Spontaneous bacterial peritonitis laboratory findings: Difference between revisions

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__NOTOC__
__NOTOC__
{{Spontaneous bacterial peritonitis}}
{{Spontaneous bacterial peritonitis}}
{{CMG}} ; {{AE}} {{ADI}} {{GRN}} {{SCh}}
{{CMG}} ; {{AE}} {{SCh}}{{AY}}


==Overview==
==Overview==  
''' Early Diagnostic [[paracentesis]]''' ((needle drainage of the ascitic fluid performed in < 72hrs) is recommended in all cirrhotic patients with ascites. [[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 an Ascitic fluid analysis and culture performed before initiating antibiotic therapy by bedside inoculation of ascitIc fluid ≥ 10 mL into blood culture bottles. Ascitic fluid analysis is the gold standard and is required for the confirmation of the diagnosis of [[spontaneous bacterial peritonitis]]. 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. 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]]).
Early Diagnostic [[paracentesis]] (needle drainage of the ascitic fluid performed in < 72hrs) is recommended in all cirrhotic patients with [[ascites]]. [[Paracentesis]] reveals an ascitic fluid with a total [[white cell count]] of up to 500 cells/mcL, a high polymorphonuclear ([[PMN]]) cell count (250/mm<sup>3</sup> more). Ascitic fluid analysis and culture must be performed before initiating [[antibiotic therapy]] by bedside inoculation of ascitIc fluid ≥ 10 mL into [[blood culture]] bottles. Ascitic fluid analysis is the [[Gold standard (test)|gold standard]] for the confirmation of the diagnosis of [[spontaneous bacterial peritonitis]]. 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|neutrophil count]], which reaches its highest [[Sensitivity (tests)|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 are non-specific. 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==
{| class="wikitable"
{| class="wikitable"
! colspan="10" |Laboratory tests for the diagnosis and differential diagnosis of SBP
! colspan="9" |Laboratory tests for the diagnosis and differential diagnosis of [[SBP]]
|-
|-
!Ascitic fluid analysis
!Ascitic fluid analysis
!Normal
!Spontaneous Bacterial Peritonitis
!Spontaneous Bacterial Peritonitis
!Secondary bacterial peritonitis
![[Secondary peritonitis|Secondary bacterial peritonitis]]
!Hepatic ascites
![[Ascites|Hepatic ascites]]<ref name="pmid23717736">{{cite journal| author=Moore CM, Van Thiel DH| title=Cirrhotic ascites review: Pathophysiology, diagnosis and management. | journal=World J Hepatol | year= 2013 | volume= 5 | issue= 5 | pages= 251-63 | pmid=23717736 | doi=10.4254/wjh.v5.i5.251 | pmc=3664283 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23717736  }} </ref>
!Cardiac ascites
![[Ascites|Cardiac ascites]]<ref name="pmid3418089">{{cite journal| author=Runyon BA| title=Cardiac ascites: a characterization. | journal=J Clin Gastroenterol | year= 1988 | volume= 10 | issue= 4 | pages= 410-2 | pmid=3418089 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3418089  }} </ref>
!Nephrogenic ascites
!Nephrogenic ascites
!Pancreatic ascites
![[Pancreatitis|Pancreatic ascites]]
!Tuberculous ascites
![[Tuberculous peritonitis|Tuberculous ascites]]
!Malignant ascites
![[Malignant ascites]]<ref name="pmid3417231">{{cite journal| author=Runyon BA, Hoefs JC, Morgan TR| title=Ascitic fluid analysis in malignancy-related ascites. | journal=Hepatology | year= 1988 | volume= 8 | issue= 5 | pages= 1104-9 | pmid=3417231 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3417231  }} </ref>
|-
|-
|Gross appearance  
|Gross appearance  
|
|Cloudy or turbid
|cloudy or turbid
|Turbid or purulent
|turbid or purulent
|Clear straw or milky
|clear straw or milky
|Clear to pale yellow
|clear to pale yellow
|Straw colored or [[Chylous ascites|chylous]]
|straw colored or chylous
|Milky or cloudy or turbid
|milky or cloudy or turbid
|Milky or normal
|milky or normal
|Milky or bloody
|milky or bloody
|-
|-
|Leukocyte count and differential (cells/mm<sup>3</sup>)
|[[White blood cells|Leukocyte count]] and differential (cells/mm<sup>3</sup>)
|
|≥ 250 [[PMN]]
|≥ 250 PMN
|> 1000 [[WBC]]
|> 1000 WBC
predominantly  
predominantly  


