Spontaneous bacterial peritonitis: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
# Paracentesis results supporting a diagnosis of SBP: | #Paracentesis results supporting a diagnosis of SBP: | ||
## Absolute neutrophil count > | ##Total WBC >1000 | ||
## SAAG > 1.1 | ##Absolute neutrophil count > 250 | ||
## | ##SAAG > 1.1 | ||
# There is no platelet count or INR that is a contraindication to paracentesis | ##Protein < 1 | ||
##Glucose > 50 | |||
#There is no platelet count or INR that is a contraindication to paracentesis | |||
==Spontaneous versus secondary bacterial peritonitis== | ==Spontaneous versus secondary bacterial peritonitis== |
Revision as of 07:06, 1 August 2011
Background
- Develops in large, clinically obvious ascites 2/2 cirrhosis
- Normal flora translocate across the bowel wall into the peritoneum
- 30% of ascitic pts will develop SBP in a given year
Clinical Manifestations
- Fever - 70%
- Abdominal pain (diffuse) - 60%
- Altered mental status - 55%
- ~15% of patients have no signs/symptoms
Work-Up
- Ascitic Fluid
- Cell count, glucose, protein, gm stain, culture, LDH, alk phos
Diagnosis
- Paracentesis results supporting a diagnosis of SBP:
- Total WBC >1000
- Absolute neutrophil count > 250
- SAAG > 1.1
- Protein < 1
- Glucose > 50
- There is no platelet count or INR that is a contraindication to paracentesis
Spontaneous versus secondary bacterial peritonitis
- Importance of distinction
- Mortality of secondary bacterial peritonitis ~100% if tx is only abx without sx
- Mortality of unnecessary sx in pt w/ SBP ~80%
- Laboratory findings
- Secondary bacterial peritonitis strongly suggested by:
- Neutrocytic fluid (PMN ≥250) w/ two or more of the following:
- Total protein concentration >1 g/dL (10 g/L)
- Glucose concentration <50 mg/dL (2.8 mmol/L)
- LDH greater than upper limit of normal for serum
- Ascitic alk phos >240
- Gram Stain
- Large numbers of different bacterial forms
- Neutrocytic fluid (PMN ≥250) w/ two or more of the following:
- Secondary bacterial peritonitis strongly suggested by:
- Imaging
- If evidence of secondary bacterial peritonitis obtain abdominal imaging
- If no evidence of free air or contrast extravasation then surgery is not indicated
- If evidence of secondary bacterial peritonitis obtain abdominal imaging
Treatment
- Antibiotics
- SBP
- Broad-spectrum covering gram + and gram -
- 3rd-generation cephalosporin is agent of choice:
- Cefotaxime 2g IV q8hr or Ceftriaxone 1-2g IV q12-24hr
- If beta-lactam allergy consider ciprofloxacin 400mg IV q12hr>
- 3rd-generation cephalosporin is agent of choice:
- Broad-spectrum covering gram + and gram -
- 2ndary bacterial peritonitis
- 3rd-generation cephalosporin + metronidazole
- Surgery
- SBP
- Albumin
- Decreases incidence of renal failure
- 1.5g/kg at time of diagnosis and 1g/kg on day 3
Source
- Rosen's
- UpToDate
- Paracentesis. N Engl J Med 2006; 355