RETROALIMENTACION CASO CLINICO

RETROALIMENTACION

What is the most likely diagnosis?
SBP?
Peritonitis after surgery?
Abdominal abscess?
C. diff. colitis?
HD related sepsis?
DVT?
Endocarditis?

What laboratory workup would you order?
CBCD, CMP, INR/PTT, CXR, BCx x 2
CT of the abdomen

Would you do a paracentesis ("tap") of the ascites?
He had an ultrasound (U/S) guided paracentesis during which 700 cc of bloody fluid were drained and sent to the lab.

What happened?

RX INT:

A lateral CXR from 5 days ago (left), the new CXR showing an air/fluid level (middle); CXR report (right)

The patient was started on ciprofloxacin and given one dose of vancomycin (Vanco) (1 gm IV x 1).
The CXR showed gas under the diaphragm which can be normal after a laparotomy (also after a laparoscopy or even a PEG tube placement).

How do we use serum-ascites albumin gradient (SAAG)?
SAAG higher than 1.1 g/dL may indicate ascites due to portal hypertension (high SAAG = high pressure).
If SAAG is less than 1.1 g/dL, the reason may be peritonitis, TB or malignancy.
Our patient's SAAG (calculated from the labwork above) is 0.8 g/dL.
The PPD was negative and the cytology showed inflammatory cells but no malignant cells. Blood cultures (BCx) grew Gram-positive cocci (GPC), latex/coagulase negative but only 1 of 4 - it was most likely a contaminant. An Infectious Disease (ID) consult was called.

The patient's condition improved and his fever subsided. A CT scan of the abdomen and a WBC scan did not show any source of infection.

Final diagnosis
Spontaneous bacterial peritonitis (SBP).

What did we learn from this case?
How to order relevant labwork for ascites work-up.
Not all gas under the diaphragm is due to a perforated viscus.