A 50-year-old man comes to the office due to 2 months of progressive generalized weakness, anorexia, and abdominal distension. He has also had bilateral lower extremity swelling. The patient has a history of alcohol use disorder and liver cirrhosis, which was diagnosed 5 years ago. His last right upper quadrant ultrasound was performed 18 months ago; it showed surface nodularity and increased liver echogenicity but no free fluid in the abdomen. He has no other chronic medical conditions and takes no medications. Temperature is 37.3 C (99.1 F), blood pressure is 103/76 mm Hg, pulse is 82/min, and respirations are 14/min. Pulse oximetry shows 96% on room air. The patient is awake, alert, and oriented to time, place, and person. Temporal wasting is present. Cardiopulmonary examination is normal, and there is no jugular venous distension. The abdomen is distended, with shifting dullness to percussion, but nontender. There is bilateral lower extremity 1+ pitting edema. Palmar erythema and multiple spider angiomas are noted. Laboratory results are as follows:
| Complete blood count | |
| Hemoglobin | 11.2 g/dL |
| Platelets | 105,000/mm3 |
| Leukocytes | 6,000/mm3 |
| Serum chemistry | |
| Blood urea nitrogen | 15 mg/dL |
| Creatinine | 0.6 mg/dL |
| Liver function studies | |
| Albumin | 3.1 g/dL |
| Total bilirubin | 2.1 mg/dL |
| Alkaline phosphatase | 330 U/L |
| Aspartate aminotransferase (SGOT) | 89 U/L |
| Alanine aminotransferase (SGPT) | 95 U/L |
Serology is negative for viral hepatitis. Which of the following is the best next step in management of this patient?
This patient with alcohol-induced cirrhosis now has abdominal swelling, abdominal distension, and shifting dullness on percussion, indicating ascites. Although ascites often develops as a consequence of progressive cirrhosis, new-onset ascites may indicate acute obstruction of the portal or hepatic veins due to thrombus or hepatocellular carcinoma (HCC). Therefore, abdominal ultrasound is required to evaluate the abdominal cavity (for free fluid), the portal/hepatic vascular system (for clots), and the liver (for masses).
Patients with cirrhosis are at extremely high risk for developing HCC (risk is 1%-8% per annum). New-onset ascites and systemic manifestations (eg, weakness, weight loss, temporal wasting) should raise suspicion for HCC, as should any sign of liver decompensation (eg, variceal bleeding). However, patients with HCC are often asymptomatic. Therefore, in any patient with cirrhosis, screening abdominal ultrasound is recommended every 6 months to evaluate for new-onset HCC. This patient who had a negative screening ultrasound 18 months ago may have developed HCC in the interim.
(Choice B) Primary biliary cholangitis (PBC) is associated with antimitochondrial antibodies and is characterized by fatigue, jaundice, pruritus, and elevated alkaline phosphatase. Patients with PBC who develop cirrhosis have an increased risk of HCC. However, PBC is rare and occurs almost exclusively in middle-aged women.
(Choice C) The mainstay of therapy for ascites is diuresis and salt restriction; however, new-onset ascites requires ultrasound prior to considering therapy.
(Choice D) Patients with congestive heart failure can develop ascites and lower extremity edema but typically have elevated jugular venous pressure. This patient's history of cirrhosis and lack of elevated jugular venous pressure make his ascites most likely due to a hepatic cause; therefore, abdominal ultrasound, not echocardiography, is recommended.
(Choice E) Lactulose is used to treat hepatic encephalopathy, which is associated with confusion and asterixis. This patient is alert and oriented; he has no evidence of encephalopathy.
Educational objective:
Hepatocellular carcinoma (HCC) is a common complication of cirrhosis, with a risk of 1%-8% per annum in this population. Therefore, screening with abdominal ultrasound every 6 months is recommended. Because HCC often presents with liver decompensation (eg, new-onset ascites, variceal bleeding), this condition should prompt abdominal ultrasound to evaluate for HCC.