Spontaneous bacterial peritonitis laboratory findings: Difference between revisions

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==Overview==
==Overview==
Diagnosis requires [[paracentesis]] (needle drainage of the ascitic fluid). Ascites culture is negative in up to 60% of patients with clinical manifestations of spontaneous bacterial peritonitis (SBP), therefore, the diagnosis is based on the [[neutrophil]] count, which reaches its highest sensitivity with a cutoff [[neutrophil]] count of > 250/mm<sup>3</sup>.<ref name="pmid20633946">{{cite journal| author=European Association for the Study of the Liver| title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. | journal=J Hepatol | year= 2010 | volume= 53 | issue= 3 | pages= 397-417 | pmid=20633946 | doi=10.1016/j.jhep.2010.05.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20633946  }} </ref>
* Diagnosis requires [[paracentesis]] (needle drainage of the ascitic fluid).  
* Ascitic fluid culture is negative in up to 60% of patients with clinical manifestations of spontaneous bacterial peritonitis (SBP)
* Therefore, the diagnosis of SBP is based on the [[neutrophil]] count, which reaches its highest sensitivity with a cutoff [[neutrophil]] count of > 250/mm<sup>3</sup>.<ref name="pmid20633946">{{cite journal| author=European Association for the Study of the Liver| title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. | journal=J Hepatol | year= 2010 | volume= 53 | issue= 3 | pages= 397-417 | pmid=20633946 | doi=10.1016/j.jhep.2010.05.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20633946  }} </ref>
* [[Leukocytosis]] and [[acidosis]] may be present, but they are non-specific findings.
* Plain abdominal X-rays may reveal dilated, oedematous intestines, although it is mainly useful to look for [[pneumoperitoneum]] (free air in the peritoneal cavity), which may also be visible on [[chest X-rays]].
* If reasonable doubt still persists, an exploratory peritoneal lavage may be performed (e.g. in the case of [[physical trauma|trauma]], in order to look for [[white blood cells]], [[red blood cells]], or [[bacteria]]).


