A 58-year-old man comes to the office due to progressive generalized weakness, leg swelling, and abdominal distension for the past several months. The patient also notes that his previously small umbilical hernia has recently enlarged, and he would like it repaired. He has no abdominal pain, hematemesis, or melena. His other medical conditions include type 2 diabetes mellitus, hypercholesterolemia, hypertension, obesity, and nonalcoholic steatohepatitis. He does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 102/76 mm Hg, pulse is 74/min, and respirations are 16/min. The abdomen is moderately distended with fluid wave but nontender. There is a large, reducible, umbilical hernia with expansile cough impulse. There are no dilated superficial veins on the abdominal wall. Rectal examination reveals a normal-sized, nontender prostate gland and occult blood-negative brown stool. There is 2+ bilateral lower extremity pitting edema.
Laboratory results are as follows:
Ultrasonography of the abdomen shows moderate ascites, splenomegaly, and a shrunken liver with no focal masses. Ascitic fluid analysis reveals a leukocyte count of 440/mm³ with 20% neutrophils, protein of 1.8 g/dL, and albumin of 1.2 g/dL. Ascitic fluid culture is pending.
In addition to dietary salt restriction and diuretic therapy, which of the following is the most appropriate next step in management of this patient?

Question

A 58-year-old man comes to the office due to progressive generalized weakness, leg swelling, and abdominal distension for the past several months. The patient also notes that his previously small umbilical hernia has recently enlarged, and he would like it repaired. He has no abdominal pain, hematemesis, or melena. His other medical conditions include type 2 diabetes mellitus, hypercholesterolemia, hypertension, obesity, and nonalcoholic steatohepatitis. He does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 102/76 mm Hg, pulse is 74/min, and respirations are 16/min. The abdomen is moderately distended with fluid wave but nontender. There is a large, reducible, umbilical hernia with expansile cough impulse. There are no dilated superficial veins on the abdominal wall. Rectal examination reveals a normal-sized, nontender prostate gland and occult blood-negative brown stool. There is 2+ bilateral lower extremity pitting edema.
Laboratory results are as follows:

Ultrasonography of the abdomen shows moderate ascites, splenomegaly, and a shrunken liver with no focal masses. Ascitic fluid analysis reveals a leukocyte count of 440/mm³ with 20% neutrophils, protein of 1.8 g/dL, and albumin of 1.2 g/dL. Ascitic fluid culture is pending.
In addition to dietary salt restriction and diuretic therapy, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97fc_88b6_853d_9940cb5076bf_MD0002_00 This patient's presentation - newly developed ascites, serum albumin-ascites gradient (SAAG) >1.1, thrombocytopenia, elevated INR, and splenomegaly - is consistent with decompensated cirrhosis, likely due to nonalcoholic steatohepatitis. Current guidelines recommend a screening upper endoscopy (eg, esophagogastroduodenoscopy [EGD]) in patients with cirrhosis at the time of diagnosis to document the presence of varices. Indications for prophylaxis to reduce risk of hemorrhage in patients with documented varices are based on varix size, presence of decompensated cirrhosis, and signs indicating high-bleed risk (Table). Nonselective beta blockers (eg, propanolol, nadolol) are typically first-line agents for those who require prophylaxis, with endoscopic variceal ligation (EVL) generally reserved for patients with large varices or who cannot tolerate medications. Patients who undergo EVL require repeat EGD every few weeks until varices are obliterated. Beta blockers do not prevent the formation of varices, are not recommended in patients without varices, and should not be started prior to EGD (Choice B). (Choice A) Fluoroquinolone prophylaxis against spontaneous bacterial peritonitis (SBP) is indicated in patients with ascites during an active gastrointestinal bleed; those who have had ≥1 episodes of SBP; or those with ascitic protein <1 g/dL if they also have impaired renal function (eg, creatinine ≥1.2 mg/dL), Child-Pugh class C with bilirubin ≥3 mg/dL, or are hospitalized. Fluoroquinolones may also be used to treat SBP in patients with a penicillin allergy. This patient does not meet criteria for SBP prophylaxis; he also does not meet criteria for SBP, diagnosed by ≥250 polymorphonuclear (PMN) cells/mm³ in the ascitic fluid, as he has 440 leukocytes/mm³ × 20% neutrophils = 88 PMNs/mm³. ³ ³ ³ (Choice C) This patient has a reducible umbilical hernia; emergency hernia repair is usually indicated for impending incarceration or rupture. Otherwise, patients can be treated with adequate ascites management (eg, salt restriction, diuretics) and an abdominal binder to prevent hernia complications. Elective surgery could be considered after the ascites is adequately controlled with medical management. (Choice D) All patients with cirrhosis should be screened for hepatocellular carcinoma; however, current guidelines recommend surveillance ultrasonography every 6 months. CT scan is not recommended due to radiation exposure and high rates of false positives. Educational objective: Patients newly diagnosed with cirrhosis require esophagogastroduodenoscopy to document varices and assess the risk for variceal hemorrhage. First-line prophylaxis typically consists of nonselective beta blockers. __________ References: Role of endoscopy in primary prophylaxis for esophageal variceal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/20682232)

A 58-Year-Old Man Comes to the Office Due to Progressive