1. Medical Grand Rounds Clinical Vignette Matthias C. Kugler, M.D. Internal Medicine Resident 09-12-2008

2. Chief Complaint 53 year old Caucasian male with Hepatitis C and cirrhosis, who presented to Bellevue Hospital with 8 days of abdominal pain and increasing girth

3. History of Present Illness Right Upper Quadrant pain for 8 days, up to 8/10 intensity, aching, non-radiating, intermittent, lasting several hours, no association with nausea or vomiting. Increasing girth and abdominal swelling. He denied fever or chills

4. History Past Medical History: Hepatitis C diagnosed 15 years ago, cirrhosis since 2003, awaiting transplant Esophageal varices with endoscopic banding 2006 Past Surgical History: none Family History: non-contributory Allergies: Penicillin – rash Medications: Esomeprazole 40mg daily, Furosemide 40mg daily, Aldactone 25mg daily, Lactulose 30ml bid, Propanolol 20mg tid, Acetaminophen 500mg q6h prn pain, Docusate 100mg tid Social History: no toxic habits, married, 2 children, no intravenous drug use ROS: otherwise negative

5. Physical Examination General: Ill-appearing white male in mild distress, alert and oriented x 3 Vital Signs: BP-113/80 HR-65 RR-20-22 O 2 -sat 93% (room air) Temp-37.0°C Head/Neck: + scleral icterus Lungs: breath sounds decreased b/l bases, upper lungs clear to auscultation Abdominal: + tense, distended, diffusely tender to palpation, + fluid wave, no guarding or rebound, bowel sounds hypoactive in all 4 quadrants Extremities: 1-2+ pitting edema of the legs bilaterally Skin: + jaundice Remainder of physical exam normal

6. Laboratory Values Hepatic: AST 100 (7-27) ALT 43 (1-21) AP 112 (13-39) Tbili 7.7 (<1.0) DBili 5.1 (<0.4) Prot 10.3 (6.0-8.4) Alb 1.6 (3.5-5.0) CBC: WBC 4.2 (N53%, L26%, M15%, E5%) Hb 11.1 (13-18) Hct 31.6 (35-50) MCV 112 (86-98) plt 81 (150-350) Coags: INR 2.5 (<1.15) PTT 52 (25-38) Basic: Na 132 (140-145) ABG: pH 7.43, pCO 2 39, pO 2 87, HCO - 26, O 2 -sat 92% (room air), Lact 1.2 Paracentesis: WBC 45 (N10%, L57%, M2%,) RBC 3350 Alb 1.0 LDH 49 Gram stain: gram-negative rods

7. Imaging Data PA/Lateral chest radiograph: small pleural effusions b/l, no infiltrates, + ventral hernia

8. Working Diagnosis Bacterial peritonitis and decompensation of cirrhosis secondary to infection.

9. Hospital Course HD#1: 1.Therapeutic paracentesis with 1.5 liter fluid femoval 2.Ceftriaxon initially, when paracentesis fluid grew out pansensitive Escherichia coli, the antibiotic was switched to Ciprofloxacin 3.Forced diuresis using intravenous furosemide with monitoring of the electrolyte status 4.Patient continously afebrile HD#4: Despite improving ascites, patient noticed to be more short of breath, tachypnic and hypoxic

10. Hospital course HD #5: ABG: pH 7.37, pCO 2 43, pO 2 62, HCO - 24, O 2 -sat 88% (room air) PA/Lateral chest radiograph with increased diffuse patchy infiltrates b/l Patient was placed on CPAP with supplemental O 2 and transferred to the intensive care unit

11. Hospital course HD #7: ABG: pH 7.39, pCO 2 43, pO 2 48, HCO - 26, O 2 -sat 77% on F i O 2 50%, P a O 2 /F i O 2 96 Patient was intubated for severe hypoxemia. Portable AP chest radiograph with worsening diffuse patchy infiltrates throughout both lungs

12. Hospital course HD #8-10: Ventilation using low tidal volumes, PEEP, and permissive hypercapnea Setting V T 400 cc, F i O 2 70-80%, PEEP 7-10 mm H 2 O later increased to maximum of 14 mm H 2 O Over the next days the team was able to decrease PEEP to 8, FiO 2 to 50%, V T 400 cc, with improving hypoxemia on ABG (pH 7.38, pCO 2 31, pO 2 84, HCO - 18, O 2- sat 96% Sputum cultures remained all negative

13. Final Diagnosis Bacterial peritonitis and decompensation of cirrhosis secondary to infection. Acute Respiratory Distress Syndrome (ARDS)