What is the most appropriate treatment for a 43-year-old male with hepatitis B, presenting with abdominal distention, confusion, fever, disorientation, asterixis, and positive shifting dullness, with ascitic fluid showing high Serum-Ascites Albumin Gradient (SAAG) and elevated neutrophils?

Management of Spontaneous Bacterial Peritonitis in a Patient with Hepatitis B Cirrhosis

The most appropriate treatment for this patient with hepatitis B cirrhosis presenting with signs of spontaneous bacterial peritonitis (SBP) and hepatic encephalopathy is oral lactulose and IV ceftriaxone (option B).

Clinical Diagnosis and Rationale

This 43-year-old male presents with a classic constellation of findings consistent with both SBP and hepatic encephalopathy:

• Evidence of SBP:

  • Fever
  • Abdominal distention with positive shifting dullness (ascites)
  • Elevated ascitic fluid neutrophil count (350/mm³, which exceeds the diagnostic threshold of 250/mm³)
  • High SAAG (1.2) consistent with portal hypertension from cirrhosis

• Evidence of Hepatic Encephalopathy:

  • Confusion and disorientation
  • Asterixis (flapping tremor)

Treatment Algorithm

1. Antibiotic Therapy:

   • Start empiric third-generation cephalosporin (ceftriaxone) immediately 1
   • Ceftriaxone 1-2g IV every 8-12 hours is appropriate
   • Do not wait for culture results before initiating antibiotics

2. Management of Hepatic Encephalopathy:

   • Administer lactulose (oral or enema) to reduce ammonia levels
   • Initial dosing: 25-30 mL orally every 1-2 hours until bowel movements occur, then adjust to 15-30 mL 2-3 times daily to achieve 2-3 soft bowel movements per day

3. Supportive Care:

   • Consider IV albumin (1.5 g/kg at diagnosis, followed by 1 g/kg on day 3) to prevent hepatorenal syndrome, especially if bilirubin >4 mg/dL or creatinine >1 mg/dL 1
   • Monitor for signs of worsening encephalopathy or renal function

Why This Is The Correct Treatment

The EASL guidelines strongly recommend third-generation cephalosporins as first-line treatment for SBP, with resolution rates of 77-98% 1. Ceftriaxone covers most causative organisms of SBP, particularly gram-negative aerobic bacteria like E. coli, which are the most common pathogens 1.

Lactulose is the standard treatment for hepatic encephalopathy, which is present in this patient (confusion, disorientation, asterixis). Importantly, the development of encephalopathy in a cirrhotic patient should raise suspicion for infection, particularly SBP 1.

Why Other Options Are Inferior

• Option A (IV diuretics and metronidazole): Diuretics may worsen renal function in the setting of active infection, and metronidazole does not provide adequate coverage for the typical gram-negative bacteria causing SBP 1.

• Option C (Oral lactulose and sedation with diazepam): Sedatives like diazepam are contraindicated in hepatic encephalopathy as they can worsen mental status 1.

• Option D (High volume ascitic fluid aspiration and propranolol): Large volume paracentesis without antibiotics does not address the underlying infection. While propranolol may be used for portal hypertension management, it is not the priority in acute SBP 1.

Important Caveats

• Repeat paracentesis after 48 hours of antibiotic therapy to document response (decrease in neutrophil count to <250/mm³) 1
• If no improvement in clinical signs or neutrophil count after 48 hours, consider resistant organisms or secondary peritonitis 1
• Avoid nephrotoxic antibiotics (aminoglycosides) due to risk of renal failure 1
• Consider liver transplantation evaluation for all patients who survive an episode of SBP 1

This approach prioritizes treating both the infection and encephalopathy, which are the most immediate threats to the patient's mortality and morbidity.