A 58-year-old man is evaluated in the hospital for worsening abdominal distension and diff… — USMLE Step 2 CK

A 58-year-old man is evaluated in the hospital for worsening abdominal distension and diffuse abdominal discomfort over the past 48 hours. He has a history of alcohol-associated cirrhosis. His temperature is $37.9^\circ\text{C}$ ( $100.2^\circ\text{F}$ ), blood pressure is $105/65\text{ mm Hg}$ , and pulse is $92/\text{min}$ . Physical examination shows a protuberant abdomen with shifting dullness and mild, diffuse tenderness to palpation without rebound or guarding. Neurologic examination shows a fully oriented patient with no asterixis.

Laboratory studies show the following:

Test	Result
Serum creatinine	$1.8\text{ mg/dL}$
Blood urea nitrogen	$34\text{ mg/dL}$
Total bilirubin	$4.5\text{ mg/dL}$

Diagnostic paracentesis yields ascitic fluid with a total leukocyte count of $800/\text{mm}^3$ and $85\%$ neutrophils. Intravenous cefotaxime is initiated. Which of the following is the most appropriate additional intervention for this patient?

Administration of intravenous albuminAnswer
B
Addition of intravenous metronidazole
C
Large-volume therapeutic paracentesis
D
Placement of a transjugular intrahepatic portosystemic shunt
E
Transfusion of fresh frozen plasma

Answer

Administration of intravenous albumin

The correct intervention is the administration of intravenous albumin. This patient has spontaneous bacterial peritonitis (SBP), diagnosed by an ascitic fluid absolute neutrophil count (ANC) greater than

250/\text{mm}^3

(in this case,

800 \times 0.85 = 680/\text{mm}^3

). SBP can precipitate severe splanchnic arterial vasodilation, leading to decreased effective arterial blood volume, activation of the renin-angiotensin-aldosterone system, and subsequent severe renal vasoconstriction, a cascade known as hepatorenal syndrome (HRS). The administration of intravenous albumin expands the intravascular volume, binds vasodilatory molecules, and significantly reduces the incidence of HRS, thereby improving survival. It is specifically indicated for patients with SBP who have a serum creatinine

> 1.0\text{ mg/dL}

, BUN

> 30\text{ mg/dL}

, or total bilirubin

> 4.0\text{ mg/dL}

. This patient meets all three of these criteria.

Step-by-Step Solution

Calculate the absolute neutrophil count (ANC) in the ascitic fluid.

The ANC is

800 \times 0.85 = 680/\text{mm}^3

, which is greater than

250/\text{mm}^3

An ANC

\geq 250/\text{mm}^3

confirms the diagnosis of spontaneous bacterial peritonitis (SBP).

Evaluate the patient's laboratory values for high-risk features.

The patient has elevated serum creatinine (

1.8\text{ mg/dL}

), blood urea nitrogen (

34\text{ mg/dL}

), and total bilirubin (

4.5\text{ mg/dL}

These lab values meet the criteria for severe liver and renal impairment in the setting of SBP, indicating a high risk for hepatorenal syndrome.

Select the appropriate adjunctive therapy.

Intravenous albumin must be administered alongside antibiotics.

Current guidelines require IV albumin administration for SBP patients meeting specific renal or hepatic impairment thresholds to reduce mortality.

Key Concept

Management of spontaneous bacterial peritonitis and prevention of hepatorenal syndrome using intravenous albumin.

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