==Laboratory Findings==
==Laboratory Findings==
Laboratory tests, most importantly ascitic fluid analysis is required for confirmation of diagnosis of [[spontaneous bacterial peritonitis]].
===Routine laboratory studies for peritonitis include:===
* Ascitic fluid analysis is the gold standard and is required for the confirmation of the diagnosis of [[spontaneous bacterial peritonitis]].
* [[Complete blood count]] and [[Differential blood count (patient information)|differential count]]  are tested to confirm infection.
* [[Complete blood count]] and [[Differential blood count (patient information)|differential count]]  are tested to confirm infection.
* [[Serum electrolytes]] and [[creatinine]] to asses the renal function.
* BUN, S.creatinine to asses the renal function.
* [[Liver function tests]] are to performed for evaluation of [[cirrhosis]].
* ABG analysis
* [[Blood cultures]] may be useful in sepsis
* S.glucose
* [[Urine culture]] to rule out [[asymptomatic bacteriuria]]  
* Blood culture may be useful in sepsis
* Serum electrolytes
* Liver Function tests are to be performed for the evaluation of [[cirrhosis]]
* Coagulation profile
* Urine analysis and culture  to rule out [[asymptomatic bacteriuria]]  
* Amylase and Lipase levels to rule out pancreatitis as the cause of ascites
===SBP===
*''' Early Diagnostic paracentesis''' (< 72hrs) is recommended to perform in all cirrhotic patients with ascites:
** At the time of admission and/or
** In the case of gastrointestinal (GI) bleeding,
** Shock,
** Evident signs of inflammation,
** Hepatic encephalopathy,
** Worsening of liver function and/or
** Renal dysfunction
* Paracentesis reveals an ascitic fluid with, most commonly,
** A total white cell count of up to 500 cells/mcL with a high polymorphonuclear (PMN) cell count (250/mm<sup>3</sup> more) and a
** Protein concentration of 1 g/dL (10 g/L) or less,
** Corresponding to decreased ascitic opsonic activity.
*'''Ascitic fluid analysis and culture''' performed:
** Before initiating antibiotic therapy by
** Bedside inoculation of ascitIc fluid ≥ 10 mL into blood culture bottles.
** 80-90% positive and provides the highest yield.
* Absoulte neutrophil count - a total count of >250 cells/mm<sup>3</sup> confirm the diagnosis of spontaneous bacterial peritonitis.
** When culture is positive, the most common organisms are Gram-negative bacteria (mainly ''[[Escherichia coli]]'') and Gram-positive cocci (usually [[Streptococcus]] spp. and [[enterococci]]).<ref name="pmid8228129">{{cite journal| author=Caly WR, Strauss E| title=A prospective study of bacterial infections in patients with cirrhosis. | journal=J Hepatol | year= 1993 | volume= 18 | issue= 3 | pages= 353-8 | pmid=8228129 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8228129  }} </ref>
** If the diagnosis is doubtful, the serum procalcitonin level has a 95% sensitivity, and 98% specificity with a 0.75 ng/mL cutoff.<ref name="pmid11030164">{{cite journal| author=Viallon A, Zeni F, Pouzet V, Lambert C, Quenet S, Aubert G et al.| title=Serum and ascitic procalcitonin levels in cirrhotic patients with spontaneous bacterial peritonitis: diagnostic value and relationship to pro-inflammatory cytokines. | journal=Intensive Care Med | year= 2000 | volume= 26 | issue= 8 | pages= 1082-8 | pmid=11030164 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11030164  }} </ref> 
** Some patients may have an ascitic neutrophil count <250 cells/mm<sup>3</sup> with positive cultures. This is known as "bacterascites".
** These patients should undergo a second [[paracentesis]].
** Patients with signs of [[Systemic inflammatory response syndrome]] ([[SIRS]]) or in whom the repeat ascitic neutrophil count is >250 cells/mm<sup>3</sup> should receive antibiotic therapy,
** If not, they should be followed up.<ref name="pmid20633946">{{cite journal| author=European Association for the Study of the Liver| title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. | journal=J Hepatol | year= 2010 | volume= 53 | issue= 3 | pages= 397-417 | pmid=20633946 | doi=10.1016/j.jhep.2010.05.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20633946  }} </ref>
** Albumin concentration - it is important for the calculation of [[serum-ascites albumin gradient]] , this helps us in identifying the [[portal hypertension]] and prognosis.
** Protein concentration - [[low protein concentration]] is noticed in cases of [[spontaneous bacterial peritonitis]] which differentiates it from secondary bacterial peritonitis where it is normal.
*Recently '''leukocyte esterase calibrated reagent strips (LERS)''' to assess the PMN cell count  (cut-off of > 250 PMN/mcL) are promised to provide good screening results when the strip turns any hue of tan/brown at 3 min. High degree of sensitivity, but the sensitivity is too low for routine use.<ref name="pmid20646775">{{cite journal| author=Mendler MH, Agarwal A, Trimzi M, Madrigal E, Tsushima M, Joo E et al.| title=A new highly sensitive point of care ''screen'' for spontaneous bacterial peritonitis using the leukocyte esterase method. | journal=J Hepatol | year= 2010 | volume= 53 | issue= 3 | pages= 477-83 | pmid=20646775 | doi=10.1016/j.jhep.2010.04.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20646775  }} </ref>         
===Ascitic Fluid Analysis===
===Ascitic Fluid Analysis===
* A high index of suspicion must exist for ascitic fluid infection in a cirrhotic patient. Given the similarities in presentation between the variants of ascitic fluid infection and the inability to clinically distinguish spontaneous from secondary peritonitis, the diagnosis of SBP should be through abdominal paracentesis as it has been shown to be safe with a low risk for complication, even in patients with marked coagulopathy and thrombocytopenia.
* A high index of suspicion must exist for ascitic fluid infection in a cirrhotic patient. Given the similarities in presentation between the variants of ascitic fluid infection and the inability to clinically distinguish spontaneous from secondary peritonitis, the diagnosis of SBP should be through abdominal paracentesis as it has been shown to be safe with a low risk for complication, even in patients with marked coagulopathy and thrombocytopenia.
Line 32: Line 70:
# Albumin (if SAAG unknown)
# Albumin (if SAAG unknown)
# Serum-ascites albumin gradient (if not calculated before)
# Serum-ascites albumin gradient (if not calculated before)
* When culture is positive, the most common organisms are Gram-negative bacteria (mainly ''[[Escherichia coli]]'') and Gram-positive cocci (usually [[Streptococcus]] spp. and [[enterococci]]).<ref name="pmid8228129">{{cite journal| author=Caly WR, Strauss E| title=A prospective study of bacterial infections in patients with cirrhosis. | journal=J Hepatol | year= 1993 | volume= 18 | issue= 3 | pages= 353-8 | pmid=8228129 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8228129  }} </ref>
 