PMN
[[PMN]]
|< 500 WBC
|< 500 [[WBC]]
≥ 250 PMN or normal
≥ 250 [[PMN]] or normal
|< 500 WBC
|< 500 [[WBC]]
< 250 PMN
< 250 [[PMN]]
|< 500 WBC
|< 500 [[WBC]]
< 250 PMN
< 250 [[PMN]]
|< 500 WBC  
|< 500 WBC  
≥ 250 PMN
≥ 250 PMN
|≥ 250 PMN or normal  
|≥ 250 PMN or normal  
|≥ 500 WBC
|≥ 500 [[WBC]]
|-
|-
|Total protein
|Total [[protein]]
|
|≥ 25 g/L
|≥ 25 g/L
|> 25 g/ L
|> 25 g/ L
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|≥ 25 g/L
|≥ 25 g/L
|-
|-
|Serum-ascites albumin gradient
|[[Serum-ascites albumin gradient]]<ref name="pmid3168691">{{cite journal| author=Mauer K, Manzione NC| title=Usefulness of serum-ascites albumin difference in separating transudative from exudative ascites. Another look. | journal=Dig Dis Sci | year= 1988 | volume= 33 | issue= 10 | pages= 1208-12 | pmid=3168691 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3168691  }} </ref><ref name="pmid1616215">{{cite journal| author=Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG| title=The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. | journal=Ann Intern Med | year= 1992 | volume= 117 | issue= 3 | pages= 215-20 | pmid=1616215 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1616215  }} </ref>
|
|≥ 1.1 g/dL
|≥ 1.1 g/dL
|≥ 1.1 g/dL
|≥ 1.1 g/dL
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|< 1.1 g/dL
|< 1.1 g/dL
|-
|-
|LDH(lactate dehydrogenase)
|[[LDH]]([[lactate dehydrogenase]])
|
|↑or normal
|↑or normal
|> upper limit of normal for serum LDH
|> Upper limit of normal for serum LDH
|↓
|↓
|↓ or normal
|↓ or normal
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|↑
|↑
|-
|-
|Glucose
|[[Glucose]]
|
|↓
|↓
|< 50 mg/dL
|< 50 mg/dL
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|↓
|↓
|-
|-
|Amylase
|[[Amylase]]
|
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
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|↑or normal
|↑or normal
|-
|-
|Tumor markers
|[[Tumor markers]]
|
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
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|-
|-
|Confirmatory tests
|Confirmatory tests
|Single organism in culture, total protein < 1 g/dL, glucose > 50 mg/dl, LDH < 225 units/  L.
|
|
|single organism in culture, total protein < 1 g/dL, glucose > 50 mg/dl, LDH < 225 units/  L.
* Poly-microbial infection including [[anaerobes]] , total protein > 1 g/dL, glucose < 50 mg/dL, LDH ≥ 225 units/ L.  
|poly-microbial infection including anaerobes , total protein > 1 g/dL, glucose < 50 mg/dL, LDH ≥ 225 units/ L.upright abdominal x-ray, water soluble contrast studies of GI tract
* Upright abdominal x-ray, water soluble contrast studies of GI tract
|ultrasound and/or liver biopsy
|[[ultrasound]] and/or [[liver biopsy]]
|chest x-ray and ekg
|[[Chest X-ray|Chest x-ray]] and ekg
|24-hour urine protein excretion
|24-hour urine protein excretion
|Abdominal CT scan
|Abdominal CT scan
|mycobacterial growth on culture of laparoscopic biopsy specimen of peritoneum
|[[mycobacterial]] growth on culture of laparoscopic biopsy specimen of peritoneum
|search for primary tumor
|Search for primary tumor
|-
|-
|Additional comments
|Additional comments
|Good clinical response to [[antibiotics]].
|
|
|good clinical response to antibiotics.
* Consider surgery if [[perforation]] of gut is suspected.
|Consider surgery if perforation of gut is suspected.
 
CEA >5 ng/ml
* [[CEA]] >5 ng/ml.<ref name="pmid11281549">{{cite journal| author=Wu SS, Lin OS, Chen YY, Hwang KL, Soon MS, Keeffe EB| title=Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation. | journal=J Hepatol | year= 2001 | volume= 34 | issue= 2 | pages= 215-21 | pmid=11281549 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11281549  }} </ref>


