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Cefotaxime
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Ceftriaxone
Furosemide
Right upper quadrant ultrasound
Transjugular intrahepatic portosystemic shunt
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This patient with a history of cirrhosis who presents with abdominal pain, confusion, fever, and ascites with an ascitic fluid cell count of more than 250 PMNs/µL most likely has spontaneous bacterial peritonitis (SBP). The first-line treatment for SBP is cefotaxime because this drug is renally excreted.SBP is an acute bacterial infection of the peritoneum most commonly caused by Escherichia coli, Klebsiella pneumoniae, or Streptococcus pneumoniae. SBP is strongly associated with cirrhosis and other etiologies of portal hypertension because the accumulation of fluid in the peritoneum increases the risk for developing this disorder. Symptoms of SBP include confusion, abdominal pain, fever, vomiting, and diarrhea. Physical exam in SBP may demonstrate fever, abdominal tenderness, ascites, and flank dullness. A neutrophil count ≥ 250 PMNs/µL in the ascitic fluid confirms a diagnosis of SBP. The first-line treatment for SBP is cefotaxime because this drug undergoes renal clearance. Other antibiotics are not as effective because hepatic metabolism is likely impaired in patients with cirrhosis. Complications of SBP include renal failure and sepsis.Dever et al. review the evidence regarding the diagnosis and treatment of SBP. They discuss how third-generation cephalosporins are the first-line treatment. They recommend using piperacillin-tazobactam therapy in patients who do not improve on these first-line treatments.Figure/Illustration A is a clinical photograph demonstrating significant abdominal distention (red circle). Painful distention in the setting of cirrhosis is most likely due to peritonitis.Incorrect Answers:Answer 2: Ceftriaxone may be used to treat SBP; however, it is hepatically metabolized and hepatic metabolism is impaired in patients with cirrhosis. When both cefotaxime and ceftriaxone are available, cefotaxime is preferred due to its renal clearance.Answer 3: Furosemide is a loop diuretic that is used in patients with evidence of volume overload to relieve vascular congestion. Patients with cirrhosis are often put on a regimen of furosemide and spironolactone to alleviate the volume overload associated with portal hypertension. Though this patient has evidence of volume overload on exam with ascites and a distended abdomen, his condition requires antibiotics first for the treatment of SBP.Answer 4: Right upper quadrant ultrasound is used to evaluate the liver and gallbladder to detect conditions such as cholecystitis. Ultrasound of the liver is also recommended in order to screen patients with cirrhosis for hepatocellular carcinoma. Though this patient may eventually require a right upper quadrant ultrasound, treatment of SBP with antibiotics is more urgently indicated.Answer 5: Transjugular intrahepatic portosystemic shunt (TIPS) is a shunt that is placed between the portal vein and hepatic vein in order to relieve portal hypertension. These shunts are often placed in patients with uncontrolled ascites or recurrent episodes of variceal bleeding. There is no indication for TIPS placement in this patient at this time. Furthermore, TIPS would likely worsen this patient's mental status due to greater bypass of ammonia from the liver and worsening hepatic encephalopathy. Bullet Summary:The first-line treatment for spontaneous bacterial peritonitis is cefotaxime as this antibiotic undergoes renal metabolism.
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