We will now move to our next case.
A 52-year-old woman is hospitalized for
3 days of abdominal pain and fever.
She has a history of decompensated alcoholic
cirrhosis with ascites managed with diuretics.
Her medications are furosemide,
spironolactone and lactulose.
Vitals are notable for a temperature of 38 C,
blood pressure 115/60 mmHg, and heart rate 110 bpm.
Her abdomen is distended and moderately tender
to palpation with a positive fluid wave.
Lab studies show a bilirubin of 4.5
(mg/dL), serum creatinine of 1.3 (mg/dL)
and white cell count of 12,000 (x10^9).
What is the next best step
to confirm the diagnosis?
So let's review this case.
She has new onset abdominal pain and fever.
So in a patient with decompensated cirrhosis
and ascites, we should be very concerned.
In addition, she's febrile, tachycardic and has localizing
signs of some perhaps an infection in the abdominal area.
Her labs show high serum bilirubin and an abnormal
creatinine which can alter the treatment in this condition.
So let's talk next about spontaneous
bacterial peritonitis or SBP.
This is simply an infection
of the ascitic fluid.
It has a high mortality
risk of about 10 to 20%.
Patients may come in with abdominal
pain, they may have fever,
new onset hepatic encephalopathy
or they may have acute kidney injury.
The diagnosis must be
done with paracentesis.
That's by inserting a needle
into the peritoneal space
and withdrawing some fluid
that we can then send for analysis.
The diagnostic criteria for
SBP are you must have:
count of greater that 250 u/L,
or you may have below this threshold
but have a positive bacterial culture
in a patient who has symptoms.
The treatment is with a 3rd generation cephalosporin
and you may give IV albumin for selected patients.
So let's take a quick break to talk
about a high-yield learning point.
Any patient who has ever had a history of
SBP should receive lifelong SBP prophylaxis
with any of the medications listed here:
norfloxacin, ciprofloxacin or
Now let's take a step back
and talk about ascites.
So the initial work-up of ascites must be done
with an ultrasound to assess the ascites burden
and a diagnostic paracentesis the very
first time ascites is noted in our patient.
This is important because we want to
know the etiology of their ascites.
So we send that fluid off for albumin, a measure
of their total protein and a cell count.
This is all to confirm that their ascites is
truly due to cirrhosis and not another cause.
We do this by calculating the serum ascites
albumin gradient which we will discuss next.
In terms of basic ascites management, we
want to prevent the build up of ascites
by restricting the sodium
in the patient's diet,
giving diuretics like
furosemide and spironolactone
and in some cases, we may do
a procedure called a TIPS.
This is a transjugular
intrahepatic portosynthetic shunt.
Basically, it diverts blood flow from the
portal vein into the systemic system.
We usually only do this procedure if patients
have ascites refractory to the above treatments
because it has a high
risk of complications.
So earlier we mentioned the serum
ascites albumin gradient or the SAAG.
This is a simple calculation by measuring the serum
albumin and subtracting the ascites albumin.
By doing this, we can differentiate between causes
with a SAAG of greater than or equal to 1.1
which indicates that the ascites is
developed from high portal pressure,
the most common cause of which
is portal hypertension.
When the SAAG is less than 1.1,
this usually indicates ascites
from causes that are not associated
with increased portal pressure.
We can also further differentiate the origin
of ascites based on the ascites total protein.
That's why that test is important to get when
you first encounter a patient with new ascites.
So, we won't go into this in too much
detail since this is beyond the scope of this lecture,
but know that the total protein in the ascites can help
you differentiate between cirrhosis and the other causes.
So now let's return to our case.
Our 52-year-old woman with new onset abdominal
pain and fever with decompensated cirrhosis.
She's febrile, tachycardic, has
potential signs of an infection.
And her labs with a high bilirubin and
creatinine may alter the treatment.
So, what is the best next step
to confirm the diagnosis?
We should at this point suspect SBP.
So we now know that the best test to confirm
the diagnosis is diagnostic paracentesis.