Medical Grand Rounds Clinical Vignette

Matthias C. Kugler, M.D.

Internal Medicine Resident

09-12-2008

Chief Complaint

• 53 year old Caucasian male with Hepatitis C and cirrhosis, who presented to Bellevue Hospital with 8 days of abdominal pain and increasing girth

History of Present Illness

• Right Upper Quadrant pain for 8 days, up to 8/10 intensity, aching, non-radiating, intermittent, lasting several hours, no association with nausea or vomiting.

• Increasing girth and abdominal swelling.

• He denied fever or chills

History• Past Medical History: Hepatitis C diagnosed 15 years ago, cirrhosis since 2003, awaiting transplant Esophageal varices with endoscopic banding 2006

• Past Surgical History: none

• Family History: non-contributory

• Allergies: Penicillin – rash

• Medications: Esomeprazole 40mg daily, Furosemide 40mg daily, Aldactone 25mg daily, Lactulose 30ml bid, Propanolol 20mg tid, Acetaminophen 500mg q6h prn pain, Docusate 100mg tid

• Social History: no toxic habits, married, 2 children, no intravenous drug use

• ROS: otherwise negative

Physical Examination• General: Ill-appearing white male in mild distress, alert and oriented x 3

• Vital Signs: BP-113/80 HR-65 RR-20-22 O2-sat 93% (room air) Temp-37.0°C

• Head/Neck: + scleral icterus

• Lungs: breath sounds decreased b/l bases, upper lungs clear to auscultation

• Abdominal: + tense, distended, diffusely tender to palpation, + fluid wave, no guarding or rebound, bowel sounds hypoactive in all 4 quadrants

• Extremities: 1-2+ pitting edema of the legs bilaterally

• Skin: + jaundice

• Remainder of physical exam normal

Laboratory Values

Hepatic:

AST 100 (7-27) ALT 43 (1-21) AP 112 (13-39) Tbili 7.7 (<1.0) DBili 5.1 (<0.4) Prot 10.3 (6.0-8.4) Alb 1.6 (3.5-5.0)

CBC: WBC 4.2 (N53%, L26%, M15%, E5%) Hb 11.1 (13-18)Hct 31.6 (35-50)MCV 112 (86-98)plt 81 (150-350)

Coags:

INR 2.5 (<1.15) PTT 52 (25-38)

Basic: Na 132 (140-145)

ABG: pH 7.43, pCO2 39, pO2 87, HCO- 26, O2-sat 92% (room air), Lact 1.2

Paracentesis:

WBC 45 (N10%, L57%, M2%,) RBC 3350 Alb 1.0

LDH 49

Gram stain: gram-negative rods

Imaging Data• PA/Lateral chest radiograph: small pleural effusions b/l, no

infiltrates, + ventral hernia

Working Diagnosis

• Bacterial peritonitis and decompensation of cirrhosis secondary to infection.

Hospital Course

HD#1: 1. Therapeutic paracentesis with 1.5 liter fluid femoval2. Ceftriaxon initially, when paracentesis fluid grew out

pansensitive Escherichia coli, the antibiotic was switched to Ciprofloxacin

3. Forced diuresis using intravenous furosemide with monitoring of the electrolyte status

4. Patient continously afebrile

HD#4: • Despite improving ascites, patient noticed to be more short of

breath, tachypnic and hypoxic

Hospital courseHD #5:

• ABG: pH 7.37, pCO2 43, pO2 62, HCO- 24, O2-sat 88% (room air)

• PA/Lateral chest radiograph with increased diffuse patchy infiltrates b/l

• Patient was placed on CPAP with supplemental O2 and transferred to the intensive care unit

Hospital courseHD #7:

• ABG: pH 7.39, pCO2 43, pO2 48, HCO- 26, O2-sat 77% on FiO2 50%, PaO2/FiO2 96

• Patient was intubated for severe hypoxemia.

• Portable AP chest radiograph with worsening diffuse patchy infiltrates throughout both lungs

Hospital course

HD #8-10:• Ventilation using low tidal volumes, PEEP, and permissive

hypercapnea

• Setting VT 400 cc, FiO2 70-80%, PEEP 7-10 mm H2O later increased to maximum of 14 mm H2O

• Over the next days the team was able to decrease PEEP to 8, FiO2 to 50%, VT 400 cc, with improving hypoxemia on ABG (pH 7.38, pCO2 31, pO2 84, HCO-18, O2-sat 96%

• Sputum cultures remained all negative

Final Diagnosis

• Bacterial peritonitis and decompensation of cirrhosis secondary to infection.

• Acute Respiratory Distress Syndrome (ARDS)