55 year old man admitted to our service for ascites and anasarca (massive scrotal and leg edema.) The patient had large volume paracentesis. The SAAG (serum ascites albumin gradient) was 1.8 – consistent with portal hypertension. He had no evidence for spontaneous bacterial peritonitis. His serum ammonia was normal.
Later that evening he becomes hypoxic and is transferred to intensive care. He is placed on a 50% rebreathing mask.
In reviewing his lab data we find:
| Destruction | Obstruction | Factory | |||
| AST | 34 | alk phos | 98 | albumin | 2.7 |
| ALT | 27 | T. Bili. | 0.8 | INR | 1.3 |
His ABG the next morning on 50% O2
| pH | 7.115 |
| pCO2 | 91 |
| pO2 | 90 |
When he was admitted he had a serum bicarbonate of 31.
He has cardiomegaly on chest xray.
Questions:
1. What liver diseases might he have – what is your best guess?
2. What other tests would you order?
3. Why is his pCO2 so high?
I will provide some answers and a strong hypothesis.
