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Hepatic encephalopathy precipitated by spontaneous bacterial peritonitis — SCE Acute Medicine MCQ

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HardAcute GI PresentationsHepatic encephalopathy precipitated by spontaneous bacterial peritonitisSCE Acute Medicine

A 58-year-old man with decompensated cirrhosis becomes drowsy and confused. He has asterixis, moderate ascites, temperature 37.8 C and abdominal tenderness. Sodium is 128 mmol/L, creatinine 142 micromol/L and diagnostic ascitic tap shows 420 neutrophils/mm3. What is the most likely precipitant of his encephalopathy?

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Correct answer: E — Spontaneous bacterial peritonitis

Ascitic neutrophils above 250/mm3 indicate spontaneous bacterial peritonitis, a common precipitant of hepatic encephalopathy and renal dysfunction. Wernicke encephalopathy is important to consider in alcohol dependence but does not explain neutrocytic ascites and abdominal tenderness. Subdural haemorrhage remains a differential if trauma is suspected, but the tap identifies an immediate treatable trigger. Diagnostic paracentesis is essential in any cirrhotic patient admitted with ascites and deterioration.

Reference: EASL decompensated cirrhosis guideline, NICE NG50, BNF