Fever and ascites in decompensated cirrhosis
A 52-year-old man with alcohol-related cirrhosis (Child–Pugh class C, MELD 22) is admitted with two days of fever, diffuse abdominal discomfort and increasing girth. He has had three large-volume paracenteses in the past two months. His medications are spironolactone 100 mg, furosemide 40 mg, propranolol 40 mg twice daily, and ramipril 5 mg and ibuprofen 400 mg three times daily, both started by his GP a month ago for back pain. Temperature 38.4 °C, blood pressure 96/58 mmHg, pulse 96, no encephalopathy. The abdomen is distended with shifting dullness and mild diffuse tenderness without guarding. Sodium 127 mmol/L, potassium 5.3 mmol/L, creatinine 148 µmol/L (baseline 90), bilirubin 62 µmol/L, albumin 26 g/L, INR 1.6, CRP 88 mg/L. Diagnostic paracentesis: 900 neutrophils/mm³, no organisms on Gram stain.
1. Interpret the ascitic fluid. What is the diagnosis and what is your immediate pharmacological management, with doses?
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An ascitic neutrophil count of 900/mm³ is above the 250/mm³ threshold, so this is spontaneous bacterial peritonitis, even with a negative Gram stain and regardless of culture result. It is a medical emergency: untreated mortality is high.
Immediate treatment.
- Empirical antibiotics: cefotaxime 2 g IV every 8 hours, or ceftriaxone 2 g IV daily, for 5–7 days; adjust to culture and sensitivities. Avoid aminoglycosides (nephrotoxic in cirrhosis). Cover for resistant organisms if he has had recent hospital exposure or prior SBP prophylaxis.
- Intravenous albumin: 1.5 g/kg on day 1 and 1 g/kg on day 3. He qualifies for this because creatinine is >88 µmol/L (and bilirubin >4 mg/dL). Albumin reduces the incidence of type 1 hepatorenal syndrome and improves survival.
- Send blood cultures, repeat diagnostic tap if he fails to improve at 48 hours (to exclude secondary peritonitis), and give vitamin K and thiamine.
- Consider a further therapeutic paracentesis for symptomatic relief, with albumin cover if >5 L is removed.
2. Review his medication list: what should be stopped, what should be continued, and why?
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Stop ibuprofen. Prostaglandin inhibition causes afferent arteriolar constriction; in a patient with splanchnic vasodilatation and a marginal effective circulating volume this precipitates renal failure and diuretic resistance, and NSAIDs also increase GI bleeding risk with varices.
Stop ramipril. ACE inhibition blunts the angiotensin II–mediated efferent arteriolar tone that is maintaining his glomerular filtration pressure. In decompensated cirrhosis it is a recognised precipitant of acute kidney injury.
Hold diuretics while he is hypotensive, infected and developing AKI with hyponatraemia and hyperkalaemia; restart at reduced doses once blood pressure and renal function recover and he is passing urine.
Hold propranolol for now: he is hypotensive with a pulse of 96 and it may impair his ability to mount a compensatory response. Reintroduce at a low dose for variceal prophylaxis once he is stable - do not abandon it permanently.
Continue thiamine, vitamins and nutrition support; refer to alcohol liaison and dietetics, and give a proton-pump inhibitor only if there is a genuine indication.
3. Forty-eight hours later he is still febrile. Urine output is 0.4 mL/kg/hour, creatinine has risen to 230 µmol/L, blood pressure 92/54 mmHg and repeat ascitic neutrophils are 700/mm³. How do you manage him now?
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He has persistent SBP with hepatorenal syndrome–AKI. Check that the antibiotic is appropriate (repeat culture and sensitivities, exclude secondary peritonitis with imaging if air or multiple organisms), stop all nephrotoxins, and exclude other causes - hypovolaemia, sepsis elsewhere, obstruction (ultrasound), glomerulonephritis, and dehydration from over-diuresis.
Treatment.
- Terlipressin plus albumin: terlipressin 1 mg IV every 4–6 hours or a continuous infusion, titrated to response, with albumin 1 g/kg on day 1 then 20–40 g daily. Noradrenaline plus albumin in a critical-care setting is an alternative with comparable efficacy. Confirm there is no ischaemic heart disease, arrhythmia or peripheral vascular disease before starting terlipressin, and monitor for hyponatraemia, fluid overload and ischaemic complications.
- Continue the current antibiotics to complete the course, keep diuretics and beta-blockers off, and consider a urinary catheter to measure output accurately.
- Refer for consideration of liver transplantation - HRS in a transplant-eligible patient is time-critical; if he is not eligible, discuss ceilings of care and palliative input early with the family.
Prevention next time. After recovery, start secondary SBP prophylaxis (norfloxacin 400 mg daily or ciprofloxacin 500 mg weekly, according to local resistance patterns) and reassess variceal prophylaxis and nutrition.