A 52-year-old man with a history of alcoholic liver disease is admitted to the hospital due to fatigue and abdominal discomfort. He has had no nausea, vomiting, constipation, or diarrhea. The patient has chronic ascites treated with spironolactone and furosemide. He had an inguinal hernia repaired 20 years ago. His temperature is 37.9 C (100.2 F), blood pressure is 102/68 mm Hg, and pulse is 106/min. The patient is awake, alert, and oriented to time, place, and person but fails to perform a timed connect-the-numbers test. Auscultation of the heart and lungs is normal. Abdominal examination shows moderate ascites with diffuse discomfort to palpation. There is no rigidity or rebound. Bowel sounds are decreased. The rectal examination is normal, with brown stool negative for occult blood. Abdominal x-ray shows dilated loops of large bowel with air in the colon and rectum. Which of the following is the most likely diagnosis in this patient?

Question

A 52-year-old man with a history of alcoholic liver disease is admitted to the hospital due to fatigue and abdominal discomfort.  He has had no nausea, vomiting, constipation, or diarrhea.  The patient has chronic ascites treated with spironolactone and furosemide.  He had an inguinal hernia repaired 20 years ago.  His temperature is 37.9 C (100.2 F), blood pressure is 102/68 mm Hg, and pulse is 106/min.  The patient is awake, alert, and oriented to time, place, and person but fails to perform a timed connect-the-numbers test.  Auscultation of the heart and lungs is normal.  Abdominal examination shows moderate ascites with diffuse discomfort to palpation.  There is no rigidity or rebound.  Bowel sounds are decreased.  The rectal examination is normal, with brown stool negative for occult blood.  Abdominal x-ray shows dilated loops of large bowel with air in the colon and rectum.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d406_91f5_bc81_3f5f0daf16ab_MD0003_00 This patient's presentation is consistent with spontaneous bacterial peritonitis (SBP), an ascitic fluid infection without an obvious intraabdominal surgical etiology. SBP is most likely due to either intestinal bacterial translocation directly into the ascitic fluid or hematogenous spread to the liver and ascitic fluid (due to other bacterial infections). Patients with cirrhosis are often relatively hypothermic, and any temperature ≥37.8 C (100 F) warrants investigation. Other manifestations of SBP may include diffuse abdominal discomfort/tenderness and/or mental status changes. The Reitan trail test, a timed connect-the-numbers test similar to children's connect-the-dots pictures, is excellent for use in detecting subtle mental status changes sometimes present in patients with cirrhosis and SBP. Hypotension, hypothermia, or paralytic ileus (dilated loops of bowel on x-ray) indicate severe SBP. As the vast majority of cases of SBP are associated with cirrhosis, the serum-ascites albumin gradient (SAAG) is usually ≥1.1 g/dL (a SAAG <1.1 g/dL makes SBP unlikely). Ascitic fluid with a polymorphonuclear leukocyte (PMN) count ≥250/mm³ and positive peritoneal fluid culture confirm the diagnosis. (Choice A) Patients with chronic alcohol use can develop acute pancreatitis with diffuse abdominal pain and ileus, but nausea and vomiting are common in these patients and the pain frequently radiates to the back. (Choice B) Alcoholic hepatitis can also present similarly to SBP with fever, right upper quadrant abdominal pain, and peripheral leukocytosis. However, alcoholic hepatitis does not usually cause diffuse abdominal pain and decreased bowel sounds. Encephalopathy is seen only in severe cases. (Choice C) The absence of free air under the diaphragm on x-ray makes bowel perforation less likely in this patient. Ascites separates the visceral and parietal peritoneal surfaces and prevents development of a rigid abdomen, even with organ perforation. As a result, presentation of secondary peritonitis (ascitic infection due to a surgically treatable intraabdominal source such as perforated peptic ulcer) can be difficult to distinguish from SBP. free air under the diaphragm (Choice D) Small bowel obstruction (SBO) may present with diffuse abdominal pain and dilated loops of small bowel, but nausea and vomiting are much more common and bowel sounds tend to be high-pitched initially. Dilated loops of large bowel would not be expected with SBO (although air in the colon can sometimes be seen with partial SBO). Educational objective: Spontaneous bacterial peritonitis (SBP) should be suspected in any patient with cirrhosis and ascites who presents with low-grade fever, abdominal discomfort, or altered mental status. The Reitan trail test, a timed connect-the-numbers test, helps detect subtle mental status changes sometimes present in patients with SBP. References: Spontaneous bacterial peritonitis. (http://www.ncbi.nlm.nih.gov/pubmed/19266595)

A 52-Year-Old Man with a History of Alcoholic Liver Disease