Cirrhosis Complications: Ascites and Spontaneous Bacterial Peritonitis

SBP
Approximately 87% of patients with SBP will have signs or symptoms of infection,³ but symptoms can be very vague, so careful attention to detail and thorough assessment are necessary (see Table 1).^2,4,7,12 An elevated absolute polymorphonuclear (PMN) leukocyte cell count of ≥ 250 cells/µL and a positive ascitic culture, with no other apparent source of intra-abdominal infection, are diagnostic for SBP.²

Any cirrhotic patient with ascites who presents with two or more of the following criteria for systemic inflammatory response syndrome should be evaluated for an infectious cause:¹³
• Temperature > 100.4°F or < 96.8°F
• Heart rate > 90 beats/min
• Tachypnea (respiratory rate > 20 breaths/min) or hyperventilation (arterial carbon dioxide tension [PaCO₂] < 32 mm Hg)
• Abnormal white blood cell count (> 12,000/µL or < 4,000/µL or > 10% immature neutrophils [band forms])

CASE Abdominal x-ray, CT, and laboratory testing were ordered in the ED (see Table 2 for laboratory test results). Imaging revealed multiple loops of small bowel in the midabdomen, with several air-fluid levels and a paucity of gas in the rectum. These findings were consistent with small bowel obstruction. In addition, laboratory data were significant for leukocytosis (higher than the patient’s usual level), worsening hyperbilirubinemia and hypoalbuminemia, elevated serum creatinine level indicating acute kidney injury (AKI), and lactic acidosis. The patient was admitted to the hospital for further management.

Because of his severe abdominal pain and leukocytosis, bedside paracentesis was performed. He was found to have an absolute PMN cell count of approximately 1,273 cells/µL, suggesting a diagnosis of SBP. The patient’s status on the transplant list was changed to inactive due to the infection.

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