* If the diagnosis is doubtful, the serum procalcitonin level has a 95% sensitivity, and 98% specificity with a 0.75 ng/mL cutoff.<ref name="pmid11030164">{{cite journal| author=Viallon A, Zeni F, Pouzet V, Lambert C, Quenet S, Aubert G et al.| title=Serum and ascitic procalcitonin levels in cirrhotic patients with spontaneous bacterial peritonitis: diagnostic value and relationship to pro-inflammatory cytokines. | journal=Intensive Care Med | year= 2000 | volume= 26 | issue= 8 | pages= 1082-8 | pmid=11030164 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11030164  }} </ref> 
* Some patients may have an ascitic neutrophil count <250 cells/mm<sup>3</sup> with positive cultures. This is known as "bacterascites". This patients should undergo a second [[paracentesis]]. Patients with signs of [[Systemic inflammatory response syndrome]] ([[SIRS]]) or in whom the repeat ascitic neutrophil count is >250 cells/mm<sup>3</sup> should receive antibiotic therapy, if not, they should be followed up.<ref name="pmid20633946">{{cite journal| author=European Association for the Study of the Liver| title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. | journal=J Hepatol | year= 2010 | volume= 53 | issue= 3 | pages= 397-417 | pmid=20633946 | doi=10.1016/j.jhep.2010.05.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20633946  }} </ref>
* Albumin concentration - it is important for the calculation of [[serum-ascites albumin gradient]] , this helps us in identifying the [[portal hypertension]] and prognosis.
* Protein concentration - [[low protein concentration]] is noticed in cases of [[spontaneous bacterial peritonitis]] which differentiates it from secondary bacterial peritonitis where it is normal.
*Given the rapidity (90 s), low cost, and availability ‘dipstick’ testing of ascites allows for more rapid diagnosis and management of SBP.
*Given the rapidity (90 s), low cost, and availability ‘dipstick’ testing of ascites allows for more rapid diagnosis and management of SBP.



Revision as of 01:39, 17 January 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Guillermo Rodriguez Nava, M.D. [3] Shivani Chaparala M.B.B.S [4]

Overview

  • Diagnosis requires paracentesis (needle drainage of the ascitic fluid).
  • Ascitic fluid culture is negative in up to 60% of patients with clinical manifestations of spontaneous bacterial peritonitis (SBP)
  • Therefore, the diagnosis of SBP is based on the neutrophil count, which reaches its highest sensitivity with a cutoff neutrophil count of > 250/mm3.[1]
  • Leukocytosis and acidosis may be present, but they are non-specific findings.
  • Plain abdominal X-rays may reveal dilated, oedematous intestines, although it is mainly useful to look for pneumoperitoneum (free air in the peritoneal cavity), which may also be visible on chest X-rays.
  • If reasonable doubt still persists, an exploratory peritoneal lavage may be performed (e.g. in the case of trauma, in order to look for white blood cells, red blood cells, or bacteria).

Laboratory Findings

Routine laboratory studies for peritonitis include:

  • Ascitic fluid analysis is the gold standard and is required for the confirmation of the diagnosis of spontaneous bacterial peritonitis.
  • Complete blood count and differential count are tested to confirm infection.
  • BUN, S.creatinine to asses the renal function.
  • ABG analysis
  • S.glucose
  • Blood culture may be useful in sepsis
  • Serum electrolytes
  • Liver Function tests are to be performed for the evaluation of cirrhosis
  • Coagulation profile
  • Urine analysis and culture to rule out asymptomatic bacteriuria
  • Amylase and Lipase levels to rule out pancreatitis as the cause of ascites

