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Liver function tests: Hepatic

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Liver function tests:Hepatic. Megan Chan, PGY-1. ... Liver anatomy. Afferent vessels. Hepatic artery 30% of blood flow, oxygenated. Portal vein 70% of blood flow. – PowerPoint PPT presentation

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Title: Liver function tests: Hepatic


1
Liver function testsHepatic
  • Megan Chan, PGY-1
  • UHCMC 2015

2
Liver function
  • Bile synthesis secretion
  • Bilirubin production and excretion
  • Detoxification e.g. converts ammonia into urea
  • First pass metabolism
  • Phase 1 reaction via cytochrome P450 enzymes
  • Phase 2 reactionconjugation of substances
  • Kupffer cellsliver macrophages
  • Metabolic function
  • Gluconeogenesis, glycogen storage
  • Synthesis of plasma proteins, albumin, clotting
    factors, non-essential amino acids
  • Fatty acid oxidation, synthesis of cholesterol,
    lipoproteins

3
Liver anatomy
  • Afferent vessels
  • Hepatic artery30 of blood flow, oxygenated
  • Portal vein70 of blood flow
  • Efferent vessels
  • Bile duct
  • Central vein (aka Terminal hepatic vein)
  • Portal Triad
  • Bile duct Hepatic artery Portal vein

4
http//studydroid.com/imageCards/0a/k1/card-111431
24-back.jpg
5
Bilirubin
First Aid for USMLE Step 1
6
Guess the LFTs
7
Acute hepatitis
  • AST
  • Elevated
  • ALT
  • Elevated
  • Alk Phos
  • Normal
  • T bili
  • Normal

http//www.atsu.edu/faculty/chamberlain/Website/le
ctures/lecture/hepatit2.htm
8
Cirrhosis
  • AST
  • Normal/Elevated
  • ALT
  • Normal/Elevated
  • Alk Phos
  • Normal/Elevated
  • T bili
  • Normal/Elevated

http//hepatitiscnewdrugresearch.com/evaluation-st
aging-and-monitoring-of-chronic-hepatitis-c.html
9
Cirrhosis
  • As cirrhosis progresses, Total Bili increases
    because the liver can still conjugate bilirubin
    but cant excrete it.
  • MELD Score for 3 month mortality
  • Total bilirubin
  • Serum creatinine
  • INR
  • Dialysis

40 --71.3 mortality 30-39 52.6
mortality 20-29 19.6 mortality 10-19 6.0
mortality lt9 1.9 mortality
10
Child pugh score
  • Classification to assess severity of liver
    disease hepatic functional reserve

Points 1 2 3
Ascites None Controlled Uncontrolled
Bilirubin lt2.0 2.0-3.0 gt3.0
Encephalopathy None Minimal Severe
INR lt1.7 1.7-2.2 gt2.2
Albumin gt3.5 2.8-3.5 lt32.8
Classification A B C
Total points 5-6 7-9 10-15
1-yr survival 100 81 45
2-yr survival 85 57 35
11
Liver transplant
  • Evaluate when Child Class B or MELD 10
  • Indications
  • Recurrent/severe encephalopathy
  • Refractory ascites
  • SBP
  • Recurrent variceal bleeding
  • Hepatorenal or Hepatopulmonary syndrome
  • HCC if no single lesion gt 5cm or 3 lesions w/
    largest 3 cm
  • Fulminant hepatic failure
  • Contraindications
  • Advanced HIV, active substance abuse (ETOH w/in 6
    mo), sepsis, extrahepatic malignancy, severe
    comorbidity (esp cardiopulm), persistent
    non-compliance

12
Practice cases
13
Case 1
  • 65 y/o male with 25 year history of alcohol and
    tobacco abuse who presents with abdominal
    swelling and confusion. Pt reports an
    unintentional 15 lbs weight gain and frequent
    forgetfulness. On exam, pt is AO x1 (only to
    person), is slow to answer questions and often
    answers inappropriately. Pt has scleral icterus,
    distended abdomen with fluid wave, and several
    ecchymoses on his lower extremities. Slight
    asterixis is observed.
  • What is the most likely diagnosis?

