Contributor: Michael Hunt, MD
- Cirrhosis is the end stage of chronic structural damage to the liver. This is most commonly due to alcohol but other causes viral hepatitis and hepatotoxic drugs
- Cirrhotic patients are very prone to GI bleeding and infections, partially due to the role the liver plays in producing immune and clotting factors
- These patients can easily become “sick”. Use the shock index (heart rate / systolic blood pressure) as a rapid assessment of hemodynamic status. >0.7 is worrisome, >1 should prompt resuscitation.
- Because cirrhotic patients are immunocompromised, do not rely on the presence of fever and peritonitis to diagnose spontaneous bacterial peritonitis (SBP), and have a low threshold to perform a diagnostic paracentesis
- Polymorphonuclear (PMN) count > 250 in the ascitic fluid suggests SBP
- With GI bleeding in cirrhotics, antibiotics have a mortality benefit, while PPIs and octreotide have limited benefit
Chinnock B, Hendey GW, Minnigan H, Butler J, Afarian H. Clinical impression and ascites appearance do not rule out bacterial peritonitis. J Emerg Med. 2013 May;44(5):903-9. doi: 10.1016/j.jemermed.2012.07.086. Epub 2013 Mar 7.
Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations. Eur J Gastroenterol Hepatol. 2016 Mar;28(3):e10-8. doi: 10.1097/MEG.0000000000000548.
Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, Uribe M.Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther. 2011 Sep;34(5):509-18. doi: 10.1111/j.1365-2036.2011.04746.x. Epub 2011 Jun 27.
Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD