A 54-year-old man with a history of alcoholic cirrhosis and esophageal varices is brought … — USMLE Step 3

A 54-year-old man with a history of alcoholic cirrhosis and esophageal varices is brought to the emergency department by his wife due to worsening confusion, subjective fever, and increasing abdominal distension over the past 48 hours. His home medications include spironolactone, furosemide, propranolol, and lactulose, though his wife reports he has refused to take them for the last three days. His temperature is $38.2^\circ\text{C}$ ( $100.8^\circ\text{F}$ ), blood pressure is $88/54\text{ mmHg}$ , heart rate is $112/\text{min}$ , and respiratory rate is $18/\text{min}$ . Physical examination reveals scleral icterus, marked ascites with shifting dullness, and diffuse mild abdominal tenderness without rebound. He is lethargic and exhibits asterixis.

Laboratory results are as follows:

Laboratory Parameter	Result	Reference Range
Leukocytes	$14,500/\mu\text{L}$	$4,500-11,000/\mu\text{L}$
Platelets	$78,000/\mu\text{L}$	$150,000-400,000/\mu\text{L}$
Total bilirubin	$4.5\text{ mg/dL}$	$0.1-1.2\text{ mg/dL}$
Blood urea nitrogen	$38\text{ mg/dL}$	$8-20\text{ mg/dL}$
Serum creatinine	$2.1\text{ mg/dL}$	$0.6-1.2\text{ mg/dL}$

Baseline serum creatinine from three weeks ago was $0.9\text{ mg/dL}$ . Diagnostic paracentesis yields cloudy ascitic fluid with a total leukocyte count of $850/\mu\text{L}$ and a neutrophil count of $520/\mu\text{L}$ .

In addition to judicious fluid resuscitation, which of the following pharmacologic interventions should be included in this patient's immediate management plan? (Select all that apply)

Intravenous cefotaximeCevap
Intravenous albuminCevap
Enteral lactuloseCevap
D
Intravenous furosemide
E
Enteral propranolol

Cevap

Intravenous cefotaxime, intravenous albumin, and enteral lactulose

The correct combination of interventions addresses all aspects of this patient's decompensated cirrhosis. He has Spontaneous Bacterial Peritonitis (SBP), diagnosed by an ascitic neutrophil count > 250/μL, requiring immediate empiric therapy with a third-generation cephalosporin (intravenous cefotaxime). Because his SBP is complicated by acute kidney injury (creatinine > 1.0 mg/dL, BUN > 30 mg/dL, bilirubin > 4.0 mg/dL), he is at high risk for hepatorenal syndrome; intravenous albumin is proven to reduce renal impairment and mortality in this specific scenario. Lastly, his lethargy and asterixis indicate acute hepatic encephalopathy, making the re-initiation of enteral lactulose necessary.

Adım Adım Çözüm

Diagnose the primary acute complication based on paracentesis.

The ascitic fluid neutrophil count is > 250/μL, confirming Spontaneous Bacterial Peritonitis (SBP).

SBP requires immediate empiric antibiotics (e.g., IV cefotaxime or ceftriaxone) to reduce mortality.

Assess the patient's renal function and hemodynamic status.

The patient has severe acute kidney injury (creatinine up to 2.1 mg/dL from 0.9 mg/dL), hypotension (88/54 mmHg), and meets criteria for high-risk SBP (BUN > 30 mg/dL, bilirubin > 4.0 mg/dL).

High-risk SBP complicated by AKI necessitates the administration of intravenous albumin (1.5 g/kg on day 1, 1 g/kg on day 3) to mitigate the risk of hepatorenal syndrome and improve survival.

Evaluate the patient's neurologic status.

The patient is lethargic with asterixis, indicating Hepatic Encephalopathy (HE).

HE requires treatment with ammonia-lowering agents, such as enteral lactulose.

Review home medications for absolute contraindications in the current clinical context.

Identify that both furosemide (a diuretic) and propranolol (a non-selective beta-blocker) are contraindicated.

Diuretics and beta-blockers worsen renal perfusion and systemic hemodynamics in decompensated cirrhosis with sepsis/AKI and must be temporarily discontinued.

Anahtar Kavram

Management of spontaneous bacterial peritonitis (SBP) complicated by acute kidney injury requires empiric antibiotics, intravenous albumin, and the cessation of diuretics and non-selective beta-blockers.

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