Alkaline phosphatase > 240 units/ L
* [[Alkaline phosphatase]] > 240 units/ L.<ref name="pmid11281549">{{cite journal| author=Wu SS, Lin OS, Chen YY, Hwang KL, Soon MS, Keeffe EB| title=Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation. | journal=J Hepatol | year= 2001 | volume= 34 | issue= 2 | pages= 215-21 | pmid=11281549 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11281549  }} </ref>
|
|
|
|
|
|
|ascitic fluid amylase > 100 units/ L
|Ascitic fluid amylase > 100 units/ L
|laparoscopy, peritoneal biopsy, bacteriology, PCR.
|[[laparoscopy]], peritoneal biopsy, bacteriology, [[Polymerase chain reaction|PCR]].
|cytology
|[[cytology]]
|-
|-
|Relative frequency
|Relative frequency
|
| -
| -
| -
| -
|81%
|81%
|3%
|3%
|Dialysis associated- 1%
|[[Dialysis]] associated- 1%
|1%
|1%
|2%
|2%
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===Routine laboratory studies for spontaneous bacterial peritonitis include:===
===Routine laboratory studies for spontaneous bacterial peritonitis include:===
* [[Complete blood count]] and [[Differential blood count (patient information)|differential count]] to confirm infection.
* [[Complete blood count]] and [[Differential blood count (patient information)|differential count]] to confirm infection.
* BUN, S.creatinine to asses the renal function.
* [[BUN]], S.[[creatinine]] to asses the [[renal function]].
* ABG analysis
* [[ABG]] analysis
* S.glucose
* [[Serum glucose|S.glucose]]
* Blood culture may be useful in sepsis
* [[Blood culture]] may be useful in [[sepsis]]
* Serum electrolytes
* [[Electrolyte|Serum electrolytes]]
* Liver Function tests and serum.bilirubin to assess the liver function.
* [[Liver function tests]] and [[serum bilirubin]] to assess the liver function.<ref name="TergGadano2009">{{cite journal|last1=Terg|first1=Rubén|last2=Gadano|first2=Adrian|last3=Cartier|first3=Mariano|last4=Casciato|first4=Paola|last5=Lucero|first5=Romina|last6=Muñoz|first6=Alberto|last7=Romero|first7=Gustavo|last8=Levi|first8=Diana|last9=Terg|first9=Gonzalo|last10=Miguez|first10=Carlos|last11=Abecasis|first11=Raquel|title=Serum creatinine and bilirubin predict renal failure and mortality in patients with spontaneous bacterial peritonitis: a retrospective study|journal=Liver International|volume=29|issue=3|year=2009|pages=415–419|issn=14783223|doi=10.1111/j.1478-3231.2008.01877.x}}</ref>
* Coagulation profile
* Coagulation profile
* Urine analysis and culture  to rule out [[asymptomatic bacteriuria]]  
* [[Urinalysis|Urine analysis]] and [[Urine culture|culture]] to rule out [[asymptomatic bacteriuria]]  
* Amylase and Lipase levels to rule out pancreatitis as the cause of ascites
* [[Amylase]] and [[Lipase]] levels to rule out [[pancreatitis]] as the cause of [[ascites]]
* [[Procalcitonin|Procalcitonin level (PCT)]] level was higher in advanced [[Cirrhosis|Liver cirrhosis]] patients with SBP than culture negative nuerocytic ascites (CNNA) which indicated it may represent as a simple biomarker for differentiating SBP from CNNA. [[Procalcitonin|PCT]] may be a prognostic predictor to guide the [[Antimicrobial|empirical antimicrobial therapy]] in order to decrease the [[Mortality rate|in-hospital mortality]] and the frequency of complications. <ref name="WuChen2016">{{cite journal|last1=Wu|first1=Hongli|last2=Chen|first2=Lin|last3=Sun|first3=Yuefeng|last4=Meng|first4=Chao|last5=Hou|first5=Wei|title=The role of serum procalcitonin and C-reactive protein levelsin predicting spontaneous bacterial peritonitis in patients with advanced liver cirrhosis|journal=Pakistan Journal of Medical Sciences|volume=32|issue=6|year=2016|issn=1681-715X|doi=10.12669/pjms.326.10995}}</ref>
 


=== ''' Diagnostic [[paracentesis]]''': ===
=== ''' Diagnostic [[paracentesis]]''': ===
Performed usually within 72hrs of admission.<ref name="RimolaGarcía-Tsao2000">{{cite journal|last1=Rimola|first1=Antoni|last2=García-Tsao|first2=Guadalupe|last3=Navasa|first3=Miquel|last4=Piddock|first4=Laura J.V.|last5=Planas|first5=Ramon|last6=Bernard|first6=Brigitte|last7=Inadomi|first7=John M.|title=Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document|journal=Journal of Hepatology|volume=32|issue=1|year=2000|pages=142–153|issn=01688278|doi=10.1016/S0168-8278(00)80201-9}}</ref>
Performed usually within 72 hrs of admission.<ref name="RimolaGarcía-Tsao2000">{{cite journal|last1=Rimola|first1=Antoni|last2=García-Tsao|first2=Guadalupe|last3=Navasa|first3=Miquel|last4=Piddock|first4=Laura J.V.|last5=Planas|first5=Ramon|last6=Bernard|first6=Brigitte|last7=Inadomi|first7=John M.|title=Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document|journal=Journal of Hepatology|volume=32|issue=1|year=2000|pages=142–153|issn=01688278|doi=10.1016/S0168-8278(00)80201-9}}</ref>
{| class="wikitable"
{| class="wikitable"
!Indications for diagnostic paracentesis
!Indications for diagnostic paracentesis
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|-
|-
|
|
* Upon admission to the hospital and/or,
* Upon admission to the hospital  
|-
|-
|
|
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* Worsening of liver function and [[Hepatic encephalopathy]].
* Worsening of liver function and [[Hepatic encephalopathy]].
|}
|}
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.
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]].