14
Case 1
  • 65 y/o male with 25 year history of alcohol and
    tobacco abuse who presents with abdominal
    swelling and confusion. Pt reports an
    unintentional 15 lbs weight gain and frequent
    forgetfulness. On exam, pt is AO x1 (only to
    person), is slow to answer questions and often
    answers inappropriately. Pt has scleral icterus,
    distended abdomen with fluid wave, and several
    ecchymoses on his lower extremities. Slight
    asterixis is observed.
  • What is the most likely diagnosis?
  • Alcoholic Cirrhosis

15
Early/Late Cirrhosis
http//radiopaedia.org/cases/cirrhosis
16
Histology
  • Focal hepatocellular necrosis with 3
    characteristics
  • Fibrosis
  • Nodular regeneration
  • Distortion of hepatic architecture

http//tissupath.com.au/education-medical-student-
liver/
http//medchrome.com/basic-science/pathology/morph
ology-alcoholic-liver-disease/
17
liver stamp
  • Liver US with dopplers (for portal vein
    thrombosis)
  • ANA, Anti smooth muscle Ab (autoimmune)
  • Anti-mitochondrial Ab (primary biliary cirrhosis)
  • Ceruloplasmin (Wilsons)
  • Ferritin Iron studies w/ TIBC (Hemochromatosis)
  • HepBs Ag, HepBs Ab, HepBc Ab
  • HepC Ab, HepC PCR
  • Alpha-antitrypsin

18
liver stamp
Average cost?
1,200
19
cirrhosis Etiology
  • Fatty liver diseases
  • Alcoholic liver disease
  • NASH/NAFLD
  • Viral hepatitis Hep B, C, D
  • Autoimmune
  • Autoimune hepatitis
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Cardiovascular
  • Budd-Chiari syndrome
  • Chronic right heart failure
  • Chronic biliary disease
  • Recurrent bacterial cholangitis
  • Bile duct stenosis
  • Storage diseases
  • Hemochromatosis
  • Wilson disease
  • a-1-antitrypsin deficiency
  • Meds APAP toxicity, MTX
  • Cryptogenic 10-15

20
Diagnostic imaging
  • Ultrasound
  • Surface nodularity 88 sensitive, 82-95
    specific (1)
  • Coarse heterogeneous echotexture
  • Signs of portal HTN
  • Portal vein gt13mm 42 sensitive, 95-100
    specific (2)
  • Splenomegaly, ascites
  • CT insensitive in early cirrhosis
  • MRI also insensitive in early cirrhosis, but
    significant role in assessing small
    hepatocellular carcinoma (HCC)develops in 10-25
  • Liver biopsy gold standard for diagnosis

21
Treatment
  • Ascites
  • Furosemide Spironolactone with goal negative
    1L/day (80 effective)
  • Lasix Aldactone ratio of 25 helps maintain K
    (thus Lasix 40mg qday, Aldactone 100mg qday
    initially)
  • Low-sodium diet (1-2 g/day)
  • Refractory Ascites no response on max doses of
    Lasix (160mg) Aldactone (400mg)
  • LVP 4-6L (does not improve mortality)
  • Albumin replacement controversial. AASLD 2009
    guidelines recommend if gt5L removed, provide 6-8
    g/L of albumin 25 (IIA, Grade C)
  • If gt5L removed, can have post-paracentesis
    circulatory dysfxn via RAAS activation
  • TIPS (? ascites in 75, improves mortality but ?
    HE, 40 need revision for stent stenosis)
  • Hepatic encephalopathy
  • Lactulose
  • Hepatorenal syndrome
  • Transplantation

22
Case 2
  • 57 y/o known HepC cirrhotic presents with
    malaise, fevers and chills. Her husband reports
    she has been intermittently confused over the
    past few days despite taking her lactulose. Exam
    shows significant ascites and diffuse abdominal
    tenderness to palpation. Diagnostic paracentesis
    reveals straw-colored fluid with pH lt 7.3, WBC
    1000 with 70 PMNs, glucose 35, total protein 30.
    SAAG is calculated to be 1.5.
  • What is the most likely diagnosis?

