Review Question - QID 206406

The patient presents with signs and symptoms of spontaneous bacterial peritonitis. The next step in management is paracentesis for gram stain, culture, and cell count.

Cirrhotic patients with ascites who develop a fever or a change in mental status should be worked up for spontaneous bacterial peritonitis (SBP). In SBP, the ascitic fluid becomes infected. The condition is associated with a high mortality rate (20-30%) as well as a high recurrence rate (up to 70% in the first year). Common pathogens are E. coli, Klebsiella, and Streptococcus pneumoniae. Patients present clinically with abdominal pain, fever, vomiting, and rebound tenderness and may progress to sepsis. Diagnosis is made via paracentesis which reveals WBCs, PMNs, and positive gram stain or culture growth. Greater than 250 PMNs per mm3 meets criteria for SBP. Treatment is with broad-spectrum antibiotics, which is later narrowed with culture results.

Starr and Raines discuss diagnosis, management, and prevention of cirrhosis. Alcohol abuse and viral hepatitis are the most common causes of cirrhosis, although nonalcoholic fatty liver disease is emerging as an increasingly important cause. Patients with cirrhosis should be screened for hepatocellular carcinoma with imaging studies every 6 to 12 months. Physicians should be vigilant for spontaneous bacterial peritonitis.

Gordon discusses ascites, the pathologic accumulation of fluid in the peritoneum. It is the most common complication of cirrhosis, with a prevalence of approximately 10%. Over a 10-year period, 50% of patients with previously compensated cirrhosis are expected to develop ascites. As a marker of hepatic decompensation, ascites is associated with a poor prognosis, with only a 56% survival 3 years after onset.

Illustration A depicts the classic appearance of ascites. Illustration B shows the classification of cirrhosis based on the Childs score. Illustration C shows a treatment algorithm for SBP.

Incorrect Answers:
Answer 1: This would be indicated in a patient presenting with signs and symptoms of cholecystitis.
Answer 2: CT would administer radiation and is not indicated at this time.
Answer 3: Endoscopic retrograde cholangiopancreatography is used in obstructive jaundice where a stone is blocking the biliary tract. It is not useful in this patient.
Answer 4: A transjugular intrahepatic portosystemic shunt is a bridge to transplant. This patient is still drinking and is not a candidate for transplant. Further his acute infection should be addressed first.