Gastroenterology and hepatology for MRCPI Part 2

A 58-year-old woman with cirrhosis and known ascites is admitted with abdominal pain and fever. Diagnostic paracentesis shows an ascitic neutrophil count of 480 cells/mm³ with a negative Gram stain. What is the most appropriate management?

1. Urgent surgical laparotomy Wrong. Spontaneous bacterial peritonitis is a medical diagnosis. Surgery is for SECONDARY peritonitis, suggested by polymicrobial growth, very high protein, multiple organisms and a failure to respond.
2. Intravenous cefotaxime and intravenous albumin correct Correct. An ascitic neutrophil count of 250 cells/mm³ or more establishes spontaneous bacterial peritonitis regardless of culture, and treatment starts immediately. Albumin given alongside the antibiotic reduces hepatorenal syndrome and mortality, which is the part candidates most often omit.
3. Large-volume paracentesis alone Wrong as treatment for infection. Therapeutic paracentesis relieves tense ascites but does not treat the peritonitis.
4. Oral ciprofloxacin as an outpatient Wrong for an acute episode with fever and pain. Oral quinolones have a role in secondary prophylaxis after recovery, not in treating the acute infection in an unwell inpatient.
5. Await ascitic culture before starting antibiotics Wrong. Cultures are negative in a substantial proportion of genuine cases, and delay increases mortality. The neutrophil count is the diagnostic criterion.

The point: Ascitic neutrophils 250/mm³ or more is spontaneous bacterial peritonitis, culture or no culture. Cefotaxime plus albumin. Everyone with cirrhosis and new ascites, deterioration or encephalopathy needs a diagnostic tap. Start secondary prophylaxis after recovery and consider transplant assessment.

Source: EASL clinical practice guidelines for the management of patients with decompensated cirrhosis EASL · tier 2, specialty society or college