Case Study of Ravi Maharaj (Alcoholic Liver Disease and Ascites)

This annotated bibliography discusses the symptoms and treatment procedures for alcoholic liver disease and ascites through a case study of Ravi Maharaj. It covers topics such as diet, medication, and care coordination plans for managing the disease. The research highlights the importance of managing symptoms and improving the quality of life for patients suffering from liver cirrhosis.

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1ANNOTATED BIBLIOGRAPHY
Topic: Case study of Ravi Maharaj (Alcoholic Liver Disease and Ascites)
Ge, P.S. and Runyon, B.A., 2016. Treatment of patients with cirrhosis. New England
Journal of Medicine, 375(8), pp.767-777.
The following descriptive research by Phillip and Runyon (2016), elaborately highlights
the various symptoms associated with liver cirrhosis and the required treatment procedures. The
diseases condition of liver cirrhosis is highly debilitating and is associated with extensive liver
damage followed by portal hypertension, scar tissue formation, ascetic fluid accumulation and
protein catabolism, as can observed in the symptoms presented by the case study patient, Ravi
(Tsai et al. 2014). It is seen that the patient is highly malnourished, which is prevalent in chronic
liver disease (de Lima et al. 2015). Hence, for combating Ravi’s hyper-metabolic state and
muscle depletion, he can be given a diet consisting of 1 to 1.5 gram of proteins (Sinclair et al.
2016), with further 2000mg recommended sodium to mitigate his ascites (Morando et al. 2015).
Ravi can also be given non-steroidal anti-inflammatory drugs to manage his severe pain. For
mitigating difficulties in sleep due to alcohol withdrawal and pain, he can be administrated short-
acting benzodiazepines (Weersink et al. 2015). A care coordinator plan consisting of in-home
medical professionals providing palliative care would be helpful for Ravi’s disease management
(Beste et al. 2015). The procedure of paracentesis, consisting of removal of approximately 5
liters of fluid, would be helpful in the management of Ravi’s ascitic conditions. Ravi has a
recurrent medical condition of hypertension and hence, administration of non-selective beta
blockers will be beneficial (Mookerjee et al. 2016).

2ANNOTATED BIBLIOGRAPHY
Perri, G.A., 2013. Ascites in patients with cirrhosis. Canadian Family Physician, 59(12),
pp.1297-1299.
The following research by Perri (2013) discusses in detail, the key features of symptom
control management of a patient suffering from severe liver cirrhosis and ascites, through the aid
of a case study which is similar to that of Ravi Maharaj. For management of hypertension and
ascites, Ravi’s sodium intake must be restricted to 88 mmol per day (Yao et al. 2018). The
prevalence of hypertension is associated with fluid retention, for which Ravi should be
administered diuretics like spirolactone of maximum 400 milligram per day or furosemide at 160
milligram per day, during unresponsiveness of the former (Mori et al. 2017). However, it is seen
that Ravi is suffering from extensive ascitic fluic retention, for which the usage of paracentesis is
of utmost importance. While large volume paracentesis procedures comprising of 5 liter fluid
removal per day can be beneficial for Ravi, he may still be required to ingest diuretics and
restrict salt consumption (Solbach et al. 2017). An alternative ascitic management strategy would
require usage of indwelling peritoneal catheters, which however is not supported by adequate
considering the prevalence of severity of patient symptoms and the possible risk of microbial
infection acquisition (Ahmed et al. 2018). Considering Ravi’s symptoms, transjugular
intrahepatic portosystemic shunt, bypassing damaged hepatic tissues would be beneficial in
decreasing fluid accumulation, portal hypertension and sodium retention (Bureau et al. 2017).

3ANNOTATED BIBLIOGRAPHY
Kim, S.H., Oh, E.G. and Lee, W.H., 2006. Symptom experience, psychological distress, and
quality of life in Korean patients with liver cirrhosis: a cross-sectional survey. International
journal of nursing studies, 43(8), pp.1047-1056.
The following research paper by Kim, Oh and Lee (2006), aimed to focus on the
symptoms associated with liver cirrhosis patients and their quality of life, through a study using
cross-sectional research, ‘profile of mood states (POMS)’ and ‘quality of life index’ acquired
from the review conducted by the researchers. A reduced quality of life, was highly prevalent in
patients suffering from liver cirrhosis, which is due to prevalence of factors such as lack of
employment, strained familial relationships, severity of symptoms and psychological stress
(Patel et al. 2015). From the case study, it is evident in Ravi’s deteriorating condition has
resulted in lack of employment, which acts as determinant for poor life quality (Rudler et al.
2016). It was observed in accordance to the research results that the symptoms of distress and
anxiety were most prevalent (Russ et al. 2015), as evident in Ravi’s case, where he is frequently
perturbed by his past alcohol addictions, family burden due to his lack of recovery and inability
to reconnect to his spiritual desires. Further resultant factors associated with a detrimental quality
of life is the severe prevalence of associated symptoms (Orr et al. 2014). This can be clearly
observed in Ravi’s case, where his symptoms of severe pain, malnourishment, sleep deprivation
and the associated ascites have led to a poor quality of life led by him.