23
Case 2
  • 57 y/o known HepC cirrhotic presents with
    malaise, fevers and chills. Her husband reports
    she has been intermittently confused over the
    past few days despite taking her lactulose. Exam
    shows significant ascites and diffuse abdominal
    tenderness to palpation. Diagnostic paracentesis
    reveals straw-colored fluid with pH lt 7.3, WBC
    1000 with 70 PMNs, glucose 35, total protein 30.
    SAAG is calculated to be 1.5.
  • What is the most likely diagnosis?
  • Spontaneous Bacterial Peritonitis (SBP)

24
Sbp
  • Develops in 20 cirrhotics, 10-25
    asymptomatic, 20 mortality
  • Risk factors
  • AFTP lt 1 g/dL, current GIB, hx of SBP,
    Lines/catheters, Childs C cirrhosis, fulminant
    hepatic failure
  • Culture can be negative in 30-50, Gram stain
    in only 5-10
  • 70 is GNR (E.coli, Klebs), 30 GPC (S. pneumo,
    Enterococcus)

25
SBP
  • Treatment
  • Cefotaxime 2gm IV q8hrs x 5 days, Norfloxacin PO
    in uncomplicated SBP
  • IV albumin 1.5g/kg at time of dx then 1g/kg on
    day 3 (? survival and ? renal impairment)
  • If no improvement, repeat para at 48 hrs (25 ?
    PMN count tx success)
  • Prophylaxis
  • GI bleeds Norfloxacin 400mg PO q12 hrs
  • Hx of SBP Norfloxacin400mg qd, Cipro 750mg qwk,
    Bactrim DS qd (? 1 yr recurrence from 70 to 20,
    ? survival)

http//medicine.ucsf.edu/education/resed/Chiefs_co
ver_sheets/SBP,20cirrhosis,20empyema.pdf
26
ASCITES Pathophysiology
  • Also
  • 1. Hypoalbuminemia ? ? serum oncotic pressure
  • 2. ? hepatic lymph ? ? splanchnic pressure

http//medical-dictionary.thefreedictionary.com/as
cites
27
PARACENTESIS
  • What tests would you send?
  • 4 Cs Cells, Culture, Chemistry, Cytology
  • Cell count and differential, gram stain, culture,
    albumin, total protein, glucose, LDH, cytology
  • Optional amylase, bilirubin, Cr, TG, AFB cx
    adenosine deaminase
  • How do you calculate the SAAG?
  • SAAG Serum albumin Ascites albumin
  • What does the SAAG indicate?
  • If 1.1 g/dL, portal HTN is very likely (97
    accurate1)
  • If lt 1.1 g/dL, portal HTN is unlikely.

Runyon et al. The serum-ascites albumin gradient
is superior to the exudates-transudate concept in
the differential diagnosis of ascites. Annals of
Internal Medicine 1992 117215-20.
28
Paracentesis
  • SAAG 1.1
  • SAAG lt 1.1
  • Peritonitis TB, ruptured viscus
  • Peritoneal carcinomatosis
  • Pancreatitis
  • Vasculitis
  • Hypoalbuminemia (e.g. nephrotic syndrome)
  • Meigs syndrome (ovarian tumor)
  • Bowel obstruction/infarction
  • Post-op lymphatic leak
  • Sinusoidal
  • Cirrhosis(81), SBP
  • Acute hepatisis
  • Extensive malignancy (HCC/mets, 10)
  • Postsinusoidal
  • R heart failure (3)
  • Budd-Chiari Syndrome
  • Presinusoidal
  • Portal/splenic vein thrombosis

Runyon et al. The serum-ascites albumin gradient
is superior to the exudates-transudate concept in
the differential diagnosis of ascites. Annals of
Internal Medicine 1992 117215-20.
29
Paracentesis
  • Ascites fluid total protein (AFTP) useful when
    SAAG 1.1
  • Cirrhosis (AFTP lt 2.5) vs Cardiac ascites (AFTP gt
    2.5)
  • Bloody fluid 50 with HCC, 22 with malignancy
  • For traumatic taps, subtract 1 PMN for every 250
    RBC.
  • Cell count PMN 250 cells/µL SBP (93
    sensitivity, 94 specificity)
  • Total protein lt 1 g/dL ? high risk for SBP
  • Glucose ? in infection and malignancy
  • LDH ? in infection and malignancy
  • Amylase (fluid/serum ratio gt 0.4) pancreatitis,
    gut perforation
  • TG gt 1000 in chylous ascites
  • Cytology overall sensitivity 58-75
  • However 100 sensitive in peritoneal
    carcinomatosis (2/3 of malignant-related ascites)