===Ascitic Fluid Analysis===
===Ascitic Fluid Analysis===
* {| class="wikitable" ! colspan="2" |Ascitic fluid analysis in SBP |- !Tests !Diagnostic Values |- |Cell count with differential |Leukocyte count > 500 cells/mm<sup>3</sup> Absolute neutrophil count  >250 cells/mm<sup>3</sup>  |- |Bacterial culture |usually positive for Gram-negative bacteria (mainly ''[[Escherichia coli]] and Klebsiella'') and Gram-positive cocci (usually [[Streptococcus]] spp. and [[enterococci]]). |- |Protein concentration |1 g/dL (10 g/L) or less |} Ascitic fluid analysis is the gold standard and is required for the confirmation of the diagnosis of [[spontaneous bacterial peritonitis]].
Ascitic fluid analysis is the [[Gold standard (test)|gold standard]] and is required for the confirmation of the diagnosis of [[spontaneous bacterial peritonitis]].<ref name="pmid19701963">{{cite journal| author=Riggio O, Angeloni S| title=Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis. | journal=World J Gastroenterol | year= 2009 | volume= 15 | issue= 31 | pages= 3845-50 | pmid=19701963 | doi= | pmc=2731245 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19701963  }} </ref>
* As high index of suspicion must exist for ascitic fluid infection in a cirrhotic patient.  
{| class="wikitable"
* The following tests are recommended for suspected infection of the ascitic fluid:
|-
# Cell count with differential : Absoulte neutrophil count - a total count of >250 cells/mm<sup>3</sup> confirm the diagnosis of spontaneous bacterial peritonitis.
!Tests !!Diagnostic Values
* It is the most sensitive and single best test in diagnosing ascitic fluid infection.
|-
* Although, not all cases in which the PMN count is above this threshold represent infection, values in this range can also be seen with hemorrhage into ascites, peritoneal carcinomatosis, or pancreatic ascites.
|[[PMN|Cell count]] with differential
* A useful distinguishing feature is that the PMN is usually not the predominant cell type in these cases
|[[Leukocyte|Leukocyte count]] > 500 cells/mm<sup>3</sup> Absolute neutrophil count  >250 cells/mm<sup>3</sup> 
# Ascitic fluid culture.<ref name="pmid3049220">{{cite journal| author=Runyon BA, Canawati HN, Akriviadis EA| title=Optimization of ascitic fluid culture technique. | journal=Gastroenterology | year= 1988 | volume= 95 | issue= 5 | pages= 1351-5 | pmid=3049220 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3049220  }} </ref>
|-
* Performed before initiating antibiotic therapy by
|[[Bacterial cultures|Bacterial culture]]<ref name="pmid3049220">{{cite journal| author=Runyon BA, Canawati HN, Akriviadis EA| title=Optimization of ascitic fluid culture technique. | journal=Gastroenterology | year= 1988 | volume= 95 | issue= 5 | pages= 1351-5 | pmid=3049220 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3049220  }} </ref>
* By bedside inoculation of ascitIc fluid ≥ 10 mL into blood culture bottles, instead of sending the fluid to the laboratory in a syringe or container, since immediate inoculation improves the yield on bacterial culture from approximately 65% to 90%, when the ascitic fluid cell count is at least 250 cells/mm<sup>3</sup>.
|Usually positive for [[gram-negative bacteria]] (mainly ''[[Escherichia coli]] and [[Klebsiella]]'') 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><ref name="pmid27539758">{{cite journal| author=Sajjad M, Khan ZA, Khan MS| title=Ascitic Fluid Culture in Cirrhotic Patients with Spontaneous Bacterial Peritonitis. | journal=J Coll Physicians Surg Pak | year= 2016 | volume= 26 | issue= 8 | pages= 658-61 | pmid=27539758 | doi=2399 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27539758 }} </ref>
* Separate and simultaneous blood cultures should also be obtained, as up to 50% of patients with SBP have concomitant bacteremia.
|-
* 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><ref name="pmid27539758">{{cite journal| author=Sajjad M, Khan ZA, Khan MS| title=Ascitic Fluid Culture in Cirrhotic Patients with Spontaneous Bacterial Peritonitis. | journal=J Coll Physicians Surg Pak | year= 2016 | volume= 26 | issue= 8 | pages= 658-61 | pmid=27539758 | doi=2399 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27539758  }} </ref>
|[[Protein]] concentration
* Neither sensitive/specific.
|1 g/dL (10 g/L) or less
* But is indicated to rule out secondary peritonitis caused by many organisms usually anaerobes and also to guide and narrow down the appropriate antibiotic of choice based on the culture and sensitivity results.
|}
# Gram stain: To identify the number of organisms causing peritonitis, most helpful in the diagnosis of free perforation of the intestine, where many different organisms are found including gram negative bacteria and anaerobes, fungi.
===='''Ascitic fluid Culture'''====
# Total protein: 20% of ascitic samples in patients with cirrhosis will have a protein concentration greater than 2.5 g/dL
* Performed before initiating [[antibiotic therapy]] by bedside inoculation of ascitIc fluid ≥ 10 mL into [[blood culture]] bottles, instead of sending the fluid to the laboratory in a syringe or container, since immediate inoculation improves the yield on [[Bacterial cultures|bacterial culture]] from approximately 65% to 90%, when the ascitic fluid cell count is at least 250 cells/mm<sup>3</sup>.<ref name="pmid2280015">{{cite journal| author=Runyon BA, Antillon MR, Akriviadis EA, McHutchison JG| title=Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. | journal=J Clin Microbiol | year= 1990 | volume= 28 | issue= 12 | pages= 2811-2 | pmid=2280015 | doi= | pmc=268281 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2280015  }} </ref> 
# Lactate dehydrogenase: In SBP, the AF LDH rises because of the release of LDH from neutrophils, and the concentration will be more than serum concentration. In secondary peritonitis, the levels are even more elevated than in SBP.
* Separate and simultaneous [[blood cultures]] should also be obtained, as up to 50% of patients with SBP have concomitant [[bacteremia]].
# Glucose: Under normal conditions, and in early SBP, the ascitic fluid glucose concentration is similar to that of serum. By contrast, in SBP detected later in its course, and as well as in the setting of intestinal perforation into ascitic fluid, the AF concentration drops to 0mg/dL because of consumption by glucose by increased numbers of neutrophils and bacteria.
* Neither [[Sensitivity (tests)|sensitive]]/[[Specificity|specific]]
# Amylase: In uncomplicated ascites in the setting of cirrhosis, the AF amylase concentration usually one half that of the serum value. In patients with acute pancreatitis or intestinal perforation (with release of luminal amylase into the ascitic fluid), the fluid amylase concentration is elevated markedly, and approximately five-fold greater than simultaneous serum values.
* But is indicated to rule out [[secondary peritonitis]] caused by many organisms usually [[anaerobes]] and also to guide and narrow down the appropriate antibiotic of choice based on the [[Culture medium|culture]] and sensitivity results.
# Albumin (if SAAG unknown) concentration - it is important for the calculation of [[serum-ascites albumin gradient]] , and helps us in identifying the [[portal hypertension]] and associated prognosis.
 
