The lung volumes were slightly decreased but they were clear. His primary problem was hypoxia. There are other causes of hypoxia in a cirrhotic aside from volume overload. He has ascites and lower extremity edema mainly 2/2 to his portal hypertension. Our initial thoughts were to get an ABG to see if he had an elevated A-a gradient and grab a chest Xray.
The CXR was read as low lung volumes and a ? of atelectasis at the bases. His ABG showed a respiratory alkalosis and gap acidosis along with an elevated A-a gradient (I can't remember his initial gas).
So, as far as his hypoxia was concerned -> we were concerned about hepatopulmonary syndrome (hypoxia didn't fully correct with O2 either) but were also thinking about bad portopulmonary hypertension. He had a couple spider angiomata, which actually raises the pretest probability of hepatopulmonary syndrome. The other thing that can happen in cirrhotics with ascites is hepatohydrothorax, but he had nothing going for him on exam for that. And of course, they can get all the other causes of hypoxia i.e. PNA, PE, CHF, etc.
To answer some of the other questions -> we grabbed the sonosyte in the ED and found a nice pocket of ascites for a diagnostic para and sent it for cell count and culture. His gram stain was negative. His cell count showed 750 PMN's and his ascites culture grew out Klebsiella. The tap looked cloudy and we emperically started him on cefepime along with 1.5g/kg albumin. We did not do a large volume paracentesis initially.
We also did the rest of the infectious w/u and blood cultures, U/A and Ucx were negative.
He had an elevated anion gap, a creatinine of 1.4, an INR of 1.4, platelets of 80 and a Tbili of 4.2. K was normal as was his sodium. The ED sent a lactate, but you can't make much of that in the setting of liver disease.
By the time he we admitted him, he was on IV abx and periodic boluses for MAPS < 60, getting lactulose and flagyl through an NGT, had gotten albumin and was put no PPI BID.
By the next morning he had had 8 bowel movements and his mental status had dramatically improved. He did not have any fevers and his bx cultures continued to be negative. His ascites cultures wound up being a Klebsiella senstive to Levo and his antibiotics were tailored.
Are you guys comfortable with SBP as the explanation for his HE? Any other labs or studies you'd want to be more comfortable?
How do you want to work up his hypoxia? I'll tell you that his O2 sat was better laying down than when he would sit up. His tachypnea improved somewhat by the next day to about 12-14 laying down. Sitting up he'd get more SOB. He was able to say that his shortness of breath has been this way for months.
What's up with his creatinine? He initially got some fluids in the ED for a couple MAPS <60 and his creatinine the following day was unchanged. How would you work that up?