Wednesday, November 2, 2016

CONTOH CASE REPORT


CONTOH CASE REPORT

L-ornithin L-aspartate in Hepatic Encephalopathy due to Liver Cirrhosis
1Suzanna Ndraha, 2Marcellus Simadibrata
1 Department of Internal Medicine, Faculty of Medicine, University of Indonesia
2 Division of Gestroenterology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia

Abstrak
Pasien laki-laki 62 tahun dibawa ke ruang gawat darurat RS Tebet Jakarta dengan keluhan utama penurunan kesadaran sejak 6 jam sebelumnya.  Dia telah diketahui menderita penyakit liver sirosis sejak 6 tahun, akibat hepatitis B. Beberapa hari sebelumnya pasien makan banyak putih telur dan ikan karena tahu albumin darahnya rendah Pada pemeriksaan fisik didapatkan keadaan gizi kurang, kesadaran delir, ada flapping tremor. Encefalopati hepatikum ditegakkan berdasarkan hasil critical flicker test (CFF) yang rendah (33,8 ± 0,58 Hz), dan kadar amonia darah yang tinggi (189 mmol/L). Pasien mendapatkan diet 35 kcal/kg per hari dan  protein 1.5 g/kg/ha ri. L-ornithine L-aspartate diberikan untuk menurunkan ammonia darah dan meningkatkan angka critical flicker test. Dalam pemantauan selajutnya didapatkan pasien membaik, kesadaran berangsur normal, critical flicker test (CFF) meningkat dan ammonia darah menurun.
Key words: sirosis hati, ensefalopati, L-ornitin L-aspartat, critical flicker test, kadar ammonia darah

Abstract
A 62-year-old man was brought into emergency room of Tebet Hospital Jakarta, Indonesia, with chief complaint of reduced consciousness since 6 hours before admission. He had been diagnosed as liver cirrhosis for 6 years, due to chronic hepatitis B infection. Several days prior to admission he took high protein diet, in order to reach normal blood albumin level. Physical examination revealed unconsciousness and flapping tremor. Hepatic encephalopathy was confirmed with critical flicker test (CFF) less than normal (33,8 ± 0,58 Hz), and blood ammonia level higher than normal (189 mmol/L). He was treated with diet 35 kcal/kg per day and  protein 1.5 g/kg/day, L-ornithine L-aspartate to decrease blood ammonia and improve the critical flicker test. During the treatment, the patient’s condition improved, level of consciousness improved to normal, critical flicker test (CFF) increased and blood ammonia level decreased.
Key words: liver cirrhosis, hepatic encephalopathy, L-ornithine L-aspartate, critical flicker test, blood ammonia level

