Case Presentation

1
Case Presentation

• Int. ???

2
Patient Profile

• Name ?O?
• Age 45
• Gender Male
• Admission Period 2009/01/14 now

3
Chief Complain

• Fever and bilateral feet edema for 5-6 days.

4
Present Illness

• This 45 y/o man had following history
• GU and DU for 10 years.
• Liver cirrhosis, Child C, alcohol related.
• In waiting list of liver transplantation.
• Multiple hepatic nodules suspect HCC
• Esophageal Varices
• SBP

5
Present Illness

• This time he was suffered from fever, abdominal
  distention, and bilateral feet edema for 5-6
  days.
• He also complained of non-productive cough, mild
  dyspnea without relation to posture, and dysuria.
• But he denied decreased urine output, exertional
  dyspnea or paroxysmal nocturnal dyspnea.

6
Medical History

• Hypertension (-)
• Diabetes mellitus (-)
• Chronic hepatitis B (?)
• Chronic hepatitis C (?)
• Others
• EU and DU for more than 10 years.
• Liver cirrhosis with EV

7
Personal History

• Smoking (-)
• Alcohol ??? 300 ml/day for 20 years.
• Betel nut (-)
• Herbal medication (-)
• Allergy history (-)
• Travel history (-)

8
Family history

• non-contributory

9
Physical Examination

• Vital signs
• T/P/R 40.4?/126/26, BP 104/51 mmHg
• General appearance
• chronic ill and poor nourished.
• Consciousness
• Clear, Coma scale E4V5M6
• Skin
• Icteric skin color, no ecchymosis

10
Physical Examination

• HEENT
• Eyes icteric sclera, no pale conjunctiva
• Chest and Heart
• Bilateral clear breath sounds
• No rales or wheezing
• Regular heart beat, no murmur
• Abdomen
• Hyperactive bowel sounds
• Soft and distended, diffuse abdominal tenderness
• No rebound tenderness, Shifting dullness()
• Extremities
• Pitting edema over bilateral lower legs and feet.

11
At ER (2009/01/14)

• Infiltration or partial atelectasis of RLL and
  LLL
• Hypoinflation of both lungs
• Bilateral hilar vascular engorgement
• Borderline cardiomegaly

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Lab data (2009/01/14)
13
Lab data (2009/01/14)

• Ascites analysis and culture

PMN (5961 91) (4300250) 5424
17 5407
14
Lab data (2009/01/15)

• Urine analysis and culture

15
Impression

• spontaneous bacterial peritonitis, favor liver
  cirrhosis related.
• Pathogen E. coli
• Urinary tract infection

16
Treatment

• Antibiotic use for infection control.
• Flumarin ? Zinacef 1500mg Q8H
• Body fluid control
• Salt and water restriction
• FFP infusion
• Diuretics
• Lasix 1amp QD
• Aldactone 2 BID

17
Management of Adult Patients With Ascites Due to
Cirrhosis

• Adapted from
• 1. AASLD PRACTICE GUIDELINE
• 2.UpToDate
• 3.????????

18
Background

• Cirrhosis was the tenth leading cause of death in
  the United States, according to a 2000 Vital
  Statistics Report, in which data was collected
  through 1998.
• Ascites is the most common of the 3 major
  complications of cirrhosis the other
  complications are hepatic encephalopathy and
  variceal hemorrhage.
• Development of ?uid retention in the setting of
  cirrhosis is an important landmark in the natural
  history of chronic liver disease approximately
  50 of patients with ascites succumb in 2 years.

19
Evaluation and Diagnosis

• History
• risk factors for liver disease
• Alcohol volume and duration
• Viral hepatitis
• Family history of liver disease
• nonalcoholic steatohepatitis
• obesity, diabetes, and hyperlipidemia
• PH of cancer, heart failure, tuberculosis,
  dialysis, pancreatic disease.

