and gastritis.

Current Status: His current problems include hepatic encephalopathy, gastrointestinal bleed, coagulopathy, jaundice, history of tuberculosis (age 15 with treatment), and hypoxia; all present were on previous admission. Medications at last discharge included spironolactone (25 mg twice a day), ranitidine (150 mg twice a day), antacid (Maalox), and multivitamins.

R. S. was found unconscious in a pool of blood and vomitus. He was taken to the hospital and admitted to the medical intensive care unit. Initial vital signs were as follows: blood pressure 90/60, heart rate 112, and respirations 12. Intravenous infusion with normal saline was begun through a central line; oxygen was started at 3 L by nasal cannula. Physical examination revealed icteric sclera, clear lungs, grade Ill/TV systolic ejection murmur, and abdomen soft and without masses, liver percussed at 12 cm below the costal margin, and skin markedly jaundiced. Deep tendon reflexes were brisk and equal bilaterally. Lab tests revealed the following: sodium 137 mEq/L, potassium 4.8 mEq/L, chloride 102 mEq/L, carbon dioxide 23 mEq/L, blood urea nitrogen 132 mg/dl, creatinine 1.3 mg/dl, glucose 115 mg/dl, hematocrit 27.7%, hemoglobin 9.3 g, white blood cell count 17,800 mm3, platelets 259,000 mm3, direct bilirubin 7.8 mg/dl, total bilirubin 16.4 mg/dl, amylase 42 somogyi units/dl, alkaline phosphatase 127 mu/dl, ammonia level 200 mg. Blood gases were as follows: Po.2 85 mm Hg, PCO2 30 mm Hg, pH 7.35, prothrombin time (PT) patient 17 sec., prothrombin time (PT) control 12.3 sec., partial prothrombin time (PIT) 46/36 sec. Treatment with blood replacement was initiated; it included transfusion of 6 units fresh frozen plasma and 5 units packed red blood cells, with antacids, ranitidine, vitamin K, thiamine, and lactulose by nasogastric tube. On the following day R. S.’s mental status was improved and his laboratory studies were as follows: sodium 133 mEq/L. potassium 3.5 mEq/L, chloride 105 mEq/L, blood urea nitrogen 15 mg/dl, creatinine 0.7 mg/dl, glucose 114 mg/dl, hematocrit 38.7%, white blood cell count 5200 mm3, PT 15.7/12 sec., ammonia 93 mg, alkaline phosphatase 92 (/dl. Vital signs were as follows: blood pressure 116/72, heart rate 72, respirations 15, afebrile. On day 2 he was oriented X3 and was transferred from the intensive care unit. During the course of his hospitalization his total bilirubin ranged from 16.4 mg/dl down to 10.7 mg/dl at discharge.

1. What is ascites? How do hypoalbuminemia and increased serum aldosterone levels contribute to the development of ascites?
2. Explain the cause of the patients’ clotting defects.
3. The sclera of R. S.’s eyes are icteric and his skin yellowed. What is the cause of these discolorations, and what do they indicate about his pathophysiology?
4. Explain why esophageal varices are the leading cause of death in patients with cirrhosis.
5. What is the physiological benefit of having a hepatic portal system?