A 52-year-old man comes to the physician with generalized weakness and abdominal distention. He has had these symptoms for the past 5 months and says that his abdominal girth has gradually increased. He has no other complaints. His other medical problems include hepatitis C-induced cirrhosis and depression. The patient has a 24-pack-year history of cigarette smoking and drinks vodka daily. He admits to using intravenous drugs in the past.
His vital signs are within normal limits, but he has gained 6.8 kg (15 lb) since his last visit 6 months ago. Examination reveals a distended and nontender abdomen with fluid wave and shifting dullness. There is no rebound tenderness or rigidity. His cardiopulmonary examination is unremarkable. Skin examination shows a few spider nevi. He has 2+ pitting pedal edema to the mid-shin bilaterally.
Laboratory results are as follows:

Abdominal ultrasound confirms the presence of a moderate amount of ascites, no focal liver masses, and moderate splenomegaly. A diagnostic paracentesis shows polymorphonuclear count of 88/mm³, total protein of 1.4 g/dL, and albumin of 0.9 g/dL.
Which of the following is the best next step in management of this patient?

Question

A 52-year-old man comes to the physician with generalized weakness and abdominal distention. He has had these symptoms for the past 5 months and says that his abdominal girth has gradually increased. He has no other complaints. His other medical problems include hepatitis C-induced cirrhosis and depression. The patient has a 24-pack-year history of cigarette smoking and drinks vodka daily. He admits to using intravenous drugs in the past.
His vital signs are within normal limits, but he has gained 6.8 kg (15 lb) since his last visit 6 months ago. Examination reveals a distended and nontender abdomen with fluid wave and shifting dullness. There is no rebound tenderness or rigidity. His cardiopulmonary examination is unremarkable. Skin examination shows a few spider nevi. He has 2+ pitting pedal edema to the mid-shin bilaterally.
Laboratory results are as follows:

Abdominal ultrasound confirms the presence of a moderate amount of ascites, no focal liver masses, and moderate splenomegaly. A diagnostic paracentesis shows polymorphonuclear count of 88/mm³, total protein of 1.4 g/dL, and albumin of 0.9 g/dL.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9801_b8e1_853d_5fa6a237be09_MD0002_00 This patient presents with ascites, a frequent complication of cirrhosis. Initial management of ascites includes ruling out infection with fluid analysis (PMN > 250 cells/mm³) and calculating the serum ascites albumin gradient (SAAG), which is serum albumin minus ascitic albumin. Patients with high-gradient SAAG (> 1.1 g/dL) have ascites due to portal hypertension and should be managed initially with complete alcohol abstinence and a 2-g/day sodium diet. ³ Patients without symptom improvement and serum sodium > 120 mEq/L require combination oral high-dose spironolactone and low-dose furosemide to reduce fluid retention and avoid hyperkalemia (Choice A). Diuretics are titrated until symptoms improve. Spironolactone is used as a single agent in patients with profound hypokalemia. Intravenous furosemide should be avoided due to the risk of acute prerenal azotemia, which could be confused with hepatorenal syndrome. Patients with refractory ascites require large-volume paracentesis, midodrine, transjugular intrahepatic portosystemic stent-shunt (TIPS), or liver transplant depending on response. (Choice C) Referral for liver transplant evaluation should be considered at every visit. Referral requires patient abstinence from alcohol and drugs for about 6 months and enrollment in an alcohol rehabilitation program. However, this patient is actively drinking and thus cannot be referred for transplant. (Choice D) Fluid restriction can help patients with serum sodium < 120 mEq/L. NSAIDs, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers should be avoided in cirrhotics as they can reduce glomerular filtration rate and precipitate renal failure. (Choice E) Therapeutic paracentesis is usually indicated to reduce intra-abdominal pressure in symptomatic patients (eg, shortness of breath, abdominal pain, and early satiety). It is also used to treat some patients with ascites refractory to initial diuretic therapy. Educational objective: Ascites is usually managed with salt restriction (< 2 g/day), abstinence from alcohol, avoidance of drugs that cause renal vasoconstriction, and oral diuretics (high-dose spironolactone and low-dose furosemide). Refractory ascites is treated with serial therapeutic paracentesis and possible definitive treatment with transjugular intrahepatic portosystemic stent-shunt or liver transplant. __________ References: Review article: management of ascites and associated complications in patients with cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/18081661)

A 52-Year-Old Man Comes to the Physician with Generalized Weakness