Day #18 - Cirrhosis

Today's case was of a 52 year-old man who presented with new diagnoses of cirrhosis with ascites, portal hypertension and probable variceal bleed who also had a new diagnosis of diabetes mellitus. The discussant showed us, although in his own uniquely tangential way, the type of clinical reasoning that great physicians use in arriving at a diagnosis.

There are a number of valuable teaching points today:

1) Ascites:

Etiology

• Elevated Hydrostatic Pressure --> CHF, constrictive pericarditis, Budd-Chiari, cirrhosis, IVC occlusion
• Decreased oncotic pressure --> malnutrition, nephrotic syndrome, protein losing enteropathy, cirrhosis/liver failure
• Increased fluid production in peritoneum --> infection (TB), neoplasm

Diagnosis on History/Exam
History

• Increased abdominal girth and ankle swelling are the most sensitive (greater than 85%)
• Past history of hepatitis or cancer are the most specific (greater than 85%)

Exam

• Not likely if no bulging flanks, no flank dullness and no shifting dullness
  
• Likely if fluid wave, shifting dullness, and peripheral edema (LR+3.8/-0.2)

2) Special Tests:

The team today also mentioned that they had performed a paracentesis in order to evaluate the ascites. This is important as paracentesis can:

1. Provide diagnostic clues
2. Exclude SBP

The Serum Albumin-Ascites Gradient (SAAG) is a valuable tool in deciding if the ascites is due to portal hypertension. SAAG = Serum albumin - Ascites Albumin. If <11 style="font-style: italic;">It should also be prevented in cirrhotic patients post GI bleed using TMP/SMX 1DS PO BID x 7d or CIPROFLOXACIN 500mg PO BID x 7d

The diagnosis can be made on the paracentesis:

• PMN >250 (LR + 6 LR - 0.2)
• WBC >1000 (LR + 9)
• Inoculation of blood culture bottles (fill them with required volume) can improve yield of the C/S

NB: In most cases, you do not need to use FFP/Platelets pre paracentesis.

Initial treatment is with CEFTRIAXONE 2g IV q24h with coverage narrowed to the culture data. You need only treat for 5 days.

Patients should get 1.5g/kg of 25% albumin within 6h then 1g/kg on day 3.

NB: Think of missed perforation if multiple organisms grow in the culture or if the WBC count in the fluid is much greater than 1000.