Volume Depletion in a Patient With Cirrhosis

Abstract

A 40-year-old mechanic was admitted to the medical service on January 16 because of progressively increasing jaundice and abdominal girth, malaise, and fevers. The patient had consumed one to two six-packs of beer daily for approximately 22 years. On physical examination the temperature was 100.2 OF, heart rate 104 beats per minute, blood pressure (BP) 110170 mm Hg supine and 100/65 mm Hg standing, and weight 205 pounds. Abnormal findings included gross (but not tense) ascites, + + pedal edema, spider angiomata, and enlarged liver (25 cm span) and spleen (edge palpated at 4 finger-breadths below costal margin). Skin turgor was normal. The stool was negative for occult blood. Low-grade fever persisted, but no source was identified from extensive culturing of blood, urine, and sputum. Selected laboratory values are shown in Table 1. Abdominal ultrasound and computed axial tomography scan showed hepatomegaly, splenomegaly, ascites, and normal-sized biliary ducts. A liver-spleen scan showed marked reticuloendothelial shift, with hepatosplenomegaly. The diagnostic impression of the gastrointestinal consultant was alcoholic hepatitis with a predominantly obstructive component. The patient was treated with bed rest, low-salt diet (2 g sodium/d), sucralfate, and vitamins. Over the next 2 weeks he remained stable and nonoliguric, but his plasma blood urea nitrogen (BUN) and creatinine increased. A renal consultation was requested on January 31. On January 31, the physical examination was essentially unchanged from admission. The heart rate was 100 beats per minute, the BP 110170 mm Hg supine, decreasing to 90/65 mm Hg standing, and light-headedness accompanied the postural hypotension. Weight was 208 pounds. The urine output had been 700 to 1,200 mLld. Urinalysis showed a specific gravity of 1.015 and a normal sediment. A renal ultrasound study showed no evidence of obstruction. The impression was that the patient had pre-renal azotemia from true ECF volume depletion. Between January 31 and February 4, to replete ECF volume, the patient received normal saline at 30 to 100 mLlh and 10 U of fresh frozen plasma. By February 4 his weight had increased by 20 pounds. Heart rate was 104 beats per minute, and BP was 110170 mm Hg supine, decreasing to 90/65 mm Hg when standing, and again postural light-headedness occurred. The ascites had increased and was more tense. Peripheral edema had increased to + + +. Neither BUN nor creatinine had improved. Two diagnostic tests were performed.