Runyon et al. The serum-ascites albumin gradient
is superior to the exudates-transudate concept in
the differential diagnosis of ascites. Annals of
Internal Medicine 1992 117215-20.
30
Bacterial Peritonitis
Type Ascites Cell Count Ascites Culture
Sterile lt 250 PMNs Neg
Spontaneous bacterial peritonitis (SBP) 250 PMNs (1 organism)
Culture neg neutrocytic ascites (CNNA) 250 PMNs Neg
Nonneutrocytic bacterascites (NNBA) lt 250 PMNs (1 organism)
Secondary 250 PMNs (polymicrobial)
Peritoneal dialysis-associated 100, PMNs predom
31
Case 3
  • 35 y/o male presents with fatigue and tea-colored
    urine for 5 days. Exam reveals jaundice and
    tender heaptomegaly but is otherwise
    unremarkable. Labs are significant for AST 2400,
    ALT 2640, Alk Phos 210, and Total Bilirubin 8.6.
  • Which of the following is least likely to cause
    this clinical picture?
  • Acute hepatitis A infection
  • Acute hepatitis B infection
  • Acute hepatitis C infection
  • Acetaminophen ingestion
  • Budd-Chiari Syndrome

32
Case 3
  • Which of the following is least likely to cause
    this clinical picture?
  • Acute hepatitis A infection
  • Acute hepatitis B infection
  • Acute hepatitis C infection
  • Acetaminophen ingestion
  • Budd-Chiari Syndrome
  • Extreme elevations in transaminases usually fall
    into 3 major categories viral infections, toxic
    ingestions, and vascular/hemodynamic causes
    (shock liver). Hep C does not typically cause
    acute infection.

33
Case 4
  • 24 y/o patient is admitted to the MICU with
    obtundation and jaundice over 1-2 days. No
    further history is available. The following labs
    are obtained
  • Total Bili 7.2, Direct Bili 4.0, AST 1478, ALT
    1056, Alk Phos 132, INR 3.1, Albumin 3.6.
  • All of the following tests are indicated except?
  • Antinuclear Ab (ANA)
  • Ceruloplasmin
  • Hepatitis B surface Ag
  • ERCP
  • Toxicology screen

34
Case 4
  • All of the following tests are indicated except?
  • Antinuclear Ab (ANA)
  • Ceruloplasmin
  • Hepatitis B surface Ag
  • ERCP
  • Toxicology screen
  • When evaluating a patient with jaundice, initial
    steps include determining whether the
    hyperbilirubinemia is predominantly unconjugated
    or conjugated and whether there is any other
    evidence for hepatobiliary dysfxn. Next is to
    discriminate into a predominantly cholestatic or
    hepatocellular pattern. In this case, the pt has
    a hepatocellular pattern with AST/ALT elevated
    out of proportion to Alk Phos.

35
Harrisons Internal Medicine
36
Case 5
  • 41 y/o male who presents to your clinic with a
    week of jaundice. He notes pruritus, icterus,
    and dark urine. He denies fever or abdominal
    pain. Exam is unremarkable except for jaundice.
  • Labs Total bili 6.0 , direct bili 5.1, AST 84 ,
    ALT 92, Alk phos 662.
  • CT scan of abdomen is unremarkable. RUQ
    ultrasound shows a normal bile duct but does not
    visualize the common bile duct.
  • What is the most appropriate next management
    step?
  • Antibiotics and observation
  • ERCP
  • Hepatic serologies
  • HIDA scan
  • Serologies for antimitochondrial Ab

37
Case 5
  • What is the most appropriate next management
    step?
  • Antibiotics and observation
  • ERCP
  • Hepatic serologies
  • HIDA scan
  • Serologies for antimitochondrial Ab
  • Anatomic abnormalities are more common when there
    is a cholestatic pattern of injury (Alk Phos
    elevated out of proportion to AST/ALT). Painless
    jaundice always requires extensive workup with
    concern for malignant causes (e.g.
    cholangiocarcinoma, tumor of ampulla of vater) vs
    nonmalignant causes (e.g. primary sclerosing
    cholangitis), which may only be detected by
    direct visualization with ERCP. Negative CT does
    not rule out source of cholestatis in biliary
    tree. Furthermore, ERCP is useful therapeutically
    with stenting to alleviate the obstruction.

