A 58-year-old man comes to the office due to increasing abdominal girth for the past several months. The patient also reports progressive fatigue, weight gain, and nausea but no vomiting. Medical history is significant for gastroesophageal reflux and hypertension. He drinks 12 beers a day but denies smoking or intravenous drug use. Temperature is 37 C (98.6 F), blood pressure is 122/76 mm Hg, pulse is 80/min, and respirations are 18/min. Mental status is normal. Cardiopulmonary examination is unremarkable. The abdomen is grossly distended, and shifting dullness is elicited. There is no asterixis. Chest x-ray is normal. Basic metabolic panel is unremarkable. Abdominal ultrasonogram shows splenomegaly, moderate ascites, and a shrunken liver with no masses. Diagnostic paracentesis reveals straw-colored fluid. In addition to recommending complete abstinence from alcohol use, which of the following is the best next step in management?

Question

A 58-year-old man comes to the office due to increasing abdominal girth for the past several months.  The patient also reports progressive fatigue, weight gain, and nausea but no vomiting.  Medical history is significant for gastroesophageal reflux and hypertension.  He drinks 12 beers a day but denies smoking or intravenous drug use.  Temperature is 37 C (98.6 F), blood pressure is 122/76 mm Hg, pulse is 80/min, and respirations are 18/min.  Mental status is normal.  Cardiopulmonary examination is unremarkable.  The abdomen is grossly distended, and shifting dullness is elicited.  There is no asterixis.  Chest x-ray is normal.  Basic metabolic panel is unremarkable.  Abdominal ultrasonogram shows splenomegaly, moderate ascites, and a shrunken liver with no masses.  Diagnostic paracentesis reveals straw-colored fluid.  In addition to recommending complete abstinence from alcohol use, which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d1a2_63ae_bc81_a73b6c164da7_MD0003_00 This patient with a history of heavy alcohol use has new-onset ascites and a shrunken liver on ultrasound, suggesting decompensated cirrhosis. Portal hypertension in cirrhosis leads to hemodynamic changes (eg, splanchnic vasodilation) that promotes fluid and sodium retention, ultimately resulting in ascites and peripheral edema. The workup of ascites is directed at confirming the underlying etiology and ruling out infection. In addition to imaging (eg, abdominal ultrasound), a diagnostic paracentesis should be performed in all patients. Ascites from cirrhosis is usually yellowish or straw-colored; analysis reveals low total protein (<2.5 g/dL) and a high serum-ascites albumin gradient (≥1.1). Cell count and differential should be obtained to rule out spontaneous bacterial peritonitis (ie, neutrophil count ≥250/mm³). Management includes sodium restriction as well as spironolactone and furosemide, which improve both ascitic fluid retention and peripheral edema. These medications are usually used concurrently to increase the efficacy of natriuresis and prevent electrolyte disturbances. Alcohol abstinence is also important since cessation improves portal hypertension and decreases ascites. Large-volume paracentesis or transjugular intrahepatic portosystemic shunt may be required for refractory ascites. (Choice A) Fluid restriction is used to treat hypervolemic hyponatremia. Although hyponatremia can develop in cirrhosis, fluid restriction is not indicated in patients with normal sodium levels, such as this patient. (Choice B) Although spironolactone is occasionally used by itself in patients prone to hypokalemia, furosemide monotherapy is usually avoided in cirrhosis because it is less effective in this population and predisposes to electrolyte wasting. (Choice D) Patients with cirrhosis have low mean arterial pressure due to splanchnic vasodilation and are dependent on the renin-angiotensin-aldosterone system to help normalize blood pressure and renal perfusion. ACE inhibitors (eg, lisinopril) and angiotensin receptor blockers blunt this critical response and promote organ hypoperfusion in this group. These medications should be avoided in patients with cirrhosis. (Choice E) Periodic large-volume paracentesis is used in those whose condition fails to improve with diuretics or who develop diuretic-related side effects (eg, acute kidney injury, electrolyte disturbances). It is invasive and not recommended prior to a trial of spironolactone and furosemide. Educational objective: Workup of ascites includes ultrasonography and a diagnostic paracentesis (ie, serum-ascites albumin gradient, cell count and differential, total protein) to determine the underlying etiology and rule out spontaneous bacterial peritonitis. Initial management of ascites from cirrhosis includes spironolactone and furosemide, sodium restriction, and alcohol abstinence. References: Combined versus sequential diuretic treatment of ascites in non-azotaemic patients with cirrhosis: results of an open randomised clinical trial. (http://www.ncbi.nlm.nih.gov/pubmed/19570764)

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