Gastroenterology Book

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Spontaneous Bacterial Peritonitis

Aka: Spontaneous Bacterial Peritonitis, Acute Spontaneous Bacterial Peritonitis
  1. Epidemiology
    1. Incidence
      1. May represent as many as 25% of emergency department patients with Cirrhotic Ascites
      2. May represent as many as 30% of hospitalized patients with Cirrhotic Ascites
  2. Causes
    1. Escherichia coli
    2. Gram Positive Streptococcus (e.g. Streptococcus Pneumoniae)
    3. Enterococcus faecalis
    4. Klebsiella
  3. Symptoms
    1. Asymptomatic in 40% of cases
    2. Fever
    3. Abdominal Pain
    4. Increasing Ascites
    5. Nausea
    6. Vomiting
  4. Signs
    1. Generalized abdominal tenderness
    2. Rebound Tenderness
    3. Fever
    4. Chills
    5. Tachycardia
    6. Tachypnea
    7. Shock state
    8. Acute liver decompensation (e.g. worsening encephalopathy, Renal Failure)
  5. Precautions
    1. Symptoms and signs are variably present with 40% of patients asymptomatic
  6. Labs
    1. Complete Blood Count
      1. Leukocytosis
    2. Ascitic Fluid by Paracentesis
      1. Ascitic Fluid Culture
        1. False negative in 60% of cases
      2. Ascitic Fluid cell count and differential
        1. Total White Blood Cells (WBC ,Leukocytes) > 500/mm3
        2. Neutrophils (PMNs) > 250/mm3
          1. Test Sensitivity and Test Specificity: 93-94%
      3. Leukocyte esterase test strips positive
        1. Test Sensitivity: 93%
        2. Test Specificity: 100%
        3. Positive Predictive Value: 100%
        4. Negative Predictive Value: 98%
        5. Torun (2007) World J Gastroenterol 13(45):6027-30 [PubMed]
      4. Other markers that distinguish SBP from secondary peritonitis causes
        1. Peritoneal fluid protein, Glucose, LDH, CEA, Alkaline Phosphatase
  7. Imaging
    1. CT Abdomen and Pelvis
      1. Consider in cases where secondary peritonitis cause other than SBP is suspected
  8. Management: Empiric antibiotics
    1. Indications
      1. Ascitic fluid PMNs >250/mm3
      2. Signs of symptoms of SBP regardless of ascites PMN Count
        1. Repeat Paracentesis if negative ascitic fluid exam despite signs and symptoms
        2. Treat empirically with antibiotics until confirmatory results
    2. Start immediately (high mortality rate)
    3. Duration: 10-14 days
    4. Parenteral antibiotics
      1. Cefotaxime 2 grams every 8 hours
      2. Nosocomial source of infection may require broadening of antibiotic coverage
    5. Oral antibiotics
      1. Oral agents
        1. Ofloxacin 400 mg orally twice daily
        2. Amoxicillin-Clavulanate (Augmentin)
      2. Indications for oral therapy
        1. Tolerating oral (no Vomiting)
        2. No shock or severe Hepatic Encephalopathy
        3. Serum Creatinine <3 mg/dl
      3. Spanish Study (n=123)
        1. Stable patients with SBP treated for 7 days
        2. Cipro PO as effective as Cefotaxime IV (84%)
        3. Navasa (1996) Gastroenterology 111:1011-7 [PubMed]
  9. Management: Adjunctive Albumin
    1. Indications: SBP and one of the following lab findings
      1. Serum Creatinine >1 mg/dl
      2. Blood Urea Nitrogen >30 mg/dl
      3. Total Bilirubin >4 mg/dl
    2. Give albumin IV within 6 hours of diagnosis
      1. Dose 1: Albumin 1.5 gram/kg body weight initially
      2. Dose 2: Albumin 1 gram/kg on day 3
    3. Albumin efficacy in SBP
      1. Reduces in-hospital mortality and Renal Failure progression
      2. Jamtgaard (2016) Ann Emerg Med 67(4): 458-9 [PubMed]
  10. Prognosis
    1. Mortality approaches 20% per episode (as high as 40% in some studies)
  11. Prevention
    1. Indications: Survivors of prior SBP episode
    2. Refer for liver transplantation
    3. Long-term prophylactic antibiotics
      1. Norfloxacin
      2. Trimethoprim-sulfamethoxazole (Septra)
  12. References
    1. Swaminathan and Pescatore in Herbert (2017) EM:Rap 17(11): 3
    2. Swencki (2015) Crit Dec Emerg Med 29(11):2-10
    3. Runyon (2004) Hepatology 39:841-56 [PubMed]

acute spontaneous bacterial peritonitis (C2062979)

Concepts Disease or Syndrome (T047)
English acute spontaneous bacterial peritonitis (diagnosis), spontaneous bacterial peritonitis, acute spontaneous bacterial peritonitis
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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