4. Case
HPI: duration of exposure and LFT abnormalities
PMH: DM, high BMI, autoimmune disease, transfusion
or transplant before 1972 (HBV) or 1992 (HCV)
Meds: new meds, vitamins, herbals, OTCs,
acetaminophen
FH: liver disease, autoimmune disease
SH: alcohol consumption, occupational exposure,
travel, from viral hepatitis endemic areas, IVDU,
tattoos
ROS: jaundice, rash, arthralgia, myalgia, anorexia,
weight loss, abdominal pain, fever, chills, pruritus
PE: Encephalopathy (inverted sleep-wake, irritability,
tremor, confusion), asterixis, jaundice, temporal
wasting, scleral or sublingual icterus, fetor hepaticus,
JVD, spider angiomata, gynecomastia, hepatomegaly,
splenomegaly, caput medusae, ascites, testicular
atrophy, thenar atrophy, palmar erythema,
Dupuytren’s contractures, LE edema
5. LFTs
• Total Protein 8.2
• Albumin 4.6
• TBili 18.9
• AST 1460
• ALT 2645
• Alk Phos 120
• PT 16.4
• INR 1.39
• PTT 35.8
6. LFTs: the players
LFT Abnormality measured Notes
Albumin Synthetic function Heavy alcohol use, chronic
inflammation, malnutrition
PT/INR Synthetic function Low vitamin K, warfarin
AST Hepatocellular damage High concentrations in cardiac
tissue, skeletal muscle, blood
ALT Hepatocellular damage Low concentrations in non-
hepatic tissue; more specific
Bilirubin Cholestasis, impaired
conjugation, biliary
obstruction
Hemolysis
Alkaline phosphatase Cholestasis, infiltrative
disease, biliary obstruction
Bone disease, leukemia,
lymphoma, CKD, CHF,
sarcoidosis, hyperthyroidism,
hyperparathyroidism,
pregnancy, post-prandial
7. LFT pattern is important for DDx
HEPATOCELLULAR
ALT, AST > Alk Phos
CHOLESTATIC
Alk Phos > ALT, AST
*Bilirubin can be elevated in both and do not help to distinguish
10. Back to the case
Acute viral hepatitis (A-E, EBV, CMV)
Medications/toxins
Autoimmune hepatitis
Wilson’s disease
Ischemic hepatitis
Acute Budd-Chiari syndrome
Acute bile duct obstruction
• Total Protein 8.2
• Albumin 4.6
• TBili 18.9
• AST 1460
• ALT 2645
• Alk Phos 120
Hep A total Ab positive
Hep A IgMAb negative
Hep B surface Ab positive
Hep B surface Ag negative
Hep B core Ab negative
Hep B PCR <5 IU/mL
Hep C antibody negative
Hep C PCR <10 IU/mL
29. Paracentesis
Indications
• To evaluate new onset ascites of
unclear etiology
• To evaluate for SBP
(spontaneous bacterial
peritonitis) in pt with known
ascites
• To perform large volume
paracentesis and provide comfort
or relieve respiratory
compromise
Contraindications
• Coagulopathy?
• Thrombocytopenia?
• DIC
• Abdominal wall collateral veins
• Abdominal wall cellulitis
• Surgical scars
• Caution in:
– Renal failure, organomegaly,
bowel obstruction, intrabdominal
adhesions, distended bladder
30.
31. Sites
2 cm below umbilicus in midline
- linea alba lacks blood vessels
RLQ or LLQ 2 to 4 cm medial and
cephalad to ASIS
- lateral to rectus sheath to avoid
puncture of inferior epigastric artery
An ultrasound study demonstrated that a LLQ tap site is superior to a midline site; the
abdominal wall is relatively thinner in the left lower quadrant while the depth of fluid
is greater
Sakai H et al. Choosing the location for non-image guided abdominal paracentesis. Liver Int. 2005.
33. Albumin after LVP in portal HTN & cirrhosis
• “interesting” “unresolved” “controversial”
• No study has shown a survival advantage
• Reasonable to forego albumin if <5L LVP
• I was taught give 50cc of 25% albumin (12.5g) per 2L removed
• NEJM article and video: recommend use of albumin if >5 L of ascites
removed (6 to 8 g per liter of fluid removed)
34. Appearance of ascites
• Clear/translucent yellow: uncomplicated in the setting of
cirrhosis
• Cloudy: infection
• Milky: “chylous ascites”, high triglyceride concentration,
cirrhosis or malignancy
• Pink/bloody: traumatic tap, leakage from punctured collateral
from previous tap, malignancy
• Brown/molasses: if bilirubin is greater than serum, concern
for ruptured gallbladder or perforated duodenal ulcer
Diagnosis and evaluation of patients with ascites. UpToDate.
35. 2 questions: Infection? Portal HTN?
• Cell count: PMN > 250 cells/mm3
• If bloody or >50K RBCs, subtract 1
PMN for every 250 red cells
• Culture used to confirm diagnosis of
SBP
– Volume affects culture
sensitivity; goal 10cc per bottle
– Fill culture bottles at bedside
• SAAG = Ascites albumin value –
Serum albumin value