Introduction
. Liver cirrhosis is the end of various type of liver disease, it can evoke various complications such as reduce of liver synthetic function (coagulopathy), reduce liver capability for detoxification (Hepatic Encephalopathy), and portal hypertension with all its complications [1,2]. Hepatic Encephalopathy (HE) is one of all liver cirrhosis that brings high morbidity and mortality effect. The incidence rate of HE in liver cirrhosis are various from 30-45% [3] and also 50-70% [4], where most of it considered as minimal HE.
Increases of ammonia level in the blood, among others is the effect of over intake protein and gastrointestinal bleeding, until now is considered to have the major role in HE pathogenesis [4,5]. Due to that, the management of HE especially tend to reduce the amount of ammonia in the blood, besides to overcome the initiating factor. The efforts to reduce the amount of ammonia in the blood are done by giving lactulose, antibiotics for intestine sterilization, and constrict the protein intake. Constricting protein intake in HE nowadays is becoming a controversy, cause it can worsen malnutrition [6]. Few research reports that malnutrition can increase mortality rate in liver cirrhosis [6,7]. Contrariwise nutrition improvement can increase muscle mass, which is needed for ammonia detoxification. For the nutrition improvement a diet 25-35 kcal/Kg per day and protein 1-1.5g/Kg/day is suggested. 
L-ornithine-L-aspartate (LOLA) nowadays started to be used to overcome EH cause its proven can reduce ammonia level in the blood [8], LOLA stimulates the urea cycle and glutamine synthesis, which is the important mechanism in ammonia detoxification [9,10]. With the intake of LOLA intend to reduce the ammonia level in the blood, so that it is unnecessary to constrict protein intake in liver cirrhosis patient with malnutrition.
This article reports the case of hepatic encephalopathy which is treated with L-ornithine-L-aspartate (LOLA) and given 35 kcal/kg/day diet and 1.5g/kg/day protein.
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Case
Patient is a 62 years old man who was brought in the emergency ward with chief complaint of reduced consciousness which manifested as having difficulty in speaking since 6 hours prior to hospital admission. From his present history of illness, patient has been experiencing fatigue and loss of balance since 3 days prior to admission. Furthermore, patient constantly feels drowsy therefore his sleeping hours have increased in both duration and frequency and family members are often unable to comprehend what the patient says. 6 hours prior to admission, he was unable to recognize the people around him, further deterioration of speech skills therefore family members decided to bring him to the emergency ward of RS Tebet Jakarta.
Patient was diagnosed with liver cirrhosis due to hepatitis B infection 6 years prior to admission. His symptoms were swollen abdomen and feet which resolved every time he received medications from the doctor. He always performed his check-up routinely every month up to this incident; furthermore, he also pays high attention on his daily diet which was specifically recommended by a nutritionist. However, since several days prior to admission, patient’s serum albumin level had been low, therefore his wife decided to add more fish into his daily diet.
During physical examination in the emergency ward, patient was deemed with severely ill condition, delirious. His body height was 168 cm; his weight was at 62 kg and mid arm muscle circumference (MAMC) of 228 mm. He had normal blood pressure, no signs of fever, however abnormalities were found in his eyes which had anemic conjunctiva and icteric sclera. Other abnormalities seen were spider nevi on the chest and palmar erythem on his extremities. In addition, collateral veins were discovered on his abdomen with enlarged spleen up to shuffner II, with no signs of ascites or extremity edema, and a flapping tremor was also noticeable.
Laboratory results on admission showed a condition of pancytopenia (Hb 11,7 g/dl, leukocyte 3270/uL, platelets 65.600/uL, LED 50 mm/jam. Electrolyte balance and prothrombine time were under normal limits. Albumin 2,4 g/dl, total bilirubin 1,98 mg/dl, SGOT 75 iu/L, SGPT 32 iu/L. Urinalysis tests showed no abnormalities and were under normal limits.
            Current working diagnosis on arrival is hepatic encephalopathy due to increased protein intake on cirrhotic patient due to chronic hepatitis B infection. Pancytopenia was suspected due to hypersplenism with liver cirrhosis. To confirm this diagnosis, USG of the abdomen is planned to confirm the cirrhosis, blood ammonia level as well as critical flicker test (CFF) to confirm hepatic encephalopathy.  Patient is given a diet of 2100 calories daily with 90 grams protein along with substituted multiple chained amino acids (AARC),  L-ornithine L-aspartate (HepamerzÒ) I.V.  20 grams of (4 ampoules) /day in 250 ml of infuse line for 5 days and later replaced with oral route dose of 3 x 6 gram for 2 weeks in order to reduce the ammonia levels in the blood. Lactulose of PO 4 x 15 ml is administered to facilitate transit to reduce further breakdown of ammonia.
            During the follow up, we acquired the abdominal USG results which confirmed the diagnosis of liver cirrhosis and splenomegaly with minimal ascites. Ammonia level shows 189 mmol/L (normal < 50 mmol/L), CFF 33,8 ± 0,58 Hz (normal ≥ 39 Hz). These results further strengthen the diagnosis of hepatic encephalopathy on liver cirrhosis. After 2 days of treatment, patients condition improved with increased consciousness level up to fully alert (compos mentis), and no flapping tremor was noticeable. Repeated measurement of blood ammonia levels shows an improvement (reduction up to155mmol/L) and furthermore, CFF has increased up to 38.8 ± 0.62 Hz.

Discussion
             This is a case of liver cirrhosis with the complication of encephalopathy due to excessive protein intake. Excessive protein intake is one of several initiating factor of HE that cause increased ammonia production [11]. Encephalopathy diagnosis was proven with the increased of ammonia level, supported the theory that acknowledge that ammonia hold an important role in the HE mechanism. Laboratory results shown 2,4 g/dl albumin level, 1,98 mg/dl total bilirubin level, normal prothrombine time, minimal ascites (under control) and minimal encephalopathy shown that liver function level of the patient is classified as Child Pugh B so the possibility of HE due to endogen factor is not likely.
Flicker test nowadays considered as a sensitive test, simple, and reliable to diagnose minimal HE in liver cirrhosis [12, 13]. The Critical Flicker Test (CFF) of 33,8 ± 0,58 Hz in this patient showed the existence of HE cause by increased ammonia level due to increased protein intake priory. 
The patient has 22, 7 kg/m2 BMI (Body Mass Index) that shows normal nutritious, but apparently from MAMC shows that actually the patient has started to undergo minor malnutrition. It was known that the weight of liver cirrhosis patients is more affected by ascites and edema, therefore calculation and measurement using MAMC is more suggested to evaluate nutrition status [14]. Patient is treated with 2100 calories diet, 90 gram of protein with branch chain amino acid (BCAA) substitute, in order to maintain the nutrition status. To overcome the risk of increasing ammonia level, patient is given L-ornithine-L-aspartate (LOLA) 20 g intravenous (4 ampoules dissolved in 250 cc carrier solution over 4 hours) for 5 days followed by L-ornithine-L-aspartate granules 6 g three times daily for 2 weeks. It appears that the diet treatment given to this patient did not worsen EH, in this circumstance maybe cause of LOLA treatment that helps decreasing the plasma ammonia level.

Conclusion
This case reports liver cirrhosis that nutrition status was measured base on MAAC, EH was diagnosed based on CFF (critical flicker test), then for this case, patient is given appropriate diet according to the nutrition status to avoid worsening of the malnutrition. However, EH is improving due to LOLA treatment which can reduce plasma ammonia level.

References
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14.  Kalaitzakis E, Olsson R, Henfridsson P, Hugosson I, Bengtsson M, Jalan R. et al. Malnutrition and diabetes mellitus are related to hepatic encephalopathy in patients with liver cirrhosis. Liver International 2007;27(9):1194-201



Case report ini dipublikasi di majalah ACTA MEDICA Vol 42 • No 3 • Juli 2010 hal 158-161
  

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