A 56-year-old man is brought to the emergency department with new-onset lethargy and confusion. The patient has a history of cirrhosis secondary to chronic alcoholism. His medications include spironolactone and furosemide. His temperature is 38.0 C (100.4 F), blood pressure is 123/70 mm Hg, pulse is 112/min, and respirations are 24/min. Physical examination reveals a flapping tremor of his hands when they are held out. The patient's breathing is labored, but his lungs are clear to auscultation. Abdominal examination reveals distension with shifting dullness and diffuse tenderness to palpation. There is bilateral pitting edema of his lower extremities. Laboratory results are as follows: Chest x-ray reveals no abnormalities. Abdominal x-ray reveals gas in the small and large bowels without air-fluid levels. Which of the following is the most appropriate next step in management?

Question

A 56-year-old man is brought to the emergency department with new-onset lethargy and confusion.  The patient has a history of cirrhosis secondary to chronic alcoholism.  His medications include spironolactone and furosemide.  His temperature is 38.0 C (100.4 F), blood pressure is 123/70 mm Hg, pulse is 112/min, and respirations are 24/min.  Physical examination reveals a flapping tremor of his hands when they are held out.  The patient's breathing is labored, but his lungs are clear to auscultation.  Abdominal examination reveals distension with shifting dullness and diffuse tenderness to palpation.  There is bilateral pitting edema of his lower extremities.  Laboratory results are as follows:  Chest x-ray reveals no abnormalities.  Abdominal x-ray reveals gas in the small and large bowels without air-fluid levels.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d405_f5b4_bc81_9335f2c65048_MD0003_00 This patient has cirrhosis and ascites accompanied by fever and lethargy, a presentation concerning for spontaneous bacterial peritonitis (SBP) and hepatic encephalopathy. The asterixis (flapping hand tremor), ascites, and laboratory abnormalities are all manifestations of his underlying cirrhosis. SBP superimposed on cirrhosis can be a subtle presentation, requiring a low threshold of suspicion. Fever and subtle changes in mental status are the most common symptoms, while abdominal pain often less prominent than in peritonitis due to other causes. For making the diagnosis, paracentesis is the test of choice with the main diagnostic criteria being a positive ascites fluid culture and neutrophil count of >250/mm³. Paracentesis should be done before antibiotic therapy is initiated as therapy often results in negative ascites cultures. Enteric organisms such as Escherichia coli and Klebsiella are the most commonly cultured organisms followed by the streptococcal species; empiric therapy usually includes a third-generation cephalosporin. > (Choices A and B) There is nothing in this patient's presentation to suggest colon pathology. A barium enema or colonoscopy is unlikely to be helpful. (Choice C) Diagnostic laparoscopy may rarely be required in patients with peritoneal signs on examination if imaging studies have not revealed a source. However, the paracentesis results can also help distinguish between SBP and bacterial peritonitis secondary to other causes such as intestinal perforation or abscess. (Choice E) Although fever and mental status changes are common signs in meningoencephalitis, a patient with ascites and abdominal pain should first be evaluated for SBP as it is much more prevalent in patients with cirrhosis. Lumbar puncture is much less likely to yield a diagnosis. (Choice F) Serum alpha-fetoprotein level is elevated in patients with hepatocellular carcinoma, which is a possibility in this patient given his underlying cirrhosis. However, his acute changes (fever and altered mental status) are more concerning for SBP, which should be ruled out first. Educational objective: Spontaneous bacterial peritonitis can have a subtle presentation and should be considered in any patient with cirrhosis and ascites accompanied by either fever or a change in mental status. Paracentesis is the test of choice, with the main diagnostic criteria being a positive ascites fluid culture and neutrophil count of >250/mm³. > References: Spontaneous bacterial peritonitis. (http://www.ncbi.nlm.nih.gov/pubmed/19266595) Spontaneous bacterial peritonitis. (http://www.ncbi.nlm.nih.gov/pubmed/17551068)

A 56-Year-Old Man Is Brought to the Emergency Department with New-Onset