# Serum-ascites albumin gradient (if not calculated before): SAAG > 1.1 g/dL indicates the presence of portal hypertension. Peritoneal carcinomatosis is the most common cause of a low SAAG.
The following tests are recommended for suspected infection of the ascitic fluid.<ref name="pmid24508989">{{cite journal| author=Lippi G, Danese E, Cervellin G, Montagnana M| title=Laboratory diagnostics of spontaneous bacterial peritonitis. | journal=Clin Chim Acta | year= 2014 | volume= 430 | issue=  | pages= 164-70 | pmid=24508989 | doi=10.1016/j.cca.2014.01.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24508989 }} </ref>
# AFB smear and culture: Helps in the identification of tuberculous peritonitis which presents similarly to SBP, with fever, abdominal pain and one half of patients have cirrhosis.
# '''[[Gram stain]]''': To identify the number of organisms causing [[peritonitis]], most helpful in the diagnosis of free [[perforation]] of the intestine, where many different organisms are found including [[Gram-negative bacteria|gram negative bacteria]] and [[anaerobes]], [[fungi]].
# Bilirubin: AF bilirubin > 6 mg/dL suggests biliary or small intestinal perforation into AF.
# '''[[Total protein]]''': 20% of ascitic samples in patients with cirrhosis will have a [[protein]] concentration greater than 2.5 g/dL  
# Triglyceride: A triglyceride level should be measured in opalescent or frankly milky ascitic fluid. Chylous ascites has a triglyceride concentration greater than serum (200 mg/dL).
# '''[[Lactate dehydrogenase]]''': In SBP, the ascitic fluid [[Lactate dehydrogenase|LDH]] rises because of the release of [[Lactate dehydrogenase|LDH]] from [[neutrophils]], and the concentration will be more than [[Serum|serum concentration]]. In [[secondary peritonitis]], the levels are even more elevated than in SBP.
# '''[[Glucose]]''': Under normal conditions, and in early SBP, the ascitic fluid glucose concentration is similar to that of [[serum]]. By contrast, in SBP detected later in its course, and as well as in the setting of [[intestinal perforation]] into ascitic fluid, the ascitic fluid concentration drops to 0 mg/dL because of consumption of glucose by increased numbers of [[neutrophils]] and [[bacteria]].
# '''[[Amylase]]''': In uncomplicated [[ascites]] in the setting of [[cirrhosis]], the ascitic fluid [[Amylase|amylase concentration]] usually one half that of the serum value. In patients with [[acute pancreatitis]] or [[intestinal perforation]] (with release of luminal amylase into the ascitic fluid), the fluid amylase concentration is elevated markedly, and approximately five-fold greater than simultaneous serum values.
# '''[[Albumin]]:''' It is important for the calculation of [[serum-ascites albumin gradient]] , and helps us in identifying the [[portal hypertension]] and associated prognosis.
# '''[[Serum-ascites albumin gradient]]''' (if not calculated before): [[Serum-ascites albumin gradient|SAAG]] > 1.1 g/dL indicates the presence of [[portal hypertension]]. [[Peritoneal carcinomatosis]] is the most common cause of a low [[Serum-ascites albumin gradient|SAAG]].
# '''Ascitic Fluid smear and culture''': Helps in the identification of [[tuberculous peritonitis]] which presents similarly to SBP, with [[fever]], [[abdominal pain]] and one half of patients have [[cirrhosis]].
# '''[[Bilirubin]]''': AF [[bilirubin]] > 6 mg/dL  suggests biliary or [[Bowel perforation|small intestinal perforation]] into AF.
# '''[[Triglyceride]]''': A triglyceride level should be measured in opalescent or frankly milky ascitic fluid. [[Chylous ascites]] has a triglyceride concentration greater than serum (200 mg/dL).
# '''[[Cytology]]''': Expensive and is only revealing in the setting of [[peritoneal carcinomatosis]], typically in patients with a history of [[Breast cancer|breast]], [[Colorectal cancer|colon]], [[Stomach cancer|gastric]] or [[pancreatic carcinoma]].


