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What causes rapid hemoglobin reduction while treating cirrhosis and 45% EF?

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Posted on Wed, 22 Nov 2017
Question: My father is a Cirrhosis and heart patient with EF 45%.
He is currently taking medicines such as
Ciplar 10 - twice daily
Nexpro 40, Rancil 10, Syrup Looz (35ml/day) , Zevitt Capsules, Orofer XT, Me12, Folvite - Once Daily
Atorva 20, Dytor Plus 10- Once daily, Normaxin RT- for abdominal pain or emergency only
His hemoglobin was ranging between 9-10 for the last 1 year but suddenly it shifted to 7.5 without any changes in his medication or routine.Please guide me.
His creatinine levels range between 1.2-19 ( Reference range 1.4 max). At present his creatinine is 1.8.
His LFT is in range. He has no issues with his health right now. Should I be Concerned?
doctor
Answered by Dr. Ramesh Kumar (19 minutes later)
Brief Answer:
Yes cause should be found out.

Detailed Answer:
Hi,
Thanks for query.

Anaemia is classified as-
Grade 1, considered mild anemia, is Hb from 10 g/dL to the lower limit of normal.
grade 2 anemia, or moderate anemia is Hb from 8 to less than 10 g/dL
grade 3, or severe anemia, is below 8 g/dl.

Your father right now is severely anemic and therefore priority should be find out the cause of fall in hemoglobin.

Few investigations suggested are-
Iron profile
Transferrin saturation
serum ferritin
Peripheral smear of blood.
Serum B12 level
Serum erythropoetin
Thalessemia profile.
Stool test for occult blood.

These tests should be done initially to find the cause of anemia.

After that treatment should be done as per the cause.

Regards!

Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Ramesh Kumar (2 days later)
Respected Sir,

My fathers hemoglobin is 7.5 and creatinine is 1.8( 0.5-1.4 ref range). The blood test was conducted on 18-10-2017.At present he is suffering from bloating in his stomach whenever he consumes a meal. He takes Normaxin RT whenever the problem exceeds to a large scale.He also takes SYP LOOZ 35 ml/day.Should we increase the dosage to 50-60 ml per day?

He also takes OROFER XT once daily. Can we increase it twice daily for his anemia problem?

We are also considering him do a proper medical checkup next week.Apart from the blood tests you suggested we are considering Endoscopy and Ultrasound-Whole abdomen, Echocardiography etc. Should we consider doing a fibroscan (only if you suggest). What kinds of other tests do you suggest we do?
doctor
Answered by Dr. Ramesh Kumar (16 hours later)
Brief Answer:
Follow up.

Detailed Answer:
Hi again,
Yes you could increase the doses to 60 ml once daily.
Instead of OroferXT give him PP 26 12 mg once daily for 1 month followed by 6 mg once daily for next 3 months..Iron polypeptides are easy to digest absorbality is excellent and gastric side effects are almost negligible.
I don't feel that fibroscannis required initially.
Better to go for a CT abdomen then Ultrasound.
CT is a highly sensitive non invasive test which would provide a much better picture of overall condition of liver.
Other tests suggested are
Serum calcium
Vitamin D
B12 levels
PSA levels
Stress echo( highly sensitive)
Kidney function tests.
Renal doppler.


Regards!
Above answer was peer-reviewed by : Dr. Kampana
doctor
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Follow up: Dr. Ramesh Kumar (34 hours later)
Thank You Sir for your suggestion.60 ml of Looz helped in reducing his abdominal discomfort.

Could you please provide a generic substitute for PP 26 12mg. It is out of stock and I can't even purchase it online.

In 2015 a CT Tripahse Upper abdomen was conducted. However since his creatinine was above reference range the doctors suggested unless his creatinine reached normal a CT scan should not be conducted.We are planning to conduct the tests on 2nd of Nov and I wouldn't be surprised if his KFT shows an abnormality.He is taking Dytor Plus 10 regularly. We tried stopping the medicine or taking it every alternate day but any change leads to pedal edema.

What do you suggest?
doctor
Answered by Dr. Ramesh Kumar (16 minutes later)
Brief Answer:
Follow up.

Detailed Answer:
Hello there,
You can ask the pharmacy to provide you with Heme iron polypeptide.

Creatine and normal KFT is required for contrast enhanced CT scan.For a plain CT scan normal KFT is not a criteria.Contrast is used only when a plain CT shows some anomaly or a Doctor is suspecting some pathology inside abdomen.
Why do your gastro wants to go for CECT and nor plain CT?
Want to know the answer before making any further comment.

Waiting.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Ramesh Kumar (2 hours later)
Thank you Sir for your guidance.

We are currently consulting doctors at Institute of Liver and Biliary Sciences, XXXXXXX Infact the doctor we are consulting suggested an Ultrasound and Endoscopy on our next followup.I am not sure whether he would suggest a CT Scan or not nevertheless as per your suggestion I would definitely go for a CT Scan as KFT isnt an issue now.

The doctors suggested a contrast CT in 2015 since biopsy was not an option for my father who is above 75.The fibroscan test result was not very encouraging.Moreover he had to be hospitalised during that time.

His Endoscopy report of 2015 says:
Esophagus shows small grade 2 varices without RCS with portal Hypertension

CECT Report of 2015 says:
CLD with findings suggestive of early portal hypertension( dilated SP-axis with mild ascites and splenomegaly).No significant focal enhancing lesion is seen in the liver.


doctor
Answered by Dr. Ramesh Kumar (9 hours later)
Brief Answer:
follow up.

Detailed Answer:
Hello again my dear patient,
As CT scan report revealed earlier he had cirrhosis and portal htn etc,So use of CT repeat is to monitor the progression of disease.
Contrast enhancement has no role in monitoring portal veins or liver changes,Its used only when we suspect any sort of mass or structural anomaly.

Better tests for him are-
Plain CT abdomen.
Endoscopy.


Regards.
Above answer was peer-reviewed by : Dr. Yogesh D
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Dr. Ramesh Kumar

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What causes rapid hemoglobin reduction while treating cirrhosis and 45% EF?

Brief Answer: Yes cause should be found out. Detailed Answer: Hi, Thanks for query. Anaemia is classified as- Grade 1, considered mild anemia, is Hb from 10 g/dL to the lower limit of normal. grade 2 anemia, or moderate anemia is Hb from 8 to less than 10 g/dL grade 3, or severe anemia, is below 8 g/dl. Your father right now is severely anemic and therefore priority should be find out the cause of fall in hemoglobin. Few investigations suggested are- Iron profile Transferrin saturation serum ferritin Peripheral smear of blood. Serum B12 level Serum erythropoetin Thalessemia profile. Stool test for occult blood. These tests should be done initially to find the cause of anemia. After that treatment should be done as per the cause. Regards!