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A 55-year-old man with long-standing heavy alcohol use presents with increasing abdominal distension and ankle swelling. Examination shows jaundice, spider naevi, shifting dullness, and splenomegaly. Labs: bilirubin 48 µmol/L, albumin 28 g/L, INR 1.6, platelets 90 × 10⁹/L, creatinine 110 µmol/L. Ascitic tap: SAAG 1.5 g/dL, ascitic neutrophils 80/mm³.
Questions
a) What is the diagnosis for his fluid overload state, and how does SAAG support the mechanism? (2 marks)
- Cirrhotic portal-hypertensive ascites (1).
- SAAG ≥1.1 g/dL indicates portal hypertension as the driver (high portal pressure → high SAAG) rather than peritoneal carcinomatosis/TB (low SAAG) (1).
b) Calculate/interpret Child-Pugh category conceptually from the data and name the five Child-Pugh variables. (3 marks)
- Variables: bilirubin, albumin, INR/PT, ascites, encephalopathy (1.5).
- This patient has raised bilirubin, low albumin, raised INR, clinical ascites; encephalopathy not described — at least Child-Pugh B range likely; state that exact points need encephalopathy grade and precise cut-offs (1.5).
c) Outline first-line management of uncomplicated tense ascites. (3 marks)
- Salt restriction; spironolactone (e.g. start 100 mg) ± furosemide (e.g. 40 mg) with weight/electrolyte monitoring (1.5).
- Large-volume paracentesis for tense ascites with albumin cover if ≥5 L removed (typically 8 g albumin per L removed — local protocol) (1).
- Alcohol cessation, nutrition, screen varices, vaccines, avoid NSAIDs/aminoglycosides (0.5).
d) Does he have SBP from the cell count? What would change your answer? (2 marks)
- Ascitic neutrophils 80/mm³ is below the diagnostic threshold — not SBP (1).
- SBP diagnosed when ascitic PMN ≥250/mm³ (with positive culture supporting but not required for empirical treatment if PMN threshold met). If PMN ≥250, start empiric antibiotics (e.g. third-generation cephalosporin) promptly (1).