Cases 27–65

Total bilirubin 6.8 mg/dl Direct bilirubin 4.0 mg/dl AST 250 iu/l ALT 100 iu/l ALP 260 iu/l GGTP 451 iu/l Albumin 2.4 g/dl INR 1.5 Plt 95,000/μl Hb 13.5 g/dl Total bilirubin 6.8 mg/dl Direct bilirubin 4.0 mg/dl AST 250 iu/l ALT 100 iu/l ALP 260 iu/l GGTP 451 iu/l Albumin 2.4 g/dl INR 1.5 Plt 95,000/μl Hb 13.5 g/dl

A 61-year-old lady is brought to the emergency room by her husband with several hours of confusion. She has a history of alcoholic liver disease that has been complicated in the past with encephalopathy. She has esophageal varices detected on endoscopy but no history of GI bleeding. Her ascites has been controlled on diuretics in the past, but she has not been seen for almost a year. Her last imaging was an ultrasound at that time that showed portal hypertension but no mass. She is usually alert and oriented, and her husband states that he thinks she has been compliant with her lactulose and appeared to be well last night. There has been no nausea or vomiting. Her bowels have been moving normally without blood. Her past medical history is significant for diabetes controlled on diet and depression. Medications include lactulose, nadolol, and a multivitamin. She lives with her husband and they have no children. She smokes a packet of cigarettes a day. She has not been evaluated for transplant because of continued alcohol use. Her husband confirms that she drinks a bottle of vodka every few days and several beers a night. There is no history of drug use and no family history of liver disease. The rest of her review of systems is negative. On exam, she is confused and appears disheveled. Vital signs show BP 105/60, pulse 68 regular and she has a low grade temperature of 100.1°F. There is palmar erythema, scleral icterus and multiple spider nevi. Heart reveals normal S1 and S2 without added sounds. Chest reveals clear lung fields. Her abdomen is distended with a fluid thrill. Palpation of the upper abdomen elicits a grimace. Bowel sounds are sparse. Her liver and spleen are impalpable. She has +ankle edema bilaterally.

This lady presents with a relatively acute onset of change in mental status, low-grade fever, and ascites in the setting of ongoing alcohol use. She has not been seen for some time, and we are not told her baseline bilirubin. However, she is coagulopathic, has an elevated white-cell count with abdominal tenderness in the setting of jaundice. She very likely has hepatic encephalopathy, but the question is what is the etiology? The main differential diagnosis is between alcoholic hepatitis and SBP, but the development of HCC or another infection is also possible. Apart from SBP, which is defined as infection in the ascitic fluid without evidence of an intraabdominal surgically treatable source, the possibility of secondary bacterial peritonitis (from a ruptured viscus – gallbladder, colon, or peptic ulcer) should be considered and abdominal imaging is advisable. The first test that should be performed is a diagnostic ascitic tap. Despite the thrombocytopenia and elevated INR, she does not need blood products prior to the tap. Several studies have documented that a tap in this situation is very safe and guidelines from the AASLD do not recommend prophylactic platelet or plasma/cryoprecipitate transfusion. Apart from the tap, blood cultures and a sepsis workup are warranted, and abdominal imaging with ultrasound would not be unreasonable. The ascitic tap should be performed at the bedside, and antibiotics can be started while waiting for the result if the suspicion for SBP is high (as is the case in this patient). The diagnosis of SBP is made on a positive culture and an elevated absolute polymorphonuclear leucocyte (PMN) cell count of >250 cells/mm 3 . A small amount of the fluid should be sent for chemistry to determine the albumin content. In this case, the difference between the serum albumin and ascites albumin (serum ascites albumin gradient or SAAG) was 1.4 g/dl, indicative of portal hypertension. Another 10 ml should be inoculated into blood culture bottles at the bedside (rather than sent to the laboratory in a syringe since this reduces the sensitivity). The gram stain can be ordered but has a very low sensitivity in determining if bacteria are present. The cell count should be available within 1–2 h. In this case, the tap was bloody and needs to be corrected by subtracting one PMN for every 250 red cells. The PMN count was 300, positive for SBP. The choice of antibiotic should cover gut organisms, as well as streptococcal species and the possibility of staphylococcal infection and a third generation cephalosporin such as cefotaxime 2 g intravenous every 8 h is reasonable, with 5–7 days of treatment usually sufficient. We also give intravenous albumin (1.5 g/kg of body weight on day 1 and 1 g/kg of body weight on day 3) on the basis of a study that showed very low mortality in SBP patients treated in this manner. There are several SBP variants based on cell count and culture. In this patient, the ascitic fluid culture was negative, so she falls into the category of culture negative neutrocytic ascites, which may be related to poor culture technique. The opposite variant is monomicrobial, nonneutrocytic bacterascites where the culture is positive but the PMN count is <250. Both should be treated as SBP, particularly if the clinical setting is convincing. It is also possible to get polymicrobial bacterascites from trauma to the bowel during paracentesis. Prophylaxis for SBP is also important in patients with prior episodes or in those with a low protein concentration (<1.5 g/dl) in the ascitic fluid. Daily norfloxacin 400 mg or double strength bactrim, or weekly ciprofloxacin 750 mg are acceptable dosing schedules.

Hb 7.4 g/dl Platelets 56,000/μl INR 1.5 Tbili 1.9 mg/dl AST 38 iu/l ALT 32 iu/l ALP 101 iu/l GGT 49 iu/l Albumin 2.9 g/dl Creatinine 0.8 mg/dl Hb 7.4 g/dl Platelets 56,000/μl INR 1.5 Tbili 1.9 mg/dl AST 38 iu/l ALT 32 iu/l ALP 101 iu/l GGT 49 iu/l Albumin 2.9 g/dl Creatinine 0.8 mg/dl He is emergently intubated, resuscitated and transferred to the intensive care unit and started on a somatostatin analogue, and antibiotics. Endoscopy shows actively bleeding large esophageal varices and a large amount of fresh blood and clot in the stomach obscuring the fundus. Despite several attempts at endoscopic treatment, the bleeding cannot be controlled.

What treatment options are available for this patient (in the USA)? What treatment options are available for this patient (in the USA)?

Total bilirubin 2.9 mg/dl AST 20,300 iu/l ALT 14,050 iu/l ALP 93 iu/l GGTP 250 iu/l Albumin 3.0 g/dl INR 10.6 (PT 117 s) WBC 23.2 (25% bands) Platelets 55 × 10 9 Hgb 13.4 g/dl Creatinine 0.7 mg/dl Total bilirubin 2.9 mg/dl AST 20,300 iu/l ALT 14,050 iu/l ALP 93 iu/l GGTP 250 iu/l Albumin 3.0 g/dl INR 10.6 (PT 117 s) WBC 23.2 (25% bands) Platelets 55 × 10 9 Hgb 13.4 g/dl Creatinine 0.7 mg/dl

What should you do next? What should you do straight after that? Does she need albumin/octreotide/hypertonic saline? What should you do next? What should you do straight after that? Does she need albumin/octreotide/hypertonic saline? Ascitic fluid tap Blood tinged fluid Cell count 50,000 red cells 700 white cells 60% polymorphonuclear Gram stain negative for any organisms Albumin 0.9 g/dl After 48 h Ascitic fluid culture no growth

Hb 10.4 g/dl Platelets 41,000/μl WBC 12.1 × 10 3 /μl (74% neutrophils) INR 2.4 Sodium 122 mmol/l Creatinine 1.3 mg/dl Tbili 18.2 mg/dl AST 159 iu/l ALT 86 iu/l GGTP 207 iu/l ALP 175 iu/l Albumin 2.3 g/dl Hb 10.4 g/dl Platelets 41,000/μl WBC 12.1 × 10 3 /μl (74% neutrophils) INR 2.4 Sodium 122 mmol/l Creatinine 1.3 mg/dl Tbili 18.2 mg/dl AST 159 iu/l ALT 86 iu/l GGTP 207 iu/l ALP 175 iu/l Albumin 2.3 g/dl

What is the differential diagnosis? How would you manage this patient? Fig. 59.1 CT scan What is the differential diagnosis? How would you manage this patient? Fig. 59.1 CT scan Fig. 59.1 CT scan