Makindo Medical Notes.com

Related Subjects: |Chronic liver disease |Cirrhosis |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.

About

• 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.

Aetiology

• 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.

Microbiology

• Gram negative gut organisms
  • E.coli
  • Enterobacteriaceae (Klebsiella)
• Gram-positive organisms
  • Streptococcus (viridans)
  • Enterococcus
  • 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

Precipitants

• 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

Clinical

• 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

Investigations

• 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.

Management

• 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.

References

• Guidelines on the management of ascites in cirrhosis 2020
• EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis