ED Assessment - What You're Dealing With

• BP 130/80 - borderline high (not shocked yet)
• PR 100/min - tachycardia (compensatory)
• SpO2 94% on room air - mild hypoxia (concerning)
• Altered mentation (drowsy/lethargic) + abdominal pain

Immediate Stabilization (First 10 minutes)

• Supplemental O2 - aim SpO2 ≥ 96%. Start with 4-6 L/min via nasal cannula or 10 L via face mask
• If SpO2 not improving or GCS dropping - prepare for NIV/intubation

• 2x large-bore IV access (16-18G)
• Fluid bolus: 500 mL NS or RL over 15-20 min, reassess
• Cardiac monitor + continuous SpO2

• Full GCS assessment
• Blood glucose STAT - rule out hypoglycemia as cause of lethargy
• Pupil check

STAT Investigations (Send Immediately)

Broad Differentials Based on Clinical Picture

1. Acute pancreatitis (severe) - pleural effusion causing hypoxia, systemic inflammation causing encephalopathy
2. Biliary sepsis / Cholangitis - Charcot's triad / Reynold's pentad
3. Intestinal obstruction with ischemia - hypoxia from raised diaphragm + sepsis
4. Hemoperitoneum - e.g., ruptured AAA, ruptured ectopic, liver/spleen laceration
5. Hepatic encephalopathy - cirrhosis with acute decompensation
6. DKA/HHS - metabolic encephalopathy + abdominal pain
7. Mesenteric ischemia - pain out of proportion, lactic acidosis

Once USG Findings Are Known

ED Management - Critically Ill Patient with Advanced Malignancy

Reading the USG: The Big Picture

Phase 1 - Immediate Resuscitation (0-30 min)

• O2 via face mask 8-10 L/min, target SpO2 ≥ 96%
• SpO2 94% likely due to diaphragmatic splinting from tense ascites + possible pulmonary microemboli
• If GCS drops below 8 - secure airway (RSI intubation), but discuss with family re: goals of care first

• 2x large-bore IVs
• Cautious fluid resuscitation - DO NOT give aggressive boluses in portal hypertension (risk of increasing portal pressure and precipitating variceal bleeding)
• 250 mL crystalloid bolus, reassess - target MAP ≥ 65

• Continuous ECG, pulse oximetry, hourly urine output (Foley)

Phase 2 - Urgent Investigations (Send Simultaneously)

• Capillary blood glucose STAT (rule out hypoglycemia causing drowsiness)
• 12-lead ECG

• CBC - Hb (bleeding?), WCC, platelets (hypersplenism in portal hypertension)
• Coagulation - PT/INR/aPTT (expect prolonged in liver failure)
• CMP - Na, K, Cl, HCO3, creatinine, BUN (CKD + hepatorenal syndrome risk)
• LFT - bilirubin, AST, ALT, ALP, albumin, total protein
• Serum ammonia - key for confirming hepatic encephalopathy
• ABG - acid-base status, PaO2
• Serum lactate - mesenteric ischemia / sepsis
• Serum amylase/lipase - concomitant pancreatitis?
• Serum calcium - hypercalcemia of malignancy can cause altered consciousness and abdominal pain
• Blood cultures x2 - spontaneous bacterial peritonitis (SBP) is common in ascites
• Urine RE + culture

• CT Abdomen + Pelvis with contrast (if creatinine allows) - to better characterize liver lesions, portal vein thrombus extent, assess for bowel obstruction, and look for primary tumor
• CXR - pleural effusion? (explains hypoxia)

Phase 3 - Specific Management by Problem

1. Hepatic Encephalopathy (Cause of Altered Sensorium)

• Lactulose 30 mL orally (or via NGT) q1-2h until 2-3 soft stools/day, then titrate to maintenance. Goal: clear precipitating ammonia load
• Rifaximin 550 mg BD - add as second-line, especially if prior HE history
• Nutrition: 35-40 kcal/kg/day, 1.2-1.5 g protein/kg/day (do NOT restrict protein - harmful)
• Identify and treat precipitants: infection (SBP), electrolyte disturbance, bleeding, constipation, drugs

Per Yamada's Gastroenterology: "Management involves patient stabilization (airway, BP), triaging to appropriate level of care, identification of precipitating factors, and empiric lactulose." - Yamada's Textbook of Gastroenterology, 7e

