Seorang Pasien Laki Laki Dengan Sirosis Hepatis Dan

Seorang Pasien Laki Laki dengan Sirosis Hepatis dan Ensefalopati HepatikumShort Case

Identitas• Nama : Tuan L• Umur : 74 Tahun• Status : Kahwin• Alamat : Tanjung Sari Belakang Padang• Pekerjaan : Tidak bekerja• Tanggal Masuk : 9/8/12• Jam Masuk : 1125

Subjective• Os datang dengan Keluhan Utama lemah seluruh badan sejak

3 bulan SMRS• Lemah dirasakan semakin parah, sering jatuh, susah untuk

berbicara dan kadang-kadang pasien mudah lupa• Riwayat penyakit dahulu tidak didapatkan DM (-), HT(-),

Alergi(-)

Observation• TD : 130/80 mmHg• N : 100x/menit• RR : 18x/menit• S : 36.0 oC• KU : Tampak Sakit Berat • Kesadaran : Compos Mentis• Kepala : Normosefali, konjungtiva pucat -/-, Sklera Ikterik +/+• Mulut : fetor hepatikus ( sweet musty aroma)• Leher : KGB, Tiroid tidak teraba membesar• Thorak :• Jantung : S1 normal, S2 normal, reguler, m-, g-• Paru : Suara napas vesikuler, wh-/-, rh-/-

• Abdomen : bising usus + normal, Nyeri Tekan -, Supel datar• Ekstremitas : akral bawah teraba dingin, tidak didapatkan

udema , terdapat pamar eritem pada kedua telapak tangan, asterixis (+)

Pemeriksaan laboratorium

• Pemeriksaan darah lengkap

WBC 10.1x103/mm3 (3.5-10.0) MCV 109 fl (80-97)

RBC 2.58x106/mm3 (3.80-5.80) MCH 36.7 pg (26.5-33.5)

HGB 9.5 g/dl (11.0-16.5) MCHC 13.5 g/dl(31.5-35.0)

HCT 28.2 % (35-50) RDW 16.8 % (10.0-15.0)

PLT 109x103/mm3(150-500) MPV 9.5 fl (6.5-11.0)

PCT .104 109x103/mm3% (.100-.500) PDW 9.9 % (10.0-18.0)

Pemeriksaan fungsi hati dan ginjal• Bilirubin Direct 5,63 mg/dl (< 30 )• SGOT 444 U/I (up to 38)• SGPT 187 U/I (up to 41)• Ureum 41,2 (10-50)• Creatinine 1,46 (0,7-1,2)

Perjalanan PenyakitMARET 16/3/12

1. Penyakit hepar kronik2. Hematemesis melena3. Splenomegali ringan

Anam : muntah warna hitam dan BAB berdarah sejak 3 bulan SMRS, lemas, nafsu makan menurun.PF : asites, edema tungkaiLab : WBC 15.8x10 3/mm3

RBC 3.46x106/mm3

HGB 10.4 g/dlHT 31.0 %LED 17mm/jamSGOT 326 up to 38 U/ISGPT 429 up to 41 U/IGDS 156

AUGUSTUS 1/8/121.Sirosis hepatis2.Ensefalopati hepatikum

Anam : lemah badan dan semakin parah sejak 3 bulan SMRS, sering jatuh, susah berbicara, kadang-kadang lupaPF : sklera ikterik, palmar eritemaLab : RBC 2.58x106/mm3 (anemia)HGB 9.5 g/dl (anemia)HT 28.2 % (menurun)PLT 109x103/mm3

(Trombositopeni)MCV 109 fl (makrositik)MCHC 13.5 g/dl (hipokrom)Bilirubin 5.63 mg/dl SGOT 444 U/ISGPT 187 U/I

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Assessment• Sirosis Hepatis• Ensefalopati Hepatikum grade II – III• Anemia Makrositik Hipokrom• Trombositopeni

West Haven Classification System • Stage 0: Lack of detectable personality changes. No asterixis.• Stage 1: Trivial lack of awareness. Impaired attention

span. Altered sleep, euphoria or depression. Mild asterixis may be present.

• Stage 2: Lethargy or apathy. Disorientation. Inappropriate behavior. Slurred speech. Asterixis.

• Stage 3: Gross disorientation. Bizarre behavior. Semi-stupor. Asterixis absent.

• Stage 4: Coma

Planning• Diet Hati 1600 kalori BB• IVFD asering : aminoleban = 2:1• Hepamarz 2x1 amp• Inpepsa 4x CI• Hepa balance 2x1 tab• Ceftriaxon 2x1 gr

Prognosis• Ad Vitam : Dubia ad malam• Ad Functionam : Dubia ad malam• Ad Sanationam : Dubia ad malam

Terima Kasih

West Haven Classification System• Grade 0 - Minimal hepatic encephalopathy (previously known as

subclinical hepatic encephalopathy). Lack of detectable changes in personality or behavior. Minimal changes in memory, concentration, intellectual function, and coordination. Asterixis is absent.

• Grade 1 - Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria, depression, or irritability. Mild confusion. Slowing of ability to perform mental tasks. Asterixis can be detected.

• Grade 2 - Lethargy or apathy. Disorientation. Inappropriate behavior. Slurred speech. Obvious asterixis. Drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time.

• Grade 3 - Somnolent but can be aroused, unable to perform mental tasks, disorientation about time and place, marked confusion, amnesia, occasional fits of rage, present but incomprehensible speech

• Grade 4 - Coma with or without response to painful stimuli

• Aminoleban infusion• Content : High conc of branched chain amino acid & low conc of

aromatic amino acid (no tyrosine), Na, Cl, other important amino acids

• Inpepsa• Content : Sucralfate• Indications : Duodenal & gastric ulcer, chronic gastritis.• Doses : Adult 2 tsp 4 times daily.• Side Effect : Constipation, dry mouth.

• Hepamerz –• Content : (mengandung L-ornithine L-aspartate)• Indications : Treatment of hyperammonemia due to acute or

chronic liver disease eg liver cirrhosis, fatty liver, hepatitis; treatment of pre-coma or hepatic encephalopathy.

• Doses : Usually 4 amp daily. W/ incipient clouding of conciousness (pre-coma & coma) Up to 8 amp daily depending on the severity of the condition. Max infusion rate: 5 g/hr.

• CI : Severe renal impairment• Adverse Effect : Vomiting, nausea, sensation of heat &

palpitation.

• Hepa Balance • Suplemen makanan• Indikasi : memelihara kesehatan fungsi hati• Dosis : 1-2 tab per hari• komposisi

• Fructus schisandra chinensis• Lecithin• Silybum marianum semen• Curcuminoid• Vitamin B6 HCL

• Ceftriaxon• Indications : Treatment of lower resp tract, genitourinary, bones

& joints, skin & gynecological infections; CNS infections; UTI; bacteremia & septicemia; intra-abdominal infections; pre-op prophylaxis.

• Doses : Adult & childn >12 yr 1-2 g IV once daily. Max: 4 g daily. Peri-op infection prophylaxis 1 g as a single dose ½-2 hr pre-op. Infant & childn <12 yr 50-75 mg/kg/day in 2 divided doses. Max: 4 g daily. Meningits 100 mg/kg/day in 2 divided doses.

• Adverse effect : GI disturbances, hypersensitivity reactions, superinfection, transient leucopenia, eosinophilia, neutropenia, thrombocytosis. Transient SGOT or SGPT & BUN elevations.