ZSFG AM Report Pearls 7/3/2017 – Decompensated Cirrhosis and Empyema

Thank you to Kenney Pettersen, Emily Tsanotelis, and Annsa Huang for presenting a case of decompensated cirrhosis due to an empyema with communication into the peritoneum.


Top Pearls

  • Etiologies of decompensation in cirrhosis include infection, clot, GI bleed, toxins/meds, and malignancy
  • Hepatic Encephalopathy is graded on a 4 point scale
  • Empyema is diagnosed when thoracentesis reveals pus or bacteria on gram stain


Etiologies of Decompensated Cirrhosis:

Decompensation refers to (1) worsening synthetic function (hepatic encephalopathy, hypoglycemia, coagulopathy) or (2) increased portal hypertension (increased ascites, variceal bleeding, hepatorenal syndrome) in a patient with cirrhosis.

While progression of the underlying disease is a common cause of decompensation, carefully assess for these possibilities:

  • Vascular injury (portal vein thrombosis)
  • Infection (viral hepatitis, SBP, pneumonia, UTI)
  • Malignancy (HCC)
  • GI bleeding
  • Toxins/Meds (alcohol, acetaminophen, NSAIDs, diuretics)

Courtesy of Rabih Geha’s post 6/6/17:


Grading of Hepatic Encephalopathy:

  • Grade I: Changes in behavior, mild confusion, slurred speech, disordered sleep
  • Grade II: Lethargy, moderate confusion
  • Grade III: Marked confusion (stupor), incoherent speech, sleeping but arousable
  • Grade IV: Coma, unresponsive to pain




  • Uncomplicated parapneumonic effusions – lung interstitial fluid increases in an area of a lung with a pneumonia and the fluid moves across the visceral pleural membrane. The fluid will be exudative with an influx of neutrophils
  • Complicated parapneumonic effusions – bacterial invasion of the pleural space (i.e. not just fluid, but infected fluid). This fluid may show fluid acidosis (low pH), low glucose, and elevated LDH. Cultures can be falsely negative when bacterial load is low or if anaerobic cultures are not performed
  • Empyema – clear evidence of bacterial infection, resulting in either return of pus or bacterial organisms seen on gram stain. Culture is not required for diagnosis of empyema.


Imaging in Empyema:

  • CXR: pleural-based opacity
  • Ultrasound: can be used to determine if free-flowing vs. loculated vs. solid mass
  • CT chest (optimal evaluation): thickening of the visceral or parietal pleura is suggestive (especially if >30mm between the two pleural surfaces)


When to Perform Thoracentesis on Parapneumonic Effusion:


Pleural Fluid Analysis:

Studies to Obtain (additional studies may be needed depending on suspected etiology):

  • Gram stain, cultures (aerobic, anaerobic, ?mycobacterial)
  • Cell count + differential
  • Total protein
  • LDH
  • Glucose
  • pH


Etiology Appear WBC diff RBC pH Glucose Comments
Uncomp Parapneumonic Turbid 5-40,000


<5000 Normal to low >40  
Complicated Parapneumonic Turbid to purulent 5-40,000


<5000 Low <40 Needs drainage
Emphyema Purulent 25-100,00


<5000 Very Low <<40 Needs drainage






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