Decompensated cirrhosis/ Ascites / SBP

  • Duration: ___ days

  • CC: ___ Abdominal distention/girth/pain ± Fever and Confusion

  • Onset: sudden / gradual

  • Course: constant / intermittent

  • Progression: worsening / improving / unchanged

  • Assoc sx: early satiety, bloating, weight gain, dyspnea, (±): fever, chills

  • Pertinent negatives: denies GI bleeding, urinary symptoms (±): fever, chills

  • Pertinent Exam: distended abdomen with shifting dullness, diffuse tenderness, jaundice/scleral icterus, asterixis (HE), peripheral edema

  • Pertinent Data: (initial)

    • CBC – leukocytosis (SBP), anemia (GI bleed), thrombocytopenia (portal HTN)

    • BMP – renal function (AKI/HRS), Na (hyponatremia), Lytes abnormalities

    • LFTs – AST/ALT (injury), ALP, bilirubin (cholestasis/severity)

    • INR/PT – synthetic liver function (coagulopathy)

    • Albumin – low = poor synthetic function

    • Ammonia (if AMS) – hepatic encephalopathy (supportive, not diagnostic)

    • Blood cultures – bacteremia if febrile/SBP suspected

    • Diagnostic paracentesis: cell count/(PMN), culture, albumin, total protein

    • Urinalysis + urine culture if symtpmatic

    • Serum albumin for SAAG calculation

    • Serum lactate – if concern sepsis

    • RUQ ultrasound + Doppler – cirrhotic morphology, ascites, portal vein flow (thrombosis)

    • CXR – infection, hepatic hydrothorax

    • Consider CT abdomen – if unclear diagnosis, malignancy, or complication

  • Pertinent PMH/SH/FH: cirrhosis (date), Decompensation Hx: (VIBES), substance use, adherence to meds,

  • Pertinent Home meds: lasix/spironolactone

  • Hospital course to date:

  • Child-Pugh and MELD(-Na) scores

Plan

  • F/U ordered labs and imaging

  • Hold home diuretics if Cr up >50% or Na <130

  • Hold home BB , NSAIDs (AKI risk), opioids/benzos (HE), metformin/statins (hepatic injury).

  • diagnostic paracentesis in all patients ( cell count/(PMN),culture, albumin, total protein) Add-ons if indicated (Glucose/LDH , cytology, amylase, AFB/ADA (TB).

  • Serum albumin (for SAAG calculation)

  • SAAG (Serum albumin − Ascites albumin) ≥1.1 g/dL without HF, portal/hepatic vein thrombosis) and low protein (<1.5-2.5 g/dL)

  • tx SBP if neutrophil count ≥250/mm

  • Dietary modifications for reduce fluid retention-> Sodium (<2 g/day) in all

  • large volume paracentesis if tense ascites, Albumin (25%) 6–8 per liter of ascites removed after large-volume paracentesis (>5 L)

  • Spironolactone for primary diuretic + furosemide (100:40 ratio) to maintain potassium balance.

  • trend electrolytes and replete

  • Consider TIPS, requiring multiple paracenteses despite optimized diuretics

  • Refer to hepatology if pt dose not already have one

  • follow needed q 6 months with US for early detection of HCC

  • discussed lifestyle modification and alcohol cessation

    + SBP

  • treated with ceftriaxone 1 g IV daily for 5–7 days

  • if no improvement within 48 hours, or Repeat para show failure of PMNs to decrease by at least 25%. resistant organisms should be considered and broader coverage needed with meropenem

  • During SBP treatment, albumin is given at 1.5 g/kg on day 1 and 1 g/kg on day 3 to reduce the risk of hepatorenal syndrome

  • place on lifelong Prophylaxis due to ≥1 prior SBP episode with ciprofloxacin 500 mg daily or trimethoprim-sulfamethoxazole one double-strength tablet daily

Decompensation Hx: (VIBES)
-- Volume/Ascites: prior LVP, frequency, salt restriction on lasix/spironolactone
-- Infection/SBP: prior infections, h/o low protein ascites, on ppx
-- Bleeding/EV: last EGD, prior bleeds, banding, on nadolol/PPI
-- Encephalopathy/HE: prior decompensation, on lactulose/rifaximin, BM/day
-- Screening/HCC: last screen, AFP; if nodule >1cm get multiphase CT or MRI