2. Malignant Ascites

• Diagnostic + therapeutic paracentesis - urgently needed
  • Diagnostic: 60 mL for cell count, cytology, culture, albumin, LDH, protein, glucose
  • Therapeutic: drain 3-5 L to relieve respiratory compromise and abdominal pain
  • Calculate SAAG (Serum Albumin - Ascites Albumin): if SAAG ≥1.1 = portal hypertension; if <1.1 = malignant/exudative
• Albumin infusion post large-volume paracentesis (6-8 g/L of ascites drained) - prevents post-paracentesis circulatory dysfunction
• Echoic ascites on USG strongly suggests malignant ascites - send fluid for cytology
• Do NOT use diuretics aggressively in malignant ascites - poor response and risk of renal failure (note: pre-existing cortical renal atrophy)

Goldman-Cecil Medicine: "Malignant ascites portends a poor prognosis, with 1-year survival of 40% and 3-year survival of less than 10%." - Goldman-Cecil Medicine, 2 Vol Set

3. Portal Vein Thrombosis with Portal Hypertension

• The lamellar intrahepatic thrombus in this context is malignancy-related (tumor thrombus vs. bland thrombus)
• Do NOT rush to anticoagulate - in the ED, first assess:
  • Platelet count (thrombocytopenia from hypersplenism common)
  • Coagulation status (liver failure coagulopathy)
  • Active bleeding risk
• If bland thrombus and no active bleeding: LMWH (e.g., Enoxaparin) can be considered after specialist (GI/Oncology) review - not an ED decision alone
• Watch for variceal bleeding - if hematemesis or melena occurs, this becomes a hemorrhagic emergency

4. Possible SBP (Spontaneous Bacterial Peritonitis)

• Ascites fluid neutrophils >250 cells/mm³ = SBP
• Start empirical antibiotics immediately if SBP suspected clinically (fever, worsening encephalopathy, abdominal tenderness):
  • Ceftriaxone 2g IV OD (first-line in SBP)
  • Alternatives: Cefotaxime 2g IV q8h
• SBP is a common precipitant of hepatic encephalopathy and can be fatal if missed

5. Hypercalcemia of Malignancy (Must Rule Out)

• A common and reversible cause of altered consciousness + abdominal pain in malignancy
• If corrected Ca²⁺ >3.0 mmol/L:
  • Aggressive IV hydration (0.9% NS) - but cautiously in portal hypertension
  • Zoledronic acid 4 mg IV over 15 min (hold if eGFR <35)
  • Calcitonin 4-8 IU/kg SC/IM for rapid lowering

6. Pain Management

• Careful with opioids - worsen hepatic encephalopathy
• Paracetamol 500 mg (not the full 1g dose - hepatic impairment) IV/oral if pain score moderate
• Avoid NSAIDs (renal impairment + risk of GI bleeding)
• If severe pain: titrated low-dose morphine with caution

Phase 4 - Disposition & Critical Conversations

• Medical HDU / ICU given SpO2 94% + altered sensorium
• Gastroenterology + Oncology consult urgently

• Goals of care discussion with patient (when oriented) and family is mandatory
• Is this patient known to oncology? Any prior diagnosis? Any advance directives?
• The key question: Is this a new presentation of malignancy (with curative/palliative chemotherapy intent) or an end-stage known cancer patient in terminal decline?
• If new diagnosis: stabilize, investigate primary (CECT, upper GI endoscopy to assess gastric antrum thickening, tumor markers CEA/CA19-9/AFP/CA125), oncology referral
• If end-stage: shift to palliative/comfort care goals - symptom control, paracentesis for comfort, encephalopathy management for dignity

Summary Priorities in Order

1. O2, IV access, cardiac monitoring
2. Blood glucose + serum ammonia STAT
3. Therapeutic + diagnostic paracentesis (most impactful single intervention)
4. Lactulose via NGT for encephalopathy
5. Blood cultures → empirical Ceftriaxone if SBP suspected
6. Correct calcium, electrolytes
7. CECT abdomen once stabilized
8. Goals of care discussion

Sleisenger & Fordtran's Gastroenterology: "Malignant ascites with 1-year survival of 40% and <10% at 3 years. Repeated therapeutic paracentesis with or without indwelling peritoneal catheter is the most commonly used invasive treatment."