* Paracentesis reveals an ascitic fluid with, most commonly,  
* [[Paracentesis]] reveals an ascitic fluid with, most commonly:<ref name="pmid23978348">{{cite journal| author=Orman ES, Hayashi PH, Bataller R, Barritt AS| title=Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. | journal=Clin Gastroenterol Hepatol | year= 2014 | volume= 12 | issue= 3 | pages= 496-503.e1 | pmid=23978348 | doi=10.1016/j.cgh.2013.08.025 | pmc=3944409 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23978348  }} </ref>
** 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
** Decreased [[Opsonisation|ascitic opsonic]] activity.
** Protein concentration of 1 g/dL (10 g/L) or less,[[low protein concentration]] is noticed in cases of [[spontaneous bacterial peritonitis]] which differentiates it from secondary bacterial peritonitis where it is normal.
** 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 repeat [[paracentesis]].  
** Corresponding to decreased ascitic opsonic activity.
** 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]].  
** 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 repeat [[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>
** 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>


* Absoulte neutrophil count - a total count of >250 cells/mm<sup>3</sup> confirms the diagnosis of spontaneous bacterial peritonitis.
=== Video ===
 
** 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> 
 
* 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.<ref name="pmid26486286">{{cite journal| author=Honar N, Geramizadeh B, Dehghani SM, Kalvandi G, Shahramian I, Rahmani A et al.| title=EVALUATION OF LEUKOCYTE ESTERASE REAGENT STRIPS TEST IN THE DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS IN CHILDREN WITH CIRRHOSIS. | journal=Arq Gastroenterol | year= 2015 | volume= 52 | issue= 3 | pages= 195-9 | pmid=26486286 | doi=10.1590/S0004-28032015000300008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26486286  }} </ref>
* 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>
*Given the rapidity (90 s), low cost, and availability ‘dipstick’ testing of ascites allows for more rapid diagnosis and management of SBP.
 
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Latest revision as of 19:06, 18 September 2017

Peritonitis main page

Spontaneous bacterial peritonitis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]Ahmed Younes M.B.B.CH [3]

Overview

Early Diagnostic paracentesis (needle drainage of the ascitic fluid performed in < 72hrs) is recommended in all cirrhotic patients with ascites. Paracentesis reveals an ascitic fluid with a total white cell count of up to 500 cells/mcL, a high polymorphonuclear (PMN) cell count (250/mm3 more). Ascitic fluid analysis and culture must be performed before initiating antibiotic therapy by bedside inoculation of ascitIc fluid ≥ 10 mL into blood culture bottles. Ascitic fluid analysis is the gold standard for the confirmation of the diagnosis of spontaneous bacterial peritonitis. 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 are non-specific. 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

Laboratory tests for the diagnosis and differential diagnosis of SBP
Ascitic fluid analysis Spontaneous Bacterial Peritonitis Secondary bacterial peritonitis Hepatic ascites[2] Cardiac ascites[3] Nephrogenic ascites Pancreatic ascites Tuberculous ascites Malignant ascites[4]
Gross appearance Cloudy or turbid Turbid or purulent Clear straw or milky Clear to pale yellow Straw colored or chylous Milky or cloudy or turbid Milky or normal Milky or bloody
Leukocyte count and differential (cells/mm3) ≥ 250 PMN > 1000 WBC

predominantly

PMN

< 500 WBC

≥ 250 PMN or normal

< 500 WBC

< 250 PMN

< 500 WBC

< 250 PMN

< 500 WBC

≥ 250 PMN

≥ 250 PMN or normal ≥ 500 WBC
Total protein ≥ 25 g/L > 25 g/ L < 25 g/L ≥ 25 g/L < 25 g/L ≥ 25 g/L ≥ 25 g/L ≥ 25 g/L
Serum-ascites albumin gradient[5][6] ≥ 1.1 g/dL ≥ 1.1 g/dL ≥ 1.1 g/dL ≥ 1.1 g/dL < 1.1 g/dL < 1.1 g/dL < 1.1 g/dL < 1.1 g/dL
LDH(lactate dehydrogenase) ↑or normal > Upper limit of normal for serum LDH ↓ or normal ↑or normal ↑or normal
Glucose < 50 mg/dL normal normal
Amylase - - normal - - - ↑or normal
Tumor markers - - ↑or normal normal - ↑or normal ↑or normal
Confirmatory tests Single organism in culture, total protein < 1 g/dL, glucose > 50 mg/dl, LDH < 225 units/ L.
  • Poly-microbial infection including anaerobes , total protein > 1 g/dL, glucose < 50 mg/dL, LDH ≥ 225 units/ L.
  • Upright abdominal x-ray, water soluble contrast studies of GI tract
ultrasound and/or liver biopsy Chest x-ray and ekg 24-hour urine protein excretion Abdominal CT scan mycobacterial growth on culture of laparoscopic biopsy specimen of peritoneum Search for primary tumor
Additional comments Good clinical response to antibiotics. Ascitic fluid amylase > 100 units/ L laparoscopy, peritoneal biopsy, bacteriology, PCR. cytology
Relative frequency - - 81% 3% Dialysis associated- 1% 1% 2% 10%

