MRCP2-1769

MRCP2-1769

A 75-year-old man presents to the Emergency department with abdominal pain and distension. He has a past history of ischaemic heart disease.

On examination he is confused, his pulse is 124 bpm and irregular, blood pressure is 87/40 mmHg, his abdomen is distended, firm and tender with shifting dullness.

His blood tests reveal:

Haemoglobin 93 g/L (130 – 180)

White cell count 24.7 ×109/L (4 – 11)

Platelets 322 ×109/L (150 – 400)

Bilirubin 21 µmol/L (1 – 22)

ALP 145 IU/L (45 – 10)

ALT 34 IU/L (5 – 35)

AST 49 IU/L (1 – 31)

Amylase 205 IU/L (60 – 180)

Albumin 32 gl/L (37 – 49)

C reactive protein 263 mg/L (<10) INR 1.2 (< 1.4) An ascitic tap is performed and bloody fluid is aspirated from the abdominal cavity. Analysis of the fluid reveals: Red cell count 21,385/mm3 White cell count 6,734/mm3 90% neutrophils Albumin 23 g/L A Gram stain reveals Gram negative bacilli and Gram positive cocci. What is the most likely cause of his ascites?