Question of the Week # 102, 103

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

F) Furosemide and Spironolactone

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

16 Responses

  1. a & d

  2. F,D

  3. aaa ddd

  4. discriminant function = 41
    B and D

  5. A: Spontaneous Bacterial Peritonitis ( WBC > 250 ): Ceftriaxone, or FQ

    • Afebril Patient with ascitis + peripheral edema–Hx acoholism–
      PMN count of > 250 cells/μL is diagnostic of SBP–this Pt has 100-next step is Furocemide and Spironolactone –water and Na restriction and frequent abdominal paracentesis

  6. Single best predictor for SBP is PMN count >500. If PMN > 250, you can suspect SBP but it’s not just the WBC count. It specifically has to be the neutrophil fraction.

  7. A diagnosis of SBP is made based on ascitic fluid with PMN>250, and NOT the PMN of the serum. So this patient does not have SBP. The issue is the amount ascitic fluid in his abdomen which needs to be tapped out. Te best initial step for tis is H2O and NO, and if that fails, then spirnolactone. So i would say the answer is F, D

  8. A and D

  9. Pt doesnot have abdominal tenderness, no alterned mental status and afebrile how can we justify it SBP. why not heptaorenal syndrome

  10. wbc more than 250 justifies SBP

  11. And: F and D
    Patient does not have alcoholic hepatitis (AH) which is the clinical syndrome of jaundice, anorexia, and tender hepatomegaly with or without fever in patients with high-dose (>100 g/d) alcohol intake. Severe AH may be accompanied by hepatic encephalopathy (HE), variceal bleeding, ascites, or hepatorenal syndrome. Laboratory evaluation may demonstrate elevated aminotransferase levels (<300-400 U/L), an AST to ALT ratio greater than 2, conjugated hyperbilirubinemia, elevated γ-glutamyltransferase level, elevated mean corpuscular volume, leukocytosis, and coagulopathy.
    Severity of AH is determined by the Maddrey discriminant function (MDF) score, which is calculated as follows:
    MDF = 4.6 (prothrombin time [s] – control prothrombin time [s]) + total bilirubin (mg/dL)
    Patients with mild disease (MDF 250 (will give cefriaxone though, if patient had varicella bleed)

    Will do TIPS is patient does not respond to conservative medical management for ascitis and keeps getting fluid reaccumulation

    Can’t do liver transplant as patient is still abusing alcohol

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