SBP

Today we talked about a young patient who came in with abdominal pain and encephalopathy in the setting of cirrhosis and ascites.

See the previous post on the approach to this patient's Ascites from block 2



Today we discussed the importance of considering SBP on the differential when:
- any cirrhotic pt is admitted to the hospital (regardless of reason)
- pt wiht ascites has a GI bleed
-pt with ascites  has abdo pain, nausea/vomiting/diarrhea, leukocytosis, encephlopathy

thus do a diagnostic tap
look for: Ascites PMN > 250 or WBC > 500 

BUT--If WBC > 1000 or polymicrobial culture or protein > 10g/L, suspect secondary peritonitis, perforation, abscess etc

Treatment of SBP includes antibiotics (3rd gen cephlosporin or cipro) and albumin if renal failure is a concern (see this NEJM article on use of albumin in SBP)

hypoglycemia and ascites

Tuesday we started off the block with talking about hypoglycaemia in a non diabetic patient.

Our key "testable" points in the work up:

1. Cpeptide and insulin are BOTH high if endogenous insulin is secreted. 

2. Cpeptide is LOW if when insulin level is high, exogenous insulin. 

2. Sulphonurea increase ENDO insulin so this has to be ruled out before you go searching for a rare tumour

Remember; glucagon 1mg sub cut or IM or IV is a good treatment of hypoglycaemia. 

Today we talked about a case of a young lady with liver disease and ascites.

Some key points for ascites physical exam:

Most sensitive findings (if they are not there, may be able to rule out)

On history:

1. increased abdo girth, 

2. weight gain, 

3. ankle swelling

On exam:

1. flank dullness

2. shifting dullness

3. bulging flanks

4. leg edema

In looking at a patient with new ascites look for:

1) signs of decompensated liver disease : scleral icterus, jaundice, edema (low albumin), asterixis (encepalopathy)

2) signs of chronic liver disease: parotid changes, temporal wasting, muscle wasting, spider nevi, gynecomastia

3) Causes of the livery disease: cardiac exam such  as TR murmur, chf, Lymph nodes, 

CNS (wilson's disorder movement disorder),etc - this is a pretty wide differential.

Here is a reminder of how liver function tests decline over time:

Here is a link to the jama article on ascites.