A 58-year-old man with a history of alcohol-associated cirrhosis and refractory ascites is… — USMLE Step 2 CK

A 58-year-old man with a history of alcohol-associated cirrhosis and refractory ascites is evaluated on hospital day 2. He initially presented with progressive confusion, fever, and diffuse abdominal discomfort. Upon admission, his temperature was $38.3^\circ\text{C}$ ( $100.9^\circ\text{F}$ ), blood pressure was $102/65\text{ mmHg}$ , and heart rate was $105/\text{min}$ . Physical examination demonstrated a tense, distended abdomen with shifting dullness and diffuse tenderness, but no guarding or rigidity.

Initial laboratory results from admission:

Parameter	Value	Reference Range
Hemoglobin	$10.4\text{ g/dL}$	$13.5-17.5\text{ g/dL}$
Leukocyte count	$11,200/\text{mm}^3$	$4,500-11,000/\text{mm}^3$
Platelets	$88,000/\text{mm}^3$	$150,000-400,000/\text{mm}^3$
Total bilirubin	$4.8\text{ mg/dL}$	$0.1-1.2\text{ mg/dL}$
Blood urea nitrogen	$34\text{ mg/dL}$	$8-20\text{ mg/dL}$
Serum creatinine	$1.5\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$ )	$0.6-1.2\text{ mg/dL}$
Serum bicarbonate	$16\text{ mEq/L}$	$22-28\text{ mEq/L}$

Diagnostic paracentesis performed in the emergency department yielded cloudy fluid with a leukocyte count of $850/\text{mm}^3$ ( $85\%$ neutrophils). Total protein in the ascitic fluid was $0.8\text{ g/dL}$ . Ascitic fluid cultures were sent, and the patient was empirically started on intravenous ceftriaxone.

Today, his temperature is $37.4^\circ\text{C}$ ( $99.3^\circ\text{F}$ ), blood pressure is $98/62\text{ mmHg}$ , and pulse is $92/\text{min}$ . He appears less confused. Urine output over the last 24 hours has been $600\text{ mL}$ .

Which of the following is the most appropriate additional step in the management of this patient?

Intravenous albumin infusionCevap
B
Addition of intravenous vancomycin
C
Arterial blood gas analysis
D
Computed tomography of the abdomen
E
Exploratory laparotomy

Cevap

Intravenous albumin infusion

The correct answer is intravenous albumin infusion. This patient has spontaneous bacterial peritonitis (SBP), diagnosed by an ascitic fluid absolute neutrophil count

>250/\text{mm}^3

(calculated as

850 \times 0.85 = 722/\text{mm}^3

). While third-generation cephalosporins (e.g., ceftriaxone) are the correct empiric antibiotic therapy, this patient is at high risk of developing hepatorenal syndrome (HRS), which occurs in up to 30% of SBP cases. The American Association for the Study of Liver Diseases (AASLD) recommends intravenous albumin (

1.5\text{ g/kg}

on day 1, and

1.0\text{ g/kg}

on day 3) for SBP patients who meet any of the following criteria: serum creatinine

>1.0\text{ mg/dL}

, blood urea nitrogen (BUN)

>30\text{ mg/dL}

, or total bilirubin

>4.0\text{ mg/dL}

. This patient meets all three criteria. Albumin expands the intravascular volume, improves renal perfusion, and significantly reduces both the incidence of HRS and overall mortality.

Adım Adım Çözüm

Diagnose Spontaneous Bacterial Peritonitis (SBP)

The patient has an ascitic fluid absolute neutrophil count > 250/mm³ (850 × 0.85 = 722/mm³).

To confirm the primary infection causing the patient's decompensation.

Assess the risk of Hepatorenal Syndrome (HRS)

The patient has markedly elevated BUN (34 mg/dL), creatinine (1.5 mg/dL), and total bilirubin (4.8 mg/dL).

To determine if adjunctive therapies are indicated to prevent acute kidney injury.

Apply guideline-based criteria for SBP management

The patient meets criteria for intravenous albumin therapy.

To expand intravascular volume, improve renal perfusion, and decrease the incidence of HRS and mortality.

Anahtar Kavram

Patients with spontaneous bacterial peritonitis (SBP) and concurrent evidence of renal dysfunction (Cr > 1.0 mg/dL, BUN > 30 mg/dL) or severe liver disease (Bilirubin > 4.0 mg/dL) require adjunctive intravenous albumin to prevent hepatorenal syndrome.

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Cevap

Adım Adım Çözüm

Anahtar Kavram

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