| Chronic liver disease
| Alkaline phosphatase (ALP)
| Liver Function Tests
| Ascites Assessment and Management
| Budd-Chiari syndrome
| Autoimmune Hepatitis
| Primary Biliary Cirrhosis
| Primary Sclerosing Cholangitis
| Wilson disease
| Hereditary Haemochromatosis
| Alpha-1 Antitrypsin (AAT) deficiency
| Non alcoholic steatohepatitis (NASH)
| Spontaneous Bacterial Peritonitis
| Alcoholism and Alcoholic Liver Disease
Diagnostic paracentesis should be performed in any patient with symptoms or signs of spontaneous bacterial peritonitis, including unexplained encephalopathy or renal dysfunction or GI haemorrhage. A diagnostic paracentesis is recommended in all patients with new-onset ascites.
- Infection of the peritoneal fluid with no obvious cause
- Most commonly seen in patients with end-stage liver disease.
- Seen in up to 8-10 % of cirrhotics with ascites. May be recurrent.
- Predisposition due to impaired immune function and shunting of blood away from the hepatic Kupffner cells through portosystemic collateral's
- This allows a transient bacteraemia to become more prolonged, thereby colonizing Ascitic fluid.
- Gram negative gut organisms
- Enterobacteriaceae (Klebsiella)
- Gram-positive organisms
- Streptococcus (viridans)
- Pneumococcus species may also be found.
- klebsiella and enterococci
When to look for SBP: Ascites +
- GI bleeding OR Shock OR Fever
- Signs of systemic inflammation
- Gastrointestinal symptoms
- Hepatic encephalopathy
- Worsening liver or renal function
- Infection e.g. UTI, sepsis, Chest infection
- Spontaneous bacterial peritonitis always check
- Enteral protein load e.g. a Bleed
- Constipation and reduced gut transit
- Drugs e.g. codeine, morphine, benzodiazepines, others
- Worsening renal/cardiac/chest function/hepatorenal syndrome
- Worsening liver function e.g. continued drinking or just ongoing liver damage e.g. paracetamol overdose
- Idiopathic - no cause found
- Can lead to decompensation and the onset of hepatic encephalopathy
- Fever, jaundice, fever, vomiting and abdominal pain
- Delirium, GI bleeding
- Classical signs of SBP such as pain and fever may be absent
- Send for Microscopy: a neutrophil count > 250/mm3 is diagnostic.
- Ascites albumin and serum albumin and measure gradient
- Ascitic fluid - low pH
- Ascitic fluid culture with bedside inoculation of blood culture bottles
- Bedside (standard urine) leukocyte esterase reagent strip testing of ascitic fluid can aid the rapid diagnosis of SBP; highly-sensitive leukocyte esterase reagent strip testing of ascitic fluid may be used to rule out SBP.
- In those with ascitic neutrophil count > 250 cells/mm3 then empirical antibiotic therapy with an intravenous third-generation cephalosporin e.g cefotaxime, ceftriaxone and fluoroquinolones is suggested. Cefotaxime 2 g tds should be started or consult local guidelines
- Patients with SBP and signs of developing renal
impairment should be given albumin at 1.5 g albumin/kg in the first six hours followed by 1 g/kg on day 3.
- Patients who have recovered from an episode of SBP should be considered for treatment with norfloxacin (400 mg once daily), Ciprofloxacin (500 mg OD PO) or co-trimoxazole (800 mg sulfamethoxazole and 160 mg Trimethoprim daily, orally) to prevent a further episode of SBP e.g. Prophylaxis of spontaneous bacterial peritonitis (SBP) Ciprofloxacin 500mg PO OD long term
- SBP in a patient for possible transplant - talk to regional liver centre and get early advice
- There is evidence that norfloxacin reduces recurrence of SBP with a history of SBP or with high protein
- Antibiotics reduce the risk of bacterial peritonitis following a GI bleed.