Does This Patient Have Bacterial Peritonitis or Portal Hypertension? How Do I Perform a Paracentesis and Analyze the Results?

Abstract

A 44-year-old man with cirrhosis is admitted with fever but has no obvious source of infection. His physical examination reveals ascites and minimal abdominal tenderness. Why Is This Procedure Important?In a previous Rational Clinical Examination article, Williams and Simel 1 discussed the previous scenario and suggested performing a diagnostic paracentesis to seek for the source of the patient's fever. Ascites is the most common major complication of cirrhosis. 2 The syndrome of infected ascites was first recognized and described in the European literature in the early 20th century. [2][3][4] Infection occurs in as many as 27% of cirrhosis patients admitted to the hospital for evaluation and management of symptoms associated with ascites. The presentation of spontaneous bacterial peritonitis can range from silent to overt 5 ; however, patients typically have nonspecific symptoms such as nausea, abdominal pain, malaise, fever, or mild confusion. In reports 6 from the 1970s, the mortality rate from spontaneous bacterial peritonitis exceeded 90% but recent data 7 show a lower mortality rate of 30%. Diagnosis and subsequent treat-See also Patient Page. CME available online at www.jamaarchivescme.com and questions on p 1203.Context Abdominal paracenteses are performed in patients with ascites, most commonly to assess for infection or portal hypertension and to manage refractory ascites.Objectives To systematically review evidence for paracentesis methods that may decrease risk of adverse events or improve diagnostic yield and to determine the accuracy of ascitic fluid analysis for spontaneous bacterial peritonitis or portal hypertension.

Spontaneous bacterial peritonitis

“…At the time of paracentesis at least 10 mL should be inoculated into hemoculture bottles for both aerobes and anaerobes, and promptly delivered to a microbiology lab. In this way culture performance in this setting has been increased to 50-70% of cases, and 90% is reached in some studies (35)(36)(37).…”

Review of the Literature and Description of a Case of Sclerosing Encapsulating Peritonitis Requiring Home Parenteral Nutrition

“…The most accurate parameters to diagnose SBP were an ascitic neutrophil count of greater than 500 cells/μL (summary LR, 10.6; 95% CI, 6.1-18.3), even though antibiotics are usually started when neutrophils are greater than 250 cells/μL. Although an ascitic neutrophil count of 250 cells/μL or less lowers the likelihood of SBP (summary LR, 0.20; 95% CI, 0.11-0.37), this is not zero [25]. The next original point in our case is the improvement of our patient's overall condition since he went on parenteral nutrition (PN) from August 2009.…”

Tow Minutes to Exclude or Diagnose SBP Using Leucocyte Esterase Reagent Strip

“…SBP is highly likely when the PMN cell count in the ascitic fluid reaches a cutoff of 250/mm 3 and antibiotic therapy must be started immediately, without waiting for a culture from the ascitic fluid. (4) However, total and PMN leukocyte counts from the ascitic fluid are not always available everywhere, or it may be impossible to obtain them in emergency situations. (3) Many hospitals in developing countries have limited laboratory facilities, or are unable to perform PMN counts in ascitic fluid at night or over the weekend.…”