Approach to the diagnosis and treatment of spontaneous bacterial peritonitis

 
 
 
 
 
 
 
 
 
Diagnostic Paracentesis
❑ Perform ascitic fluid cell count and differential
❑ Perform ascitic fluid culture (Inoculated at bedside)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PMN ≥ 250cells/mm³
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If YES
❑ Presumptive SBP
❑ Begin empiric antibiotic therapy(eg:Cefotaxime 2g IV q8H and
❑ IV Albumin on day 1 & day 3
IF serum creatinine 1mg/dl, BUN > 30mg/dl or total albumin > 4mg/dl
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IF NO
❑ Look for the signs/symptoms of Infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is Culture Positive ?
 
 
 
 
 
 
 
Absent Symptoms
❑ Is Culture Positive?
 
 
 
 
 
 
 
 
Symptoms Present
❑ Begin Empiric Antibiotic Therapy for SBP
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative Culture Culture Negative Neutrocytic Ascites ( CNNA )
❑ morbidity and mortality same as SBP
❑ Treat as SBP
❑ Complete 5 day Antibiotic Course
 
Confirmed SBP
❑ Narrow the spectrum based on the susceptibility to complete the 5 day course
 
 
Culture Negative
❑ No Antibiotics indicated
 
 
 
 
Culture Positive
Monomicrobial nonneutrocytic Bacterascites: ❑ Followup paracentesis recommended when the culture growth is discovered
❑ ~ 60% spontaneous resolution, ❑ ~ 40% turn to SBP. Polymicrobial bacterascites: ❑ Low morbidity ❑ Majority from traumatic tap
❑ Clinical followup +/- antibiotics is recommended
 
 
 

Routine laboratory studies for spontaneous bacterial peritonitis include:


Diagnostic paracentesis:

Performed usually within 72 hrs of admission.[10]

Indications for diagnostic paracentesis
  • Upon admission to the hospital

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.

Ascitic Fluid Analysis

Ascitic fluid analysis is the gold standard and is required for the confirmation of the diagnosis of spontaneous bacterial peritonitis.[11]

Tests Diagnostic Values
Cell count with differential Leukocyte count > 500 cells/mm3 Absolute neutrophil count >250 cells/mm3
Bacterial culture[12] Usually positive for gram-negative bacteria (mainly Escherichia coli and Klebsiella) and gram-positive cocci (usually Streptococcus spp. and enterococci).[13][14]
Protein concentration 1 g/dL (10 g/L) or less

Ascitic fluid Culture

  • Performed before initiating antibiotic therapy by bedside inoculation of ascitIc fluid ≥ 10 mL into blood culture bottles, instead of sending the fluid to the laboratory in a syringe or container, since immediate inoculation improves the yield on bacterial culture from approximately 65% to 90%, when the ascitic fluid cell count is at least 250 cells/mm3.[15]
  • Separate and simultaneous blood cultures should also be obtained, as up to 50% of patients with SBP have concomitant bacteremia.
  • Neither sensitive/specific
  • But is indicated to rule out secondary peritonitis caused by many organisms usually anaerobes and also to guide and narrow down the appropriate antibiotic of choice based on the culture and sensitivity results.

The following tests are recommended for suspected infection of the ascitic fluid.[16]

  1. Gram stain: To identify the number of organisms causing peritonitis, most helpful in the diagnosis of free perforation of the intestine, where many different organisms are found including gram negative bacteria and anaerobes, fungi.
  2. Total protein: 20% of ascitic samples in patients with cirrhosis will have a protein concentration greater than 2.5 g/dL
  3. Lactate dehydrogenase: In SBP, the ascitic fluid LDH rises because of the release of LDH from neutrophils, and the concentration will be more than serum concentration. In secondary peritonitis, the levels are even more elevated than in SBP.
  4. Glucose: Under normal conditions, and in early SBP, the ascitic fluid glucose concentration is similar to that of serum. By contrast, in SBP detected later in its course, and as well as in the setting of intestinal perforation into ascitic fluid, the ascitic fluid concentration drops to 0 mg/dL because of consumption of glucose by increased numbers of neutrophils and bacteria.
  5. Amylase: In uncomplicated ascites in the setting of cirrhosis, the ascitic fluid amylase concentration usually one half that of the serum value. In patients with acute pancreatitis or intestinal perforation (with release of luminal amylase into the ascitic fluid), the fluid amylase concentration is elevated markedly, and approximately five-fold greater than simultaneous serum values.
  6. Albumin: It is important for the calculation of serum-ascites albumin gradient , and helps us in identifying the portal hypertension and associated prognosis.
  7. Serum-ascites albumin gradient (if not calculated before): SAAG > 1.1 g/dL indicates the presence of portal hypertension. Peritoneal carcinomatosis is the most common cause of a low SAAG.
  8. Ascitic Fluid smear and culture: Helps in the identification of tuberculous peritonitis which presents similarly to SBP, with fever, abdominal pain and one half of patients have cirrhosis.
  9. Bilirubin: AF bilirubin > 6 mg/dL suggests biliary or small intestinal perforation into AF.
  10. Triglyceride: A triglyceride level should be measured in opalescent or frankly milky ascitic fluid. Chylous ascites has a triglyceride concentration greater than serum (200 mg/dL).
  11. Cytology: Expensive and is only revealing in the setting of peritoneal carcinomatosis, typically in patients with a history of breast, colon, gastric or pancreatic carcinoma.