38
Harrisons Internal Medicine
39
Case 6
  • 61 y/o male is admitted to your service for new
    onset ascites. You perform a paracentesis with
    the following results of the non-bloody
    peritoneal fluid
  • WBC 300 with 35 PMNs, albumin 1.2, protein 2.6,
    TG 320
  • Peritoneal cultures are pending. Serum albumin
    2.7.
  • Which of the following is the most likely
    diagnosis?
  • Peritoneal tuberculosis
  • Peritoneal carcinomatosis
  • Congestive heart failure
  • Bacterial peritonitis
  • Chylous ascites

40
Case 6
  • Which of the following is the most likely
    diagnosis?
  • Peritoneal tuberculosis
  • Peritoneal carcinomatosis
  • Congestive heart failure
  • Bacterial peritonitis
  • Chylous ascites
  • SAAG 1.5, AFTP 2.6 ? Cardiac ascites
  • Low WBC and PMNs make SBP and TB less likely

41
Case 7
  • An alcoholic cirrhosis patient has increasing
    ascites despite dietary sodium control and
    diuretics. A paracentesis shows clear, turbid
    fluid. There are 2300 WBCs and 150 RBC.
    Differential shows 75 lymphocytes. Fluid
    protein is 3.2 and SAAG is 1.0.
  • What is the most appropriate next test?
  • Adenosine deaminase activity of ascitic fluid
  • CT scan of liver
  • Peritoneal biopsy
  • None consider transplant evaluation

42
Case 7
  • What is the most appropriate next test?
  • Adenosine deaminase activity of ascitic fluid
  • CT scan of liver
  • Peritoneal biopsy
  • None consider transplant evaluation
  • In pts with chronic cirrhosis who develop new or
    worsening ascites without dietary or medication
    nonadherence, consider an occult disorder (e.g.
    peritoneal TB, HCC, portal vein thrombosis). ?
    WBC is more common in neoplasm, bacterial
    peritonitis, or TB. Predominance of lymphocytes
    raises the suspicion for TB. SAAG is classically
    low in TB peritonitis but can be elevated in
    concomitant cirrhosis/transudative ascites. The
    sensitivity of ADA is poor in those with
    cirrhosis 2/2 poor T cell-mediated response. Thus
    peritoneal biopsy or visual diagnosis during
    laparoscopy is likely needed to confirm the
    diagnosis.

43
Paracentesis
  • SAAG 1.1
  • SAAG lt 1.1
  • Peritonitis TB, ruptured viscus
  • Peritoneal carcinomatosis
  • Pancreatitis
  • Vasculitis
  • Hypoalbuminemia (e.g. nephrotic syndrome)
  • Meigs syndrome (ovarian tumor)
  • Bowel obstruction/infarction
  • Post-op lymphatic leak
  • Sinusoidal
  • Cirrhosis(81), SBP
  • Acute hepatisis
  • Extensive malignancy (HCC/mets, 10)
  • Postsinusoidal
  • R heart failure (3)
  • Budd-Chiari Syndrome
  • Presinusoidal
  • Portal/splenic vein thrombosis

Runyon et al. The serum-ascites albumin gradient
is superior to the exudates-transudate concept in
the differential diagnosis of ascites. Annals of
Internal Medicine 1992 117215-20.
44
When to Tap/REtap
  • New ascites
  • Admission of all patients with cirrhotic ascites
  • Deterioration in clinical status
  • Complication of cirrhosis (GI bleed, confusion)
  • Polymicrobial culture or culture with PMN lt 250
    (MNB that may be early SBP)
  • Retap 24-48 hrs after treatment started in pts
    with PMNgt 1000 (associated with 88 mortality) or
    lack of improvement.

http//medicine.ucsf.edu/education/resed/Chiefs_co
ver_sheets/SBP,20cirrhosis,20empyema.pdf
45
Case 8
  • When evaluating a patient with chronic ascites, a
    SAAG gt 1.1 is consistent with all of the
    following diagnoses except?
  • Cirrhosis
  • Congestive heart failure
  • Constrictive pericarditis
  • Hepatic vein thrombosis
  • Nephrosis

46
Case 8
  • When evaluating a patient with chronic ascites, a
    SAAG gt 1.1 is consistent with all of the
    following diagnoses except?
  • Cirrhosis
  • Congestive heart failure
  • Constrictive pericarditis
  • Hepatic vein thrombosis
  • Nephrosis

47
Paracentesis
  • SAAG 1.1
  • SAAG lt 1.1
  • Peritonitis TB, ruptured viscus
  • Peritoneal carcinomatosis
  • Pancreatitis
  • Vasculitis
  • Hypoalbuminemia (e.g. nephrotic syndrome)
  • Meigs syndrome (ovarian tumor)
  • Bowel obstruction/infarction
  • Post-op lymphatic leak
  • Sinusoidal
  • Cirrhosis(81), SBP
  • Acute hepatisis
  • Extensive malignancy (HCC/mets, 10)
  • Postsinusoidal
  • R heart failure (3)
  • Budd-Chiari Syndrome
  • Presinusoidal
  • Portal/splenic vein thrombosis

