What is the initial workup and management for a patient presenting to the Emergency Department (ED) with alcoholic ascites and jaundice?

Emergency Department Workup and Management of Alcoholic Ascites with Jaundice

Patients with alcoholic ascites and jaundice require immediate diagnostic paracentesis, infection screening, severity assessment, and supportive care to reduce the 40-50% 90-day mortality risk associated with alcoholic hepatitis. 1

Initial Diagnostic Workup

Laboratory Testing

• Complete blood count with differential (looking for neutrophilia which is common in alcoholic hepatitis) 1
• Comprehensive metabolic panel including:
  • Liver function tests (AST typically 2-6 times upper limit with AST/ALT ratio >1.5) 1
  • Serum bilirubin (>3.0 mg/dL indicates severe alcoholic hepatitis) 1
  • Serum albumin (typically decreased in advanced disease) 1
  • Renal function tests (BUN, creatinine to assess for hepatorenal syndrome) 1
• Coagulation profile (INR/prothrombin time) to assess severity and prognosis 1
• Urinalysis and urine culture to rule out urinary tract infection 1
• Blood cultures to identify potential infections 1

Diagnostic Paracentesis

• Mandatory for all patients with new-onset ascites or clinical deterioration 1
• Collect 10-20 mL of ascitic fluid for: 1
  • Cell count and differential (PMN count >250 cells/mm³ indicates spontaneous bacterial peritonitis) 1
  • Total protein and serum-ascites albumin gradient (SAAG) (>1.1 g/dL indicates portal hypertension) 1
  • Culture in blood culture bottles at bedside before starting antibiotics 1
  • Ascitic fluid amylase if pancreatitis is suspected 1

Imaging

• Abdominal ultrasound to: 1
  • Evaluate liver size, echogenicity, and nodularity
  • Assess for portal hypertension (splenomegaly, portal vein diameter)
  • Confirm presence of ascites and rule out hepatocellular carcinoma
• Avoid CT with contrast due to risk of acute kidney injury in these patients 1

Severity Assessment

Calculate Prognostic Scores

• Maddrey Discriminant Function (MDF): 4.6 × (PT patient - PT control) + serum bilirubin (mg/dL) 1
  • MDF >32 indicates severe alcoholic hepatitis with high 28-day mortality 1
• MELD score: based on bilirubin, creatinine, and INR 1
  • MELD >20 predicts high 90-day mortality 1
• Glasgow alcoholic hepatitis score or ABIC score may also be calculated 1

Initial Management

Infection Control

• Obtain cultures of blood, urine, and ascites regardless of fever presence 1
• If spontaneous bacterial peritonitis is suspected (PMN >250 cells/mm³), start empiric antibiotics immediately:
  • Third-generation cephalosporin (e.g., cefotaxime) 1
  • Consider antibiotic prophylaxis after resolution if protein in ascitic fluid <1.5 g/dL 1

Fluid and Electrolyte Management

• For tense, symptomatic ascites, perform therapeutic paracentesis 1
  • If >5L removed, administer albumin (8g per liter of ascites removed) to prevent post-paracentesis circulatory dysfunction 1
• Initiate sodium restriction (2000 mg/day or 88 mmol/day) 1
• Start diuretic therapy: 1
  • Spironolactone (starting dose 100 mg daily, can increase to 400 mg) 1
  • Add furosemide (starting dose 40 mg daily, can increase to 160 mg) if faster diuresis needed 1
  • Caution: Monitor for complications including hyponatremia, hypokalemia, renal dysfunction 2, 3

Alcohol Cessation and Nutritional Support

• Counsel on complete alcohol abstinence as the cornerstone of treatment 1, 4
• Assess for alcohol withdrawal and treat if present 4
• Provide thiamine supplementation (100-300 mg/day) 4
• Ensure adequate nutrition with 1-1.5g protein/kg/day and 30-40 kcal/kg/day 1, 4

Special Considerations

Hepatic Encephalopathy

• Assess mental status for signs of encephalopathy 4
• If present, initiate treatment with lactulose 4

Renal Function

• Avoid nephrotoxic drugs including NSAIDs 1
• Use diuretics cautiously in patients with impaired renal function 2, 3
• Monitor for hepatorenal syndrome (progressive oliguria, rising creatinine) 1

Severe Alcoholic Hepatitis

• For patients with MDF >32 or MELD >20 without contraindications, consider corticosteroid therapy (methylprednisolone 32 mg daily) 1
• If contraindications to steroids exist, consider pentoxifylline 400 mg three times daily 1

Disposition

• Admit patients with:
  • Severe alcoholic hepatitis (MDF >32 or MELD >20) 1
  • Evidence of infection 1
  • Hepatic encephalopathy 4
  • Renal dysfunction 1
  • Inadequate social support 1
• Consider early liver transplantation evaluation for appropriate candidates with MELD >26 1, 4

Pitfalls to Avoid

• Delaying diagnostic paracentesis (should be performed immediately) 1
• Withholding paracentesis due to coagulopathy (not contraindicated) 1
• Administering excessive diuretics leading to renal failure 2, 3
• Missing spontaneous bacterial peritonitis due to lack of fever (can be afebrile) 1
• Failing to recognize hepatorenal syndrome early 1