Internal Medicine · Year 3 · from Internal Medicine

Case 1: Acute Decompensated Cirrhosis with Ascites

Patient Presentation

A 58-year-old man with alcohol-related cirrhosis presents with 2 weeks of progressive abdominal distension, ankle swelling, and dyspnea when lying flat. He reports a 15-pound weight gain. He stopped drinking alcohol 6 months ago after being diagnosed with cirrhosis. His medications include spironolactone 100 mg and furosemide 40 mg daily, but he admits to poor compliance and eating salty foods.

Vital Signs

  • Blood Pressure: 105/62 mmHg
  • Heart Rate: 88 bpm
  • Respiratory Rate: 18/min
  • Oxygen Saturation: 95% on room air
  • Temperature: 37.1°C

Physical Examination

  • General: Chronically ill-appearing, jaundiced
  • HEENT: Icteric sclera
  • Cardiovascular: Regular rhythm, no murmurs
  • Abdomen: Distended, fluid wave positive, shifting dullness, caput medusae, no tenderness
  • Extremities: 3+ pitting edema to knees, spider angiomata on chest
  • Neurologic: Alert, no asterixis

Laboratory Results

  • Sodium: 128 mEq/L
  • Creatinine: 1.4 mg/dL (baseline 1.0)
  • Albumin: 2.6 g/dL
  • Total bilirubin: 4.8 mg/dL
  • INR: 1.6
  • Platelets: 78,000/μL
  • Diagnostic paracentesis: SAAG 1.8 g/dL, total protein 1.2 g/dL, WBC 180/μL (25% PMNs)

Clinical Image

Figure 1: Clinical photograph demonstrating tense ascites with umbilical eversion and caput medusae, signs of portal hypertension in decompensated cirrhosis.

Image Source: Educational illustration for teaching purposes.

Questions

  1. What does the SAAG (Serum-Ascites Albumin Gradient) indicate in this patient?
  • A) SAAG <1.1 indicates portal hypertension
  • B) SAAG ≥1.1 indicates portal hypertension
  • C) SAAG indicates infection
  • D) SAAG is not useful in cirrhosis
  1. Calculate this patient's MELD-Na score and what does it indicate?
  • A) 10 - low mortality
  • B) 18 - moderate mortality, consider transplant evaluation
  • C) 25 - high mortality, urgent transplant evaluation
  • D) Cannot calculate
  1. Does this patient have spontaneous bacterial peritonitis (SBP)?
  • A) Yes, any WBC in ascites indicates SBP
  • B) No, PMN count <250/μL rules out SBP
  • C) Yes, based on symptoms alone
  • D) Need culture results to determine
  1. What is the appropriate management of this patient's ascites?
  1. What is the indication for SBP prophylaxis and what regimen is used?

Answers

  1. B) SAAG ≥1.1 indicates portal hypertension - SAAG = serum albumin - ascites albumin. SAAG ≥1.1 g/dL indicates portal hypertension (97% accuracy). Causes: cirrhosis, heart failure, portal vein thrombosis, Budd-Chiari. SAAG <1.1 suggests non-portal hypertensive causes: malignancy, TB, nephrotic syndrome.
  1. Approximate MELD-Na calculation:
  • MELD = 3.78 × ln(bilirubin) + 11.2 × ln(INR) + 9.57 × ln(creatinine) + 6.43
  • With sodium adjustment for Na <137
  • Estimated MELD-Na: ~18-20 - indicates significant liver disease, should be evaluated for liver transplant, 3-month mortality approximately 6%
  1. B) No, PMN count <250/μL rules out SBP - SBP diagnosis requires ascitic fluid PMN count ≥250/μL. This patient has 180 × 0.25 = 45 PMNs/μL, below threshold. However, if clinical suspicion high, consider empiric treatment pending culture.
  1. Management of cirrhotic ascites:
  • Sodium restriction: 2 g/day (88 mEq/day)
  • Diuretics: Spironolactone 100 mg + furosemide 40 mg (maintain 100:40 ratio); increase as needed to max spironolactone 400 mg + furosemide 160 mg
  • Fluid restriction: Only if sodium <120-125 mEq/L
  • Therapeutic paracentesis: If tense ascites; give albumin 6-8 g/L removed if >5L removed
  • Alcohol abstinence: Essential
  • TIPS: Consider if refractory ascites
  • Transplant evaluation: Required given decompensation
  1. SBP prophylaxis indications and regimen:
  • Indications:
  • Prior SBP episode (secondary prophylaxis)
  • GI bleeding in cirrhosis
  • Ascitic fluid protein <1.5 g/dL with renal dysfunction or liver failure (MELD ≥15, Na ≤130, Cr ≥1.2, BUN ≥25, bilirubin ≥3)
  • Regimen:
  • Norfloxacin 400 mg daily OR
  • Ciprofloxacin 500 mg daily OR
  • TMP-SMX DS daily
  • This patient has low ascitic protein (1.2 g/dL) and liver dysfunction - qualifies for primary prophylaxis

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