Video

{{#ev:youtube|_r7MaXw1CFw}}

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. Moore CM, Van Thiel DH (2013). "Cirrhotic ascites review: Pathophysiology, diagnosis and management". World J Hepatol. 5 (5): 251–63. doi:10.4254/wjh.v5.i5.251. PMC 3664283. PMID 23717736.
  3. Runyon BA (1988). "Cardiac ascites: a characterization". J Clin Gastroenterol. 10 (4): 410–2. PMID 3418089.
  4. Runyon BA, Hoefs JC, Morgan TR (1988). "Ascitic fluid analysis in malignancy-related ascites". Hepatology. 8 (5): 1104–9. PMID 3417231.
  5. Mauer K, Manzione NC (1988). "Usefulness of serum-ascites albumin difference in separating transudative from exudative ascites. Another look". Dig Dis Sci. 33 (10): 1208–12. PMID 3168691.
  6. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG (1992). "The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites". Ann Intern Med. 117 (3): 215–20. PMID 1616215.
  7. 7.0 7.1 Wu SS, Lin OS, Chen YY, Hwang KL, Soon MS, Keeffe EB (2001). "Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation". J Hepatol. 34 (2): 215–21. PMID 11281549.
  8. Terg, Rubén; Gadano, Adrian; Cartier, Mariano; Casciato, Paola; Lucero, Romina; Muñoz, Alberto; Romero, Gustavo; Levi, Diana; Terg, Gonzalo; Miguez, Carlos; Abecasis, Raquel (2009). "Serum creatinine and bilirubin predict renal failure and mortality in patients with spontaneous bacterial peritonitis: a retrospective study". Liver International. 29 (3): 415–419. doi:10.1111/j.1478-3231.2008.01877.x. ISSN 1478-3223.
  9. Wu, Hongli; Chen, Lin; Sun, Yuefeng; Meng, Chao; Hou, Wei (2016). "The role of serum procalcitonin and C-reactive protein levelsin predicting spontaneous bacterial peritonitis in patients with advanced liver cirrhosis". Pakistan Journal of Medical Sciences. 32 (6). doi:10.12669/pjms.326.10995. ISSN 1681-715X.
  10. Rimola, Antoni; García-Tsao, Guadalupe; Navasa, Miquel; Piddock, Laura J.V.; Planas, Ramon; Bernard, Brigitte; Inadomi, John M. (2000). "Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document". Journal of Hepatology. 32 (1): 142–153. doi:10.1016/S0168-8278(00)80201-9. ISSN 0168-8278.
  11. Riggio O, Angeloni S (2009). "Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis". World J Gastroenterol. 15 (31): 3845–50. PMC 2731245. PMID 19701963.
  12. Runyon BA, Canawati HN, Akriviadis EA (1988). "Optimization of ascitic fluid culture technique". Gastroenterology. 95 (5): 1351–5. PMID 3049220.
  13. Caly WR, Strauss E (1993). "A prospective study of bacterial infections in patients with cirrhosis". J Hepatol. 18 (3): 353–8. PMID 8228129.
  14. Sajjad M, Khan ZA, Khan MS (2016). "Ascitic Fluid Culture in Cirrhotic Patients with Spontaneous Bacterial Peritonitis". J Coll Physicians Surg Pak. 26 (8): 658–61. doi:2399 Check |doi= value (help). PMID 27539758.
  15. Runyon BA, Antillon MR, Akriviadis EA, McHutchison JG (1990). "Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis". J Clin Microbiol. 28 (12): 2811–2. PMC 268281. PMID 2280015.
  16. Lippi G, Danese E, Cervellin G, Montagnana M (2014). "Laboratory diagnostics of spontaneous bacterial peritonitis". Clin Chim Acta. 430: 164–70. doi:10.1016/j.cca.2014.01.023. PMID 24508989.
  17. Orman ES, Hayashi PH, Bataller R, Barritt AS (2014). "Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites". Clin Gastroenterol Hepatol. 12 (3): 496–503.e1. doi:10.1016/j.cgh.2013.08.025. PMC 3944409. PMID 23978348.


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