HWN Suggests

A Case for the Early Tap: Spontaneous Bacterial Peritonitis

It can occur in patients OTHER THAN those with cirrhosis (nephrotic syndrome patients, for example), and has a high mortality. This is where we can actually make a difference - by making the diagnosis early. Every hour of delayed diagnosis (and then delayed treatment) raises mortality by 3%.

So if you are suspicious of it, TAP THAT BELLY. And you have to have a high degree of suspicion because up to 10% of patients with SBP will not have signs and symptoms of it!

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Articles of Interest

Albumin for Patients with SBP or Large-Volume Paracentesis

... the AASLD recommendation is to administer albumin (1.5 g/kg within 6 hours of diagnosis of SBP followed by 1.0 g/kg on day 3) in patients with a serum creatinine > 1 mg/dL OR BUN > 30 mg/dL OR bilirubin > 4 mg/dL. It should be noted that the limited administration based on these laboratory abnormalities is based on a single observational cohort study, and seems somewhat arbitrary.

Bacterial Peritonitis – Tap that Belly !

To diagnose SBP, we must do a diagnostic paracentesis and look at the absolute neutrophil count. The paracentesis findings are an ascitic absolute neutrophil count (ANC) of greater than 250 cells/mm. Is peritonitis needed to diagnose SBP? No, and in fact this is a common misconception within the name. While we look for fever and abdominal pain, only ½ of patients with SBP present with these symptoms. In fact, fever occurs in only 42% of patients. This is because cirrhotic patients are relatively immunocompromised.

Spontaneous Bacterial Peritonitis in Patients with Cirrhosis

Adopt an extremely low threshold to perform a diagnostic paracentesis in the cirrhotic patient because SBP is an emergency diagnosis with high mortality and subtle presentation.

Spontaneous Bacterial Peritonitis – Pearls & Pitfalls

SBP is commonly a part of the differential diagnosis in patients with a history of cirrhosis and ascites. However, the classic symptoms of fever, abdominal pain, and worsening ascites are rare.

Resources

CMC Compendium

The count is what counts. % segs x total nucleated cells = absolute PMN count > = 250 cells per mm3 -gram stain is highly inaccurate with 40 % FP rate -culture is also only positive 40 % of the time.

EMCrit

Spontaneous Bacterial Peritonitis (SBP) Consider using a very thin lumbar puncture needle (e.g., a 24-gague needle)...

Life in the Fastlane

Incidence 20% in those with ascites admitted to hospital

NuemBlog.com

Prompt paracentesis is the key to proper management. It is considered safe to perform diagnostic paracentesis in all patients but those with evident hyperfibrinolysis or those in DIC.

RebelEM

SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis.

WikEM

Portal hypertension → bowel edema → normal flora translocates across bowel wall into the peritoneum.