Hepatitis C + Chronic Alcoholic + Massive Ascites

45 year old male patient chronic alcoholic and anti-HCV positive with significant HCV RNA viral load along with mild ascites 100ml on USG and mild pedal edema, no cirrhosis on USG was put on combination of sofosbuvir 400mg and Daclatasvir 60mg OD for 3 months somewhere else. He had completed 2months of treatment and stopped it. Today, he presented to OPD with C/O decreased urine output, decreased appetite, abdominal distension and breathlessness, altered stool consistency. On examination - Fluid thrill + , shifting dullness + BP - 100/60 Pulse - 130/min SpO2 - 97% Pedal edema - absent Scleral icterus - absent He states that when the lockdown got over few weeks back, he had alcohol for 4 days straight after which he has developed abdominal distension like this. Upon ascitic tap, approximate 4litres of ascitic fluid was drained. My concerns are - 1) How to proceed regarding his Hep C? HCV RNA test is quite expensive for him. Should the treatment be restarted again? 2) Regarding Salt and Water, what would be the approximate allowed amount he can take in a day? 3) Regarding selective beta blocker, Carvedilol 3.125 to be added only upon confirmation of portal hypertension on USG W/A? 4) What is the dietary advice for such patient? Proteinex Powder? 5) Regarding diuretic, he was on combination of furosemide 20mg + Spironolactone 50mg combination, is it indicated as per his condition to shift him on plain spironolactone 25 or 50mg? 6) Role of rifaximin 550mg in this case? I usually use 550mg TDS for 14 days. Thank you for your patience. You have finished the case yayy. Hurray!

(Edited)

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Regarding management of recent condition, if he presented with decreased urination and tachycardia, what was the creatinine level? whether there was any SBP or other infection? No restriction of water in patients with ascites. Ask them to drink whenever they feel thirsty. Salt is maximum 5g/day. Carvedilol is not to be used in decompensated patients. You can add propranolol for the mean time until the patient undergoes endoscopy for varices. Diuretics can be titrated accordingly after ascites subsides. No role of rifaximin in this patient as he doesn't have HE and even in that lactulose is the first line. Dietary advice: Atleast 30-35 kcal/kg/d with protein of 1g/kg/d and yes you can supplement proteins. Regarding HCV therapy: what is the period of discontinuation? If the patient has discontinued drug for < 4 weeks, can be restarted to complete the therapy but if he has discontinued for > 4 weeks better to go for HCV RNA and sos restart therapy.

Thank you sir for taking out time and giving such a detailed insight into the case.
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1.Right now priority is to treat the presenting signs and symptoms and treatment for Hepatitis C to be differed for the time being - But get his HCV- RNA viral load 2.Salt to be restricted to less than 2 5 gms / day and water - 500 ml more than his urine output in 24 hours considering insensible loss 3.Yes - carvedilol 3.125 can be started to prevent him from going to secondary CCF 4.Protein restrictions are there - but get his complete LFT done which will tell the protein status .If S.Albumin is too low - Protein supplements are indicated 5.Better to use combination of loop diuretic and spironolactone as ascitis will not be controlled with spironolactone alone 6.I always,feel- Rifaximin is a wonder drug in such patients with minimal side effects as it is not absorbed but prevents hepatic encephalopathy. So continue Rifaximin 550 mg t.d.s for 2 weeks and then 400 mg t.d.s indefinitely

Thanks a lot sir for such a detailed and simple answer for a general practitioner like me.
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Tab spiromide 40mg.od in morning Tab carvediolol 6.25mg od Cap Omeprazole 20mg. Bd Syp lactulose. 30cc TDS Egg white thrice daily Dietary restriction No more than 4 glass water daily Restrict soups,garaivee, roasted foods or processed food pickles etc. No cold drink Rafixamine is expensive. Can be given 550mg. Bd He is with Chronic liver disease, PCR for hep c RNA will help little now. No need

Thank you sir for the elaborate answer and a prompt response too.
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Nice informative

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