Ascites bacterial peritonitis

Decompensated liver disease is complicated by jaundice, refractory ascites, bacterial peritonitis, coagulopathy, and variceal bleeding and may require liver transplantation. The number of liver transplants for decompensated cirrhosis doubled from 1990 to 2004, when 5845 cadaveric (orthotopic) liver transplants were performed (65). 

O Portal hypertension is the precipitating factor for the complications of cirrhotic liver disease—ascites, spontaneous bacterial peritonitis (SBP), variceal bleeding, and hepatic encephalopathy. Lowering portal pressure can reduce the complications of cirrhosis and decrease morbidity and mortality. 

Drug therapy for portal hypertension and cirrhosis can alleviate symptoms and prevent complications but it cannot reverse cirrhosis. Drug therapy is available to treat the complications of ascites, varices, spontaneous bacterial peritonitis, hepatic encephalopathy, and coagulation abnormalities. 

FIGURE 19-5. Approach to the patient with ascites and spontaneous bacterial peritonitis (SBP). 

Patients who have previously experienced spontaneous bacterial peritonitis and have low-protein ascites (ascitic fluid albumin less than 1 g/dL [less than 10 g/L]) are candidates for long-term prophylactic therapy. Recommended regimens include either a single trimethoprim-sulfamethoxazole doublestrength tablet 5 days per week (Monday through Friday) or ciprofloxacin 750 mg once weekly.19,46 Any patient who has experienced an episode of variceal bleeding should also receive prophylactic antibiotics. 

Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhotic ascites, arising most frequently in those with advanced liver disease. Its development leads to a further reduction in the effective arterial blood volume, and it has a mortality rate equivalent to that of a variceal bleed [202], Since hepatic blood flow and func-... 

Garcia-Tsao G Current management of the complications of cirrhosis and portal hypertension Variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology 2001 120 726-748. 

Runyon BA Patients with deficient ascitic fluid opsonic activity are predisposed to spontaneous bacterial peritonitis. Hepatology... 

Guarner C, Runyon BA, Heck M, Young S, Sheikh MY Effect of long-term trimetho-prim/sulfamethoxazole prophylaxis on ascites formation, bacterial translocation, spontaneous bacterial peritonitis and survival in cirrhotic rats. Dig Dis Sci 1999 44 1957— 1962. 

Peritoneal dialysis Cirrhosis with ascites Nephrotic syndrome Secondary bacterial peritonitis... 

Hepato-renal syndrome rapid progressive (type I) with rising serum creatinine levels, or non-progressive and less severe (type II) impairment of renal function, often consequent on bacterial peritonitis, with persistent ascites responds to vasoconstrictor treatment, typically with terlipressin through constriction of splanchnic vessels and improved renal perfusion. Withdrawal of treatment does not seem to lead inevitably to recurrence. Haemodialysis may also stabilise patients. 

Gines P, Arroyo V, Rhodes J. Ascites, hepatorenal syndrome, and spontaneous bacterial peritonitis. In MacDonald JWD, Burroughs AK, Feagan BG, editors. Evidence-based gastroenterology and hepatology. 2nd ed. London Blackwells Publishing, BMJ Books 2004. p. 487-503. 

The use of lUDs in patients with CLD has complicating factors. Owing to reduced hepatic complement synthesis and reticuloendothelial system dysfunction, patients with cirrhosis and ascites are prone to develop repeated episodes of spontaneous bacterial peritonitis (SBP). Historically, the risk of pelvic inflammatory disease (PID) was considered to be increased in lUD users during the first year after insertion, therefore it was thought that the presence of an lUD in approximation with the peritoneal surface in a patient with cirrhotic ascites might lead to SBP... 

Patient 4 is a 58-year-old with a history of excess alcohol intake approximately 60 units per week for the past four years. Recent admissions have been for ascites requiring paracentesis, spontaneous bacterial peritonitis, and large variceal bleeds. Over the last six months the patient has had a reduced appetite, poor nutrition and a significant loss of muscle mass. 

The aim is to induce natriuresis with consequent loss of water. Fluid restriction is unnecessary unless the plasma sodium falls below 120mmol/l. The initial management must include a diagnostic tap of the ascitic fluid as spontaneous bacterial peritonitis complicates up to 25% of patients on presentation. 

