| Parameter | 1 Point | 2 Points | 3 Points |
|---|---|---|---|
| Bilirubin | < 2 | 2โ3 | > 3 |
| Albumin | > 3.5 | 2.8โ3.5 | < 2.8 |
| INR | < 1.7 | 1.7โ2.3 | > 2.3 |
| Ascites | None | Mild (controlled) | Moderate-severe (refractory) |
| Encephalopathy | None | Grade IโII | Grade IIIโIV |
| Send | Why |
|---|---|
| Cell count + differential | PMN โฅ 250/mmยณ = SBP (treat immediately -don't wait for culture). This is the most important test. |
| Albumin | Calculate SAAG (serum albumin โ ascites albumin). SAAG โฅ 1.1 = portal hypertension (cirrhosis, HF, Budd-Chiari). SAAG < 1.1 = non-portal (malignancy, TB, nephrotic, pancreatitis). |
| Total protein | Ascites protein < 1.5 g/dL = high risk for SBP โ consider prophylaxis. |
| Culture (blood culture bottles at bedside) | Inoculate aerobic + anaerobic blood culture bottles with 10 mL each. Bedside inoculation โ yield from ~50% to ~80%. |
| Glucose, LDH, gram stain | If concerned for secondary peritonitis (perforation): glucose < 50, LDH > serum, polymicrobial โ CT + surgery. |
| Setting | Management |
|---|---|
| No varices | EGD screening. Repeat in 2โ3 years (compensated) or 1 year (decompensated). |
| Small varices, no red signs | NSBB (propranolol 20โ40 mg BID or nadolol 20โ40 mg daily or carvedilol 6.25โ12.5 mg daily Baรฑares, 2002). Target HR reduction 25% or HR 55โ60. |
| Medium/large varices | NSBB (carvedilol preferred) OR endoscopic variceal ligation (EVL). Both are first-line for primary prophylaxis. PREDESCI, 2019: NSBB in compensated cirrhosis with CSPH delayed decompensation. |
| Post-bleed (secondary prophylaxis) | NSBB + EVL (combination is superior to either alone) Lo, 2012. TIPS if rebleeding despite combo Early-TIPS, 2010. |
Patient: 58 y/o M with alcohol-related cirrhosis (Child-Pugh C, MELD-Na 22), presents with abdominal distension, fever 38.4ยฐC, and diffuse abdominal pain.
Key findings: Tense ascites, shifting dullness. Paracentesis: PMN 680/mmยณ, SAAG 2.4. WBC 14K.
Management:
Teaching point: Any cirrhotic with fever, abdominal pain, or encephalopathy needs diagnostic paracentesis before antibiotics. PMN โฅ 250 = SBP regardless of culture result.
Patient: 62 y/o M with HCV cirrhosis, large-volume hematemesis. Known varices, not on beta-blocker prophylaxis.
Key findings: HR 128, BP 82/48, Hgb 6.2, INR 2.1, platelets 68K.
Management:
Teaching point: Do NOT correct INR with FFP, cirrhotic coagulopathy is rebalanced. FFP adds volume and worsens portal hypertension. Paracentesis is safe even with elevated INR.
Patient: 55 y/o F with NASH cirrhosis, MELD-Na 28, Cr rising 1.2 โ 3.8 over 5 days despite albumin challenge.
Key findings: UNa < 10, bland sediment, renal US normal. Albumin 1.5 g/kg x2 days with no Cr improvement. FENa 0.2%.
Management:
Teaching point: HRS is a diagnosis of exclusion. The albumin challenge (1.5 g/kg x2 days) is both diagnostic and therapeutic. Avoid NSAIDs, aminoglycosides, and ACEi/ARBs in all cirrhotics.
| Parameter | Frequency | Target / Action |
|---|---|---|
| Repeat paracentesis | At 48 hours | PMN should drop > 25% from baseline. If not improving โ suspect resistant organism, secondary peritonitis, or wrong diagnosis. Broaden antibiotics and get CT abdomen. |
| BMP / Creatinine | Daily | HRS surveillance. Rising Cr despite albumin = hepatorenal syndrome โ urgent nephrology + hepatology consult. Cr is the most important lab to trend. |
| Urine output | Strict I&Os | UOP < 0.5 mL/kg/hr or declining โ early sign of HRS. Correlate with Cr trend. |
| Mental status | q4โ8h | HE surveillance -SBP is the most common precipitant of hepatic encephalopathy. Worsening confusion โ start/escalate lactulose. |
| Blood cultures | At diagnosis, repeat if persistent fever | Guide antibiotic narrowing once sensitivity data available. |
| Vitals | q4h | Fever curve, hemodynamics. Persistent fever > 72h on appropriate antibiotics โ reconsider diagnosis. |