What is the appropriate emergency department workup and management for an alcoholic patient presenting with jaundice, tremor, hepatic encephalopathy, and tense ascites?

Emergency Department Management of Alcoholic Patient with Jaundice, Tremors, and Severe Ascites

Immediate Diagnostic Workup

Perform diagnostic paracentesis immediately at the bedside before any other intervention, as this patient presentation carries a 40-50% 90-day mortality risk and infection must be ruled out urgently. 1

Essential Laboratory Studies

• Ascitic fluid analysis: Send cell count with differential, total protein, albumin, and culture in blood culture bottles at bedside before antibiotics 2, 1
• Calculate SAAG (serum-albumin minus ascitic fluid albumin) to confirm portal hypertension-related ascites (≥1.1 g/dL indicates cirrhosis) 2
• Complete blood count with differential: Look for neutrophilia (common in alcoholic hepatitis) and assess for infection 1
• Liver function tests: AST typically 2-6 times upper limit with AST/ALT ratio >1.5 in alcoholic hepatitis; bilirubin >3.0 mg/dL indicates severe disease 1
• Coagulation studies (INR): Essential for calculating severity scores 1
• Renal function (BUN, creatinine): Critical for detecting hepatorenal syndrome, which develops in up to 40% of severe alcoholic hepatitis cases 1, 3
• Serum electrolytes: Check sodium (hyponatremia common) and potassium 2

Infection Screening

Obtain blood, urine, and ascitic fluid cultures immediately regardless of fever presence, as bacterial infections occur in up to 40% of patients with severe alcoholic hepatitis. 1, 3

• Start empiric third-generation cephalosporin (cefotaxime 2g IV every 8 hours) immediately if spontaneous bacterial peritonitis is suspected (ascitic fluid neutrophil count >250 cells/mm³) 1, 3

Severity Assessment

Calculate both scoring systems to determine prognosis and guide management intensity:

• Maddrey Discriminant Function (MDF): MDF = 4.6 × (patient PT - control PT) + serum bilirubin (mg/dL). MDF ≥32 indicates severe alcoholic hepatitis with high 28-day mortality 1, 3
• MELD score: MELD >20 predicts high 90-day mortality; MELD >26 warrants early transplant evaluation 1

Initial Management Priorities

Alcohol Withdrawal Management

Assess for alcohol withdrawal syndrome immediately using CIWA-Ar protocol and treat tremors with benzodiazepines as indicated. 1

• Administer thiamine 100mg IV before any glucose-containing fluids to prevent Wernicke's encephalopathy 1
• Consider folate and multivitamin supplementation 1

Ascites Management

• Therapeutic paracentesis: If tense ascites is causing respiratory compromise, remove 4-6 liters with albumin replacement (8g albumin per liter removed if >5L) 2, 1
• Sodium restriction: 2000 mg/day (88 mmol/day) 2
• Diuretics: Hold initially if renal dysfunction present; if starting, use spironolactone 100mg plus furosemide 40mg daily for recurrent ascites 2, 1

Renal Protection

Discontinue all nephrotoxic drugs immediately, including NSAIDs and diuretics, as acute kidney injury is an early manifestation of multi-organ failure in severe alcoholic hepatitis. 3, 4

Nutritional Support

Initiate aggressive nutritional support with 1.0-1.5g protein/kg/day and 30-40 kcal/kg/day, as malnutrition worsens outcomes. 1, 3, 4

• Use enteral feeding tube if oral intake inadequate 4
• Do NOT restrict protein even if hepatic encephalopathy present 2

Hepatic Encephalopathy Assessment

Evaluate mental status for overt hepatic encephalopathy, which carries the highest mortality among decompensation complications 2, 5

• If present, initiate lactulose 15-30mL orally 2-3 times daily titrated to 2-3 soft bowel movements per day 5
• Consider rifaximin 550mg twice daily as adjunct 5

Critical Pitfalls to Avoid

• Do NOT measure serum CA125 - it is nonspecific and elevated in ascites, leading to unnecessary workups 2
• Do NOT restrict fluids - sodium restriction, not fluid restriction, mobilizes ascites 2
• Do NOT use disulfiram in these patients due to hepatotoxicity 2
• Do NOT delay antibiotics if infection suspected - treat within 1 hour 3

Disposition

Admit to hospital immediately if any of the following present:

• MDF ≥32 or MELD >20 (severe alcoholic hepatitis) 1
• Evidence of infection (SBP, bacteremia, UTI) 1
• Hepatic encephalopathy 1
• Renal dysfunction or hepatorenal syndrome 1
• Tense ascites requiring large-volume paracentesis 1

Consider ICU admission for patients with overt hepatic encephalopathy, sepsis, shock, or acute-on-chronic liver failure 6

Initiate early liver transplantation evaluation for appropriate candidates with MELD >26 who achieve abstinence 1

Corticosteroid Consideration

For patients with MDF ≥32 or MELD >20 without active infection, gastrointestinal bleeding, or renal failure, consider methylprednisolone 32mg daily after infection is ruled out 3