Spontaneous bacterial empyema is found in 1-2% of patients with cirrhosis and ascites. The diagnosis is based on a positive bacterial test in the pleural fluid and a WBC count in excess of 250/mm (or a negative bacterial culture with a cell count exceeding 500/mm ) - which is analogous to spontaneous bacterial peritonitis. (105) (s. p. 302)... 

Spontaneous bacterial peritonitis (SBP) (H.O. Conn, 1964, 1971) is the term used to describe bacterially infected ascitic fluid in liver cirrhosis where the exact source of infection or path of infection is not known. 

Each of these 3 forms of SBP has to be delimited from secondary bacterial peritonitis. In bacterial ascites, several types of microorganisms, including fungi, can usually be identified after subculturing. As a rule, the cell count exceeds 10,000/mm, the LDH value is elevated (> 225 U/1), and the glucose concentration is < 50 mg/dl. 

Transplantation of the liver essentially gives patients with refractory portal ascites a chance to start a new life. However, in the presence of large-scale ascites, the surgeon is faced with a number of specific problems such as overdilated and thin abdominal walls, existing hernia, spontaneous bacterial peritonitis, significant volume displace-... 

L., Fraquelli, M., Penagini, R., Biandii, P.A. Erequency of spontaneous bacterial peritonitis in 265 cirrhotics with ascites. Europ. X Gastroenterol. Hepatol. 1993 5 41-45... 

Evans, L.T., Kim, W.R., Poterucha, J.J., Kamath, P.S. Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology 2003 37 897-901... 

Gitlin, N., Stauffer, J.L., Silvestri, R.C. The pH of ascitic fluid in the diagnosis of spontaneous bacterial peritonitis in alcoholic patients. Hepatology 1992 2 406-411... 

Llach, J., Rimola, A., Navasa, M., Gines, R, Salmeron, J.M., Gines, A., Arroyo, V., Rodes, J. Incidence and predictive factors of first episode of spontaneous bacterial peritonitis in cirrhosis with ascites relevance of ascitic fluid protein concentration. Hepatology 1992 16 724-727... 

Pelletier, G., Salmon, D., Ink, O., Hannoun, S., Attali, R, Buffet, C., Etienne, J.P. Culture-negative neutrocytic ascites a less severe variant of spontaneous bacterial peritonitis. J. Hepatology 1990 10 327 - 331... 

Runyon, B.A., Antillon, M.R., McHutchison, J.G. Diuresis increases ascitic fluid opsonic activity in patients who survive spontaneous bacterial peritonitis. J. Hepatol. 1992 14 249-252... 

Storgaard, J.S., Svendsen, J.H., Hegnhoj, J., Krlntel, J.J., Nielsen, P.B. Incidence of spontaneous bacterial peritonitis in patients with ascites. Diagnostic value of white blood ceh count and pH measurement in ascitic fluid. Liver 1991 11 248-252... 

Complications such as variceal bleeding, hepatic encephalopathy, ascites and infections as well as reduced renal function also influence the mortality rate of liver cirrhosis (in Germany some 25,000/year). The main causes of death are hepatic coma or liver failure (25-40%), bleeding (20-30%), infections (about 10%) and HCC (about 5%). Spontaneous bacterial peritonitis is fatal in 50-70%, and with liver dysfunction even in 90% of cases. Occurrence of the hepatorenal syndrome is almost invariably fatal. 

Ascites unresponsive to treatment Hepatopulmonary syndrome Hepatorenal syndrome Recurrent varix bleeding Severe hypoalimentation Spontaneous bacterial peritonitis... 

The penetration of routinely used fluoroquinolones into ascitic fluid after intravenous administration has been studied in patients with uncompensated hepatic cirrhosis (125). Three patients received three doses of ciprofloxacin 200 mg, six received three doses of ciprofloxacin 300 mg, seven received three doses of pefloxacin 400 mg, and six received three doses of ofloxacin 400 mg. Pefloxacin and ofloxacin produced serum and ascitic fluid concentrations above the MICs of the common pathogens that cause spontaneous bacterial peritonitis, and the authors concluded that... 

Ascites is the effusion and accumulation of fluid in the abdominal cavity. Ascites is the most common chnical finding in patients with portal hypertension. Ascites itself is not life threatening, but is uncomfortable and may compromise respiration (from upward displacement of the diaphragm and compression of the lungs). It also predisposes individuals to spontaneous bacterial peritonitis, which is life threatening. 

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