This case study involves a 53-year-old woman with alcoholic cirrhosis who presents with worsening ascites, hepatic encephalopathy, and possible spontaneous bacterial peritonitis. On physical exam, she has bulging abdomen, tender hepatomegaly, and fluid wave consistent with ascites. Labs show elevated ammonia and coagulopathy. The goals of treatment are to manage ascites and its complications through dietary changes, diuretics, and paracentesis while monitoring for side effects like electrolyte abnormalities.

1. CASE
STUDY:
Ascites management in
portal hypertension and
cirrhosis

2. Learning outcomes
After completing this case study, you should be able to:
 Identify signs and symptoms of cirrhosis and associated complications.
 Provide pharmacotherapeutic and lifestyle recommendations for managing ascites due to portal hypertension and cirrhosis.
 Develop a patient-specific regimen and monitoring parameters to meet the needs of a patient with ascites, spontaneous
bacterial peritonitis, and hepatic encephalopathy.
 Interpret laboratory values associated with ascites.
 Provide appropriate patient education for the recommended pharmacologic and nonpharmacologic therapy to control
complications of cirrhosis, as well as to prevent further com

3. Patient presentation
Chief Complaint
“I can’t breathe, and my stomach is swelling again.”
HPI
Priscilla Smith is a 53-year-old woman with a history of alcoholic cirrhosis who has been admitted to the hospital due to a 6-kg
weight gain over the past 8 days, abdominal swelling and pain, shortness of breath, and confusion.
PMH
 Alcoholic cirrhosis diagnosed 6 years ago
 Bleeding esophageal varices (last one occurred 6 months ago)
 Multiple occurrences of ascites (last episode occurred 12 months ago)
 Hepatic encephalopathy (last episode occurred 12 months ago)
 Chronic sinusitis
 Hypothyroidism diagnosed 2 years ago

4. Patient presentation
FH
Father was an alcoholic and died in an MVA 12 years ago at age 62. Mother, age 75, resides in a nursing home and suffers
from Alzheimer’s disease.
SH
Lives alone, husband died 2 years ago. Works part-time at a convenience store; was a bartender for 15 years before the
cirrhosis diagnosis. History of alcohol abuse; quit 6 years ago. While abusing alcohol, drank between four and six 4-oz.
glasses of wine per day on the weekdays and added two or three 1.5-oz. shots of whiskey to that on the weekends.
ROS
Abdominal discomfort described as occurring throughout the abdomen, shortness of breath, and mild confusion. Patient
denies chills or fevers

5. Patient presentation
Meds
 Triamcinolone acetonide (Nasacort AQ), 2 sprays per nostril once daily
 Propranolol LA 80 mg po once daily
 Levothyroxine 25 mcg po once daily
 Lactulose 15 mL po BID
All
NKDA

6. Physical examination
Gen VS Skin HEENT
Lungs/
thorax
CV Abd
Genit/
Rect
MS/
Ext
Neuro
Pleasant,
chronically ill
Caucasian
woman
appearing to be
in mild distress
and fatigued
BP 121/74,
P 82,
RR 27,
T 36.9°C;
Wt 73.2 kg,
Ht 5'4)
(+) palmar
erythema,
(+) spider
angiomata,
otherwise
normal color
PERRL, EOMI,
clear sclerae,
TMs normal,
mucous
membranes moist
Supple neck, no
thyroid nodules
Mild bilateral
rales,
decreased
breath sounds
in right lower
lobe due to
enlarged liver
and ascites
RRR,
S1 and S2 are
normal,
no MRG
Bulging, tender
abdomen;
hepatomegaly;
(+) fluid wave;
bowel sounds
normal
Guaiac negative
1+ pitting edema
in both LE,
palmar
erythema;
no clubbing or
cyanos
Mildly confused,
forgetful,
A & O × 2
(oriented to
person and place
but not time)

7. Labs
Na 133 mEq/L Hgb 13 g/dL AST 108 IU/L Alb 2.8 g/dL
K 3.9 mEq/L Hct 38% ALT 120 IU/L Ca 9.2 mg/dL
Cl 103 mEq/L Plt 79 × 103 /mm3 LDH 152 IU/L Mg 2.0 mEq/L
CO2 26 mEq/L WBC 7.0 × 103/mm3
T. bili 2.9 mg/dL
Phos 3.2 mg/dL
BUN 22 mg/dL PT 14.9 sec D. bili 0.8 mg/dL TSH 5.2 mIU/L
SCr 0.8 mg/dL PTT 46 sec HIV (–) NH3 102 mcg/dL
Glu 85 mg/dL INR 1.42 T. prot 6.1 g/dL

8. Assessment
 Worsening alcohol-induced cirrhosis;
Child-Pugh score––10, grade C;
now presenting with recurrent ascites and encephalopathy Perform diagnostic and therapeutic paracentesis
 R/O spontaneous bacterial peritonitis (SBP)

9. Questions
1. Problem
identification
2. Desired outcome
3. Therapeutic
alternatives
4. Self-study
assignment
Q
1a) Create a list of the
patient’s drug therapy
problems.
1b) What information
(signs, symptoms, lab
values) indicates the
presence of ascites in this
patient?
1c) What information
(signs, symptoms, lab
values) indicates the
presence of hepatic
encephalopathy and SBP
in this patient?
2a) What are the goals
of pharmacotherapy for
managing ascites and
related complications of
cirrhosis?
3a) What
nonpharmacologic
therapies might be
considered for this
patient?
3b) What pharmacologic
therapies should be
considered for this
patient?
4a) Identify which pain
medications may be
used safely in patients
with cirrhosis and
ascites.
4b) Based on this
patient’s history, what 1-
, 2-, and 5-year survival
rates would be expected
if the patient does not
receive a liver
transplant?

10. Clinical Pearl
 Ascites that does not respond to high-dose diuretics or that persists in patients unable to tolerate high-dose
diuretics is referred to as refractory ascites.
 This complication requires the patient to undergo frequent large-volume paracenteses (one to two times
per month) and indicates a poor prognosis.

12. References
1. Dib N, Oberti F, Cales P. Current management of the complications of portal hypertension: variceal bleeding and ascites. CMAJ
2006;174:1433– 1443.
2. Garcia-Tsao G. Current management of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous
bacterial peritonitis. Gastroenterology 2001;120:726–748.
3. Gines P, Cardenas A, Arroyo V, et al. Management of cirrhosis and ascites. N Engl J Med 2004;350:1646–1654.
4. Han M, Hyzy R. Advances in critical care management of hepatic failure and insufficiency. Crit Care Med 2006;34(9
Suppl):S225–S231.
5. Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut 2006;55(Suppl 6):vi1–vi12.
6. Runyon BA, Practice Guidelines Committee, American Association for the Study of Liver Diseases (AASLD). Management of
adult patients with ascites due to cirrhosis. Hepatology 2004;39:841–856.