4ANNOTATED BIBLIOGRAPHY
References
Ahmed, O., Rodrigues, D.M., Brahmania, M. and Patel, K., 2018. A188 LOW INCIDENCE OF
SPONTANEOUS BACTERIAL PERITONITIS IN ASYMPTOMATIC OUTPATIENTS WITH
CIRRHOSIS UNDERGOING PARACENTESIS: A SYSTEMATIC REVIEW AND META-
ANALYSIS. Journal of the Canadian Association of Gastroenterology, 1(suppl_2), pp.278-278.
Beste, L.A., Harp, B.K., Blais, R.K., Evans, G.A. and Zickmund, S.L., 2015. Primary care
providers report challenges to cirrhosis management and specialty care coordination. Digestive
diseases and sciences, 60(9), pp.2628-2635.
Bureau, C., Thabut, D., Oberti, F., Dharancy, S., Carbonell, N., Bouvier, A., Mathurin, P., Otal,
P., Cabarrou, P., Péron, J.M. and Vinel, J.P., 2017. Transjugular intrahepatic portosystemic
shunts with covered stents increase transplant-free survival of patients with cirrhosis and
recurrent ascites. Gastroenterology, 152(1), pp.157-163.
de Lima, D.C., Ribeiro, H.S., Cristina, R., Oliveira, M., de Vasconcelos Generoso, S., Lima, A.S.
and Correia, M.I.T.D., 2015. Functional status and heart rate variability in end-stage liver disease
patients: Association with nutritional status. Nutrition, 31(7-8), pp.971-974.
Ge, P.S. and Runyon, B.A., 2016. Treatment of patients with cirrhosis. New England Journal of
Medicine, 375(8), pp.767-777.
Kim, S.H., Oh, E.G. and Lee, W.H., 2006. Symptom experience, psychological distress, and
quality of life in Korean patients with liver cirrhosis: a cross-sectional survey. International
journal of nursing studies, 43(8), pp.1047-1056.

5ANNOTATED BIBLIOGRAPHY
Mookerjee, R.P., Pavesi, M., Thomsen, K.L., Mehta, G., Macnaughtan, J., Bendtsen, F.,
Coenraad, M., Sperl, J., Gines, P., Moreau, R. and Arroyo, V., 2016. Treatment with non-
selective beta blockers is associated with reduced severity of systemic inflammation and
improved survival of patients with acute-on-chronic liver failure. Journal of hepatology, 64(3),
pp.574-582.
Morando, F., Rosi, S., Gola, E., Nardi, M., Piano, S., Fasolato, S., Stanco, M., Cavallin, M.,
Romano, A., Sticca, A. and Caregaro, L., 2015. Adherence to a moderate sodium restriction diet
in outpatients with cirrhosis and ascites: a real‐life cross‐sectional study. Liver
International, 35(5), pp.1508-1515.
Mori, T., Ohsaki, Y., Oba‐Yabana, I. and Ito, S., 2017. Diuretic usage for protection against end‐
organ damage in liver cirrhosis and heart failure. Hepatology Research, 47(1), pp.11-22.
Orr, J.G., Homer, T., Ternent, L., Newton, J., McNeil, C.J., Hudson, M. and Jones, D.E., 2014.
Health related quality of life in people with advanced chronic liver disease. Journal of
hepatology, 61(5), pp.1158-1165.
Patel, A.V., Wade, J.B., Thacker, L.R., Sterling, R.K., Siddiqui, M.S., Stravitz, R.T., Sanyal,
A.J., Luketic, V., Puri, P., Fuchs, M. and Matherly, S., 2015. Cognitive reserve is a determinant
of health-related quality of life in patients with cirrhosis, independent of covert hepatic
encephalopathy and model for end-stage liver disease score. Clinical Gastroenterology and
Hepatology, 13(5), pp.987-991.
Perri, G.A., 2013. Ascites in patients with cirrhosis. Canadian Family Physician, 59(12),
pp.1297-1299.

6ANNOTATED BIBLIOGRAPHY
Rudler, M., Rousseau, G., Lebray, P., Méténier, O., Vaillant, J.C., Savier, E., Eyraud, D.,
Poynard, T. and Thabut, D., 2016. Rate of employment after liver transplantation in France: a
single-centre study. European journal of gastroenterology & hepatology, 28(2), pp.159-163.
Sinclair, M., Gow, P.J., Grossmann, M. and Angus, P.W., 2016. sarcopenia in cirrhosis–
aetiology, implications and potential therapeutic interventions. Alimentary pharmacology &
therapeutics, 43(7), pp.765-777.
Solbach, P., Höner zu Siederdissen, C., Taubert, R., Ziegert, S., Port, K., Schneider, A., Hueper,
K., Manns, M.P., Wedemeyer, H. and Jaeckel, E., 2017. Home-based drainage of refractory
ascites by a permanent-tunneled peritoneal catheter can safely replace large-volume
paracentesis. European journal of gastroenterology & hepatology, 29(5), pp.539-546.
Tsai, L.H., Lin, C.M., Chiang, S.C., Chen, C.L., Lan, S.J. and See, L.C., 2014. Symptoms and
distress among patients with liver cirrhosis but without hepatocellular carcinoma in
Taiwan. Gastroenterology Nursing, 37(1), pp.49-59.
Weersink, R.A., Bouma, M., Burger, D.M., Drenth, J.P., Harkes-Idzinga, S.F., Hunfeld, N.G.,
Metselaar, H.J., Monster-Simons, M.H., Taxis, K. and Borgsteede, S.D., 2018. Evidence-Based
Recommendations to Improve the Safe Use of Drugs in Patients with Liver Cirrhosis. Drug
safety, 41(6), pp.603-613.
Yao, C.K., Fung, J., Chu, N.H.S. and Tan, V.P.Y., 2018. Dietary Interventions in Liver
Cirrhosis. Journal of clinical gastroenterology, 52(8), pp.663-673.