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

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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).