20
Evaluation and Diagnosis

• Physical Examination
• Shifting dullness
• Approximately 1,500 mL of ?uid must be present
  before ?ank dullness is detected.
• Negative ? less than 10 of probability.
• Cirrhosis
• vascular spiders and palmar erythema
• jaundice, muscle wasting, and leukonychia (white
  nails)
• Jugular vein engorgement

21
Abdominal Paracentesis

• Safety and Complications
• were reported in only about 1 of patients
  (abdominal wall hematomas), despite the fact that
  71 of the patients had an abnormal PT.
• more serious complications (hemoperitoneum or
  bowel entry by the paracentesis needle) occur,
  they are suf?ciently unusual (lt1/1,000
  paracenteses)
• fresh frozen plasma and/or platelets transfusion
  before paracentesis
• ?This policy is not data-supported.

22
Abdominal Paracentesis

• Site for paracentesis
• In the past, the midline was usually chosen
• However, the abdominal wall in the left lower
  quadrant, 2 ?nger breadths cephalad and 2 ?nger
  breadths medial to the anterior superior iliac
  spine, has been shown to be thinner and with a
  larger pool of ?uid than the midline.

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Abdominal Paracentesis
24
Ascitic Fluid Analysis
25
Serum albumin-ascites gradient
26
Treatment of Ascites
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Treatment of Ascites

• Diuretics
• The usual diuretic regimen consists of single
  morning doses of oral spironolactone and
  furosemide, beginning with 100 mg and 40 mg.
• The doses of both oral diuretics can be increased
  simultaneously every 3 to 5 days (maintaining the
  100 mg40 mg ratio) if weight loss and
  natriuresis are inadequate.
• Usual maximum doses are 400mg per day of
  spironolactone and 160 mg per day of furosemide.

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Treatment of Ascites

• Diuretics
• There is no limit to the daily weight loss of
  patients who have massive edema.
• Once the edema has resolved, 0.5 kg is probably a
  reasonable daily maximum.
• Encephalopathy, serum sodium less than 120 mmol/L
  despite ?uid restriction, or serum creatinine
  greater than 2.0 mg/dL (180 mol/L) should lead to
  cessation of diuretics, reassessment of the
  situation, and
  consideration of second-line options.

29
Refractory Ascites

• Definition
• ?uid overload that
• (1) is unresponsive to sodium-restricted diet and
  high-dose diuretic treatment (400 mg per day of
  spironolactone and 160 mg per day furosemide), or
  
• (2) recurs rapidly after therapeutic paracentesis.

30
Refractory Ascites

• Failure of diuretic therapy may be manifested
• (1) minimal to no weight loss together with
  inadequate (78 mmol per day) urinary sodium
  excretion despite diuretics, or
• (2) development of clinically signi?cant
  complications of diuretics,
• encephalopathy, serum creatinine greater than
  2.0mg/dL, serum sodium less than 120 mmol/L, or
  serum potassium greater than 6.0 mmol/L.

31
Refractory Ascites

• Options for patients refractory to routine
  medical therapy include
• (a) serial therapeutic paracenteses,
• (b) liver transplantation,
• (c) transjugular intrahepatic portasystemic
  stent-shunt (TIPS), and
• (d) peritoneovenous shunt.

32
Refractory Ascites
33
Spontaneous Bacterial Peritonitis

• Definition
• an ascitic fluid infection without an evident
  intraabdominal surgically-treatable source.
• positive ascitic fluid bacterial culture and an
  elevated ascitic fluid absolute polymorphonuclear
  leukocyte (PMN) count (250 cells/mm3).
• Symtoms and signs
• Fever, abdominal pain, AMS, abdominal tenderness,
  diarrhea, paralytic ileus, hypotension,
  hypothermia.

34
Spontaneous Bacterial Peritonitis

• SBP vs. secondary bacterial peritonitis
• PMN count 250 cells/mm3 ?2 of 3
• ? secondary
• Total protein concentration gt1 g/dL (10 g/L)
• Glucose concentration lt50 mg/dL (2.8 mmol/L)
• Lactate dehydrogenase greater than the upper
  limit of normal for serum (225 U/L)

35
Spontaneous Bacterial Peritonitis
36
Spontaneous Bacterial Peritonitis
37
Prevention of SBP
38
Ascitic Fluid Analysis
39
Take home message

• Ascites
• Is the fluid infected?
• Is portal hypertension present?
• SBP vs. secondary bacterial peritonitis