USMLE Step 3 GI question “ what do you advise at this point?”

Question

55-year-old man with cirrhosis has persistent ascites despite spironolactone 300mg a day and Lasix 120mg a day. He is required weekly paracentesis for the last month. He had prior mild Encephalopathy that is currently controlled with lactulose. No history of G.I. bleeding and he isadhering to a “no salt added diet”

physical exam: mild muscle wasting; tense ascites; no Asterixis

lab: bilirubin 1.8, AST 45, LT 29, albumin 2.6, INR 1.3, creatinine 1.5, sodium 128, potassium 3.4, Random urine sodium 126. US: patent portal and hepatic veins, no focal masses. Paracentesis: proteins 0.8, WBCs 300/ML, 10% PMNs.

A. TIPS B. Increase furosemide C. Start Metolazine D. Dietary Consult E. Start Ceftriaxone

Answer 1

C. Dietary consult.

Great USMLE question with learning points. First always check serum albumin and ascites, And cell count with differential and culture in ascites. Remember SBP only occurs in cirrhotic acites. Remember not necessary to study or memorize SAAG calculation/category it’s inherently obvious Ascites Alb High if north of the liver or malignancy, low cirrhotic or nephrotic. Urine sodium very high he’s not having a problem excreting, (even considering diuretics), so it’s diet. And increasing diuretics with his hyponatremia, electrolyte imbalance, etc..No. It’s not refractory so doesn’t need TIPS. Not infected doesn’t need antibiotics.(PMN count <250)