A 62-year-old man with a history of alcohol-associated cirrhosis (Child-Pugh class C) is b… — USMLE Step 3

A 62-year-old man with a history of alcohol-associated cirrhosis (Child-Pugh class C) is brought to the emergency department by his daughter due to increased confusion and abdominal pain over the past 2 days. Home medications include furosemide, spironolactone, nadolol, lactulose, and rifaximin.

On physical examination, temperature is $38.2^\circ\text{C}$ ( $100.8^\circ\text{F}$ ), blood pressure is 88/56 mmHg, and heart rate is 108/min. The patient is lethargic but arousable and oriented only to person. Scleral icterus is present. The abdomen is distended with a positive fluid wave and diffuse mild tenderness to palpation. Asterixis is elicited.

Laboratory results:

Test	Value
Sodium	130 mEq/L
Potassium	4.8 mEq/L
Blood urea nitrogen	45 mg/dL
Creatinine	2.5 mg/dL (baseline 1.0 mg/dL)
Total bilirubin	4.8 mg/dL

Diagnostic paracentesis is performed. Ascitic fluid analysis reveals a total protein of 1.2 g/dL and a white blood cell count of 850/mm³ with 80% neutrophils.

Which of the following pharmacologic interventions are appropriate for the initial management of this patient? (Select all that apply)

Initiate intravenous cefotaximeAnswer
Administer intravenous albuminAnswer
Discontinue nadololAnswer
D
Initiate intravenous terlipressin
E
Administer intravenous furosemide

Answer

The correct interventions include initiating intravenous cefotaxime, administering intravenous albumin, and discontinuing nadolol.

The patient has spontaneous bacterial peritonitis (SBP), defined by an ascitic fluid absolute neutrophil count

>250/\text{mm}^3

. Initial management requires a third-generation cephalosporin (cefotaxime). Furthermore, intravenous albumin is indicated to prevent hepatorenal syndrome (HRS), as the patient meets high-risk criteria (creatinine > 1.0 mg/dL, BUN > 30 mg/dL). Finally, nonselective beta-blockers (nadolol) must be discontinued in the setting of SBP, hypotension, and acute kidney injury to avoid further impairment of cardiac output and renal perfusion.

Step-by-Step Solution

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

ANC is

850 \times 0.80 = 680/\text{mm}^3

An ANC

>250/\text{mm}^3

is diagnostic for spontaneous bacterial peritonitis (SBP).

Select empiric antibiotic therapy.

Initiate an intravenous third-generation cephalosporin (e.g., cefotaxime).

SBP requires immediate empiric coverage targeting enteric Gram-negative organisms.

Assess renal function and indications for albumin.

Administer intravenous albumin.

The patient has an acute kidney injury (AKI) with a creatinine of 2.5 mg/dL; albumin infusion decreases the incidence of hepatorenal syndrome and mortality in SBP patients with high-risk features.

Review home medications for potential harm.

Discontinue nadolol.

Nonselective beta-blockers decrease cardiac output and worsen renal hypoperfusion in patients with decompensated cirrhosis presenting with AKI and hypotension.

Evaluate the indication for vasoconstrictors like terlipressin.

Withhold terlipressin at this time.

Hepatorenal syndrome cannot be diagnosed until volume depletion is formally ruled out with 48 hours of albumin challenge.

Key Concept

Management of spontaneous bacterial peritonitis (SBP) with acute kidney injury, including empiric antibiotics, albumin infusion, and withholding of contraindicated antihypertensive and diuretic medications.

Estimated Time:1m 30s

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