The Case Files

Abstract

A patient comes to the emergency department with a seemingly simple chief complaint. “My legs are swollen,” he said. The patient is a 52-year-old man with alcoholic cirrhosis who had experienced increased lower extremity edema over the past week. He admitted to noncompliance with his recently prescribed medications, Aldactone and Lasix. He reported a history of “fluid in his abdomen,” but denied any recent infections requiring antibiotics. He also denied fever, chills, chest pain, shortness of breath, and abdominal pain. The patient had a temperature of 98.9°F with a pulse of 102 bpm and a blood pressure of 95/48 mm Hg. He was alert and oriented, and appeared disheveled but was in no apparent distress. Bitemporal wasting and scleral and sublingual icterus were noted. His mucous membranes were dry. Pulmonary auscultation revealed bibasilar rales. Heart sounds were normal. Abdominal exam was nontender and otherwise notable for the findings in the photos. He was noted to have 3+ pitting edema to the hips, with additional pitting edema extending up his trunk to his chest. He had full painless range of motion of his extremities. His skin was noted to be dry and icteric, with multiple bruises and scattered petechiae.ImageHis chem 7 was reported as glucose 73, sodium 139, potassium 3.4, chloride 106, bicarbonate 25, creatinine 2.34, and BUN 43. His CBC revealed a WBC 9.0 (88% segs, 4% lymphs), Hgb 10.9, Hct 32.3, Plt 99, AST 70, ALT 41, Alk Phos 116, Tbili 2.9, Dbili 1.3, albumin 1.8, and INR 1.6 What is your doorway diagnosis? How many physical exam findings can you identify to support this diagnosis based on the photos? This patient was in fulminant hepatic failure with all the findings of hepatic congestion: icterus, ascites, edema, portal hypertension manifested by caput medusa and spider angiomata, and gynecomastia thought to be because of increased estrogen or estrogen:testosterone ratios. Given these findings, he was admitted to the medical service for worsening hepatic failure and acute kidney injury thought to be because of either prerenal causes or hepatorenal syndrome. He was noted to have a fever and increased WBC with a 9% bandemia on his second hospital day. A diagnostic and therapeutic paracentesis was performed that was consistent with spontaneous bacterial peritonitis, and he was started on antibiotics. A gastroenterology consult was obtained, and recommendations were made to stop diuresis given poor urine output and inability to appreciate the presence of hepatorenal syndrome. It was determined that he was not a candidate for liver transplantation because of alcohol abuse. One week into hospitalization, he was noted to have hematemesis. An endoscopy was performed revealing grade II esophageal varices requiring banding. He responded poorly to symptomatic care, and multidisciplinary meetings were held with the patient to discuss his poor prognosis. The patient ultimately decided to begin comfort care, with the hope of transitioning to home with hospice services. Cirrhosis is a result of irreversible scarring of the liver from many causes, among them alcohol abuse, nonalcoholic fatty liver disease, chronic viral hepatitis, biliary sclerosis or atresia, autoimmune cirrhosis, inherited disorders, and other unknown causes. Emergency physicians should maintain a high level of suspicion for spontaneous bacterial peritonitis in patients with ascites because earlier detection and treatment results in a decreased infection-related mortality. Administering antibiotics before the onset of renal failure and shock has a significant effect on improving prognosis. The one- to two-year mortality after spontaneous bacterial peritonitis remains at 70–80 percent despite these efforts. Hepatorenal syndrome is an often fatal complication of cirrhosis, and requires immediate involvement of gastroenterology or hepatology. Dr. Himelfarbis an emergency medicine resident at Rhode Island Hospital in Providence.Dr. McGregoris an assistant professor of emergency medicine at the Warren Alpert Medical School of Brown University, also in Providence.