Runyon et al. The serum-ascites albumin gradient
is superior to the exudates-transudate concept in
the differential diagnosis of ascites. Annals of
Internal Medicine 1992 117215-20.
48
http//image.slidesharecdn.com/complicationsofcirr
hosis-100914093820-phpapp02/95/complications-of-ci
rrhosis-18-728.jpg?cb1284460955
49
Case 9
  • 28 y/o woman who is 30 weeks pregnant presents
    with 2 week history of pruritus and scleral
    icterus. It is her first pregnancy, and she has
    no significant medical hx. She does not drink
    alcohol and takes only a prenatal vitamin.
    Vitals are stable. Exam reveals a gravid uterus,
    mild scleral icterus and linear excoriations on
    the skin. There is no ascites or lower extremity
    edema.

50
Case 9
  • Labs reveal
  • Hb 13.4 Platelet 275.000
  • AST 44, ALT 38, Total Bili 4.2, Direct Bili 2.3,
    Alk Phos 180
  • LDH 82, INR 1.0
  • Hep Bs Ag Neg, Hep Bs Ab Positive,
  • Hep C Ab Neg, Hep A Ab (IgG) Positive
  • ANA negative, Anti-smooth muscle Ab neg
  • Ultrasound of the liver is normal.

51
Case 9
  • Which of the following is the most likely
    diagnosis?
  • Acute fatty liver of pregnancy
  • Acute hepatitis A infection
  • Cholestasis of pregnancy
  • HELLP syndrome

52
Case 9
  • Which of the following is the most likely
    diagnosis?
  • Acute fatty liver of pregnancy
  • Acute hepatitis A infection
  • Cholestasis of pregnancy
  • HELLP syndrome
  • Cholestasis of pregnancy is the most common
    pregnancy-related liver disorder that is benign
    for the mother but increases risk for pre-term
    delivery and fetal loss if untreated. It often
    presents in the 2nd or 3rd trimester of pregnancy
    and treatment is with ursodeoxycholic acid for
    symptomatic treatment.
  • In contrast acute fatty liver occurs in the 3rd
    trimester and is associated with high AST/ALT,
    high bilirubin and fat on liver US.
  • HELLP syndrome is part of spectrum of
    eclampsia/pre-eclampsia and presents with HTN,
    hemolytic anemia, proteinuria high AST/ALT,
    thrombocytopenia. It occurs during 3rd trimester
    and up to 48 hrs postpartum. Tx is delivery of
    the baby.

53
Case 10
  • 45y/o male admitted for 2 day hx of fever and
    abdominal pain. Medical hx is notable for HepC
    cirrhosis and esophageal varices. Medications
    include furosemide, spironolactone, nadolol, and
    lactulose. Pt is afebrile, BP 100/50, HR 84.
    Abdominal exam is consistent with ascites and is
    nontender to palpation.
  • Labs Hb 10, WBC 3500, Plt 70,000, INR 1.5,
    Albumin 2.5, Alk Phos 220, AST 40, ALT 30, T bili
    4, Cr 1.8, UA normal.
  • Abdominal US shows cirrhosis, spenomegaly,
    ascites. Portal hepatic veins are patent.
    Diagnostic paracentesis shows WBC 2000 with 20
    PMNs, Total protein 1, Albumin 0.7.
  • Which of the following is the most appropriate
    treatment?
  • Cefotaxime
  • Cefotaxime and albumin
  • Furosemide and spironolactone
  • LVP
  • Observation

54
Case 10
  • Which of the following is the most appropriate
    treatment?
  • Cefotaxime
  • Cefotaxime and albumin
  • Furosemide and spironolactone
  • LVP
  • Observation
  • In patients with SBP, the concomitant use of IV
    albumin with antibiotic therapy is associated
    with a survival benefit compared with antibiotic
    therapy alone.

55
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  • http//medicine.ucsf.edu/education/resed/Chiefs_co
    ver_sheets/SBP,20cirrhosis,20empyema.pdf
  • http//radiopaedia.org
  • Special thanks to Dr. Caroline Soyka for the
    inspiration!
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