SBP

  • Early Diagnostic paracentesis (< 72hrs) is recommended to perform in all cirrhotic patients with ascites:
    • At the time of admission and/or
    • In the case of gastrointestinal (GI) bleeding,
    • Shock,
    • Evident signs of inflammation,
    • Hepatic encephalopathy,
    • Worsening of liver function and/or
    • Renal dysfunction
  • Paracentesis reveals an ascitic fluid with, most commonly,
    • A total white cell count of up to 500 cells/mcL with a high polymorphonuclear (PMN) cell count (250/mm3 more) and a
    • Protein concentration of 1 g/dL (10 g/L) or less,
    • Corresponding to decreased ascitic opsonic activity.
  • Ascitic fluid analysis and culture performed:
    • Before initiating antibiotic therapy by
    • Bedside inoculation of ascitIc fluid ≥ 10 mL into blood culture bottles.
    • 80-90% positive and provides the highest yield.
  • Absoulte neutrophil count - a total count of >250 cells/mm3 confirm the diagnosis of spontaneous bacterial peritonitis.
  • Recently leukocyte esterase calibrated reagent strips (LERS) to assess the PMN cell count (cut-off of > 250 PMN/mcL) are promised to provide good screening results when the strip turns any hue of tan/brown at 3 min. High degree of sensitivity, but the sensitivity is too low for routine use.[4]

Ascitic Fluid Analysis

  • A high index of suspicion must exist for ascitic fluid infection in a cirrhotic patient. Given the similarities in presentation between the variants of ascitic fluid infection and the inability to clinically distinguish spontaneous from secondary peritonitis, the diagnosis of SBP should be through abdominal paracentesis as it has been shown to be safe with a low risk for complication, even in patients with marked coagulopathy and thrombocytopenia.

Diagnostic paracentesis

  • Performed in all cirrhotics with ascites:
  1. upon admission to the hospital
  2. who develop any change in clinical status including fever, abdominal pain, mental status changes, ileus, or septic shock
  3. who develop laboratory abnormalities such as a leukocytosis, acidosis, or renal failure
  4. during episodes of gastrointestinal bleeding prior to the administration of antibiotics
  • The following tests are recommended for suspected infection of the ascitic fluid:
  1. Cell counts with differential : Absoulte neutrophil count - a total count of >250 cells/mm3 confirm the diagnosis of spontaneous bacterial peritonitis.most sensitive and single best

test in diagnosing ascitic fluid infection [45]. Not all cases in which the PMN count is above this threshold represent infection, and values in this range can be seen with hemorrhage into ascites, peritoneal carcinomatosis, or pancreatic ascites. A useful distinguishing feature is that the PMN is usually not the predominant cell type in these cases

  1. Culture (in blood culture bottles)[5]
  2. Gram’s stain
  3. Total protein
  4. Lactate dehydrogenase
  5. Glucose
  6. Amylase
  7. Albumin (if SAAG unknown)
  8. Serum-ascites albumin gradient (if not calculated before)
  • Given the rapidity (90 s), low cost, and availability ‘dipstick’ testing of ascites allows for more rapid diagnosis and management of SBP.

References

  1. 1.0 1.1 European Association for the Study of the Liver (2010). "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J Hepatol. 53 (3): 397–417. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.
  2. Caly WR, Strauss E (1993). "A prospective study of bacterial infections in patients with cirrhosis". J Hepatol. 18 (3): 353–8. PMID 8228129.
  3. Viallon A, Zeni F, Pouzet V, Lambert C, Quenet S, Aubert G; et al. (2000). "Serum and ascitic procalcitonin levels in cirrhotic patients with spontaneous bacterial peritonitis: diagnostic value and relationship to pro-inflammatory cytokines". Intensive Care Med. 26 (8): 1082–8. PMID 11030164.
  4. Mendler MH, Agarwal A, Trimzi M, Madrigal E, Tsushima M, Joo E; et al. (2010). "A new highly sensitive point of care screen for spontaneous bacterial peritonitis using the leukocyte esterase method". J Hepatol. 53 (3): 477–83. doi:10.1016/j.jhep.2010.04.011. PMID 20646775.
  5. Runyon BA, Canawati HN, Akriviadis EA (1988). "Optimization of ascitic fluid culture technique". Gastroenterology. 95 (5): 1351–5. PMID 3049220.


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