Art Deco glamorization of excessive martinis
Today we discussed issues related to alcoholic liver disease and SBP. Some points that came up:
Risk factors for SBP
1) Prior SBP
2) GI bleed
3) Child's C cirrhosis
4) Ascitic fluid protein 10g/L
When to suspect SBP (and therefore perform diagnostic tap)
1) Admission of all cirrhotic pts with ascites, regardless of reason for admission
2) Patients with ascites and with GI bleed routinely before abx (20% have SBP initially, 40% by discharge)
3) Patients with ascites and any of abdominal pain, rebound, vomiting, diarrhea, fever, leukocytosis, encephalopathy (although NB- abdo pain is often absent)
SBP diagnosis
Ascites PMN > 250 or WBC > 500. If WBC > 1000 or polymicrobial culture or protein > 10g/L, suspect secondary peritonitis (i.e. intra-abdominal persistent source- abscess, perforation, etc).
Evidence-based prophylaxis in cirrhosis
1) Primary SBP prophylaxis in cirrhotic patients presenting with GI bleed: quinolone or ceftriaxone
2) Secondary prophylaxis of SBP: daily norfloxacin or weekly ciprofloxacin
3) Screening OGD at time of diagnosis, repeated q1-3 years depending on compensation
4) Non-selective B-bl (i.e. nadolol) for patients with varices (including those which have not bled) 5) Endovascular ligation (i.e. banding) for high-risk varices
6) Combination of B-bl and nitrates may slow progression of portal HTN
7) HCC screening by u/s q6-12 months for cirrhotic patients and high-risk HBV carriers
8) Hepatitis A and B vaccination for all patients with chronic liver disease
Alcohol withdrawal seizures
1) Generalized
2) Possibly recurrent (i.e. "rum fits")
3) Minimal post-ictal phase
4) Not followed by Todd's (suggests focality- suspect SDH, other focal abnormality)
5) Usually self-resolving
Wernicke-Korsakoff's syndrome
1) Ataxia - "magnetic gait"
2) Ophthalmoplegia- commonly bilat 6th CN. Possibly also 3rd CN
3) Amnesia- anterograde and possible mild retrograde (cannot learn new material; often confabulate)
1+2 = Wernicke's, 3=Korsakoff's
Some references
Click here for cirrhosis guidelines
Click here for esophageal varices / portal HTN guidelines
Click here for RCT on withdrawal sz treatment
Click here for evidence for empiric abx in cirrhotics with GIB
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