102) A 65 year old man presents to your office with increasing abdominal distension and bilateral leg swelling. He reports his symptoms started 3 months ago and progressively worsening. He smokes about one pack cigarettes per day and drinks one pint vodka every day. His last drink was 1 day ago. On examination, he is afebrile and he has abdominal distension and ascites with out any tenderness on palpation. Lab studies show WBC 8k/µl, Hemoglobin of 10.2 gm%, Platelets 90k/µl, Total protein of 6.4, Albumin 2.2, SGOT 300, SGPT 130, Total Bilirubin 4.2 , Direct Bilirubin 3.3, Prothrombin time of 19 seconds and Creatinine 2.2. The patient undergoes diagnostic paracentesis which reveals a total protein of 1.4, albumin of 0.6, WBC count of 400 with polymorphonuclear neutrophils of 100cells/ml. Bacterial cultures are pending. The most important step in managing this patient is :
A) Intravenos Ceftriaxone
B) Intravenos Corticosteroids
C) Intravenos Albumin Infusion
D) Trans-jugular Intrahepatic Porto-systemic Shunt (TIPS)
E) Arrange for Liver Tranplant
103) The most important factor that should be considered in determining the etiology of this patient’s Ascites:
A) Fluid WBC
B) Fluid Albumin
C) Fluid Total protein
D) Serum – Ascites- Albumin – Gradient
E) Serum Albumin and Prothrombin time
A
D
a & d
F,D
a,d
A , D
To determine the etiology:
Do serum-ascites albumin gradient (SAAG): if SAAG is 1.1 or higher then it is portal hypertension: Cirrhosis, heart failure, Budd-Chiari syndrome (hepatic vein thrombosis).
If SAAG is less than 1.1 then it is non portal hypertension: pertonitis (e.g. TB), cancer, pancreatitis, trauma, nephrotic synd.
Dx:
U/S and paracentesis, check cell count, diff, alb, and bacterial cultures +/- AFS and +/- cytology. If the pt with cirrhosis and established ascites presents with worsening ascites, fever and abd pain (by the way our pt denies F and abd pain), think of spontaneous bacterial peritonitis (SBP). Also when peritoneal fluid neutrophil count greater than 250 or + culture, you can make the Dx of SBP (our pt neutrophil count is 100 and culture is pending).
Tx:
Portal HTN- Sodium restriction to less than 2 gm/day.
– Diuretics: combination of Furosemide and spironolactone.
– Lg vol. paracentesis for painful distension.
– TIPS can be used in refractory cases, but this increases the rate of encephalopathy.
– Ultimately, liver transplant if the pt is a candidate.
Non portal HTN- Treat the underlying disorder. Therapeutic paracentesis can also be performed. treat SBP with 3rd-gen. cephlosporin e.g. ceftriaxone (1st line therapy) or fluoroquinolone. Often recurs.