Spontaneous bacterial peritonitis in adults: Diagnosis
- Bruce A Runyon, MD
Bruce A Runyon, MD
- Section Editor — Cirrhosis and Its Complications
- Clinical Professor of Medicine
- University of New Mexico, Division of Gastroenterology and Hepatology
- Special Hepatology Consultant to the Indian Health Service
- Northern Navajo Medical Center, Shiprock, New Mexico
Spontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source . The presence of SBP, which almost always occurs in patients with cirrhosis and ascites, is suspected because of suggestive signs and symptoms, such as fever, abdominal pain, or altered mental status (table 1), though some patients are asymptomatic and are detected when they undergo paracentesis after being admitted to the hospital for another reason. (See "Spontaneous bacterial peritonitis in adults: Clinical manifestations".)
This topic will review the diagnosis of SBP, as well as distinguishing SBP from secondary bacterial peritonitis or alcoholic hepatitis with ascites. The performance of paracentesis, the pathogenesis, clinical manifestations, and treatment of SBP, and the general evaluation of adults with ascites are discussed elsewhere. (See "Diagnostic and therapeutic abdominal paracentesis" and "Pathogenesis of spontaneous bacterial peritonitis" and "Spontaneous bacterial peritonitis in adults: Clinical manifestations" and "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis" and "Spontaneous bacterial peritonitis variants" and "Evaluation of adults with ascites".)
In 2013, the American Association for the Study of Liver Diseases updated its guideline on the management of adult patients with ascites due to cirrhosis (table 2) [2,3]. The discussion that follows is consistent with that guideline.
OVERVIEW OF DIAGNOSTIC APPROACH
Spontaneous bacterial peritonitis (SBP) should be suspected in patients with cirrhosis who develop signs or symptoms such as fever, abdominal pain, altered mental status, abdominal tenderness, or hypotension (table 1). In addition, patients with ascites admitted to the hospital for other reasons should also undergo paracentesis to look for evidence of SBP. A low clinical suspicion for SBP does not obviate the need for testing . Paracentesis can be performed in the interventional radiology suite or at the bedside. It is important that trained personnel be available to perform the procedure at off hours (such as at night or on weekends). Paracentesis should be carried out promptly in patients with suspected SBP, as delays in performing paracentesis have been associated with increased mortality. (See 'Paracentesis' below and "Spontaneous bacterial peritonitis in adults: Clinical manifestations", section on 'Clinical manifestations' and "Diagnostic and therapeutic abdominal paracentesis".)
The importance of paracentesis was demonstrated in a review of a database of 17,711 patients with cirrhosis and ascites who were admitted to the hospital with a primary diagnosis of ascites or encephalopathy . Paracentesis was performed in 61 percent. Patients who underwent paracentesis had a lower in-hospital mortality rate than those who did not undergo paracentesis (6.5 versus 8.5 percent; adjusted odds ratio 0.55, 95% CI 0.41-0.74).
Subscribers log in hereLiterature review current through: Nov 2017. | This topic last updated: Aug 17, 2015.References
- Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis 1998; 27:669.
- http://www.aasld.org/practiceguidelines/Documents/ascitesupdate2013.pdf (Accessed on April 23, 2013).
- Runyon BA, AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology 2013; 57:1651.
- Chinnock B, Hendey GW, Minnigan H, et al. Clinical impression and ascites appearance do not rule out bacterial peritonitis. J Emerg Med 2013; 44:903.
- Orman ES, Hayashi PH, Bataller R, Barritt AS 4th. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol 2014; 12:496.
- Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 1990; 98:127.
- Kim JJ, Tsukamoto MM, Mathur AK, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. Am J Gastroenterol 2014; 109:1436.
- Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterology 1988; 95:1351.
- Runyon BA, Antillon MR, Akriviadis EA, McHutchison JG. Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J Clin Microbiol 1990; 28:2811.
- Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results? JAMA 2008; 299:1166.
- Chinnock B, Fox C, Hendey GW. Gram's stain of peritoneal fluid is rarely helpful in the evaluation of the ascites patient. Ann Emerg Med 2009; 54:78.
- Angeloni S, Nicolini G, Merli M, et al. Validation of automated blood cell counter for the determination of polymorphonuclear cell count in the ascitic fluid of cirrhotic patients with or without spontaneous bacterial peritonitis. Am J Gastroenterol 2003; 98:1844.
- Runyon BA. The evolution of ascitic fluid analysis in the diagnosis of spontaneous bacterial peritonitis. Am J Gastroenterol 2003; 98:1675.
- Hoefs JC. Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease. Hepatology 1981; 1:249.
- Hoefs JC. Serum protein concentration and portal pressure determine the ascitic fluid protein concentration in patients with chronic liver disease. J Lab Clin Med 1983; 102:260.
- Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215.
- Ackerman Z. Ascites in Nephrotic syndrome. Incidence, patients' characteristics, and complications. J Clin Gastroenterol 1996; 22:31.
- Runyon BA. Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis. Gastroenterology 1986; 91:1343.
- Runyon BA. Patients with deficient ascitic fluid opsonic activity are predisposed to spontaneous bacterial peritonitis. Hepatology 1988; 8:632.
- Runyon BA, Hoefs JC. Ascitic fluid chemical analysis before, during and after spontaneous bacterial peritonitis. Hepatology 1985; 5:257.
- Soriano G, Castellote J, Alvarez C, et al. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol 2010; 52:39.
- Runyon BA. Amylase levels in ascitic fluid. J Clin Gastroenterol 1987; 9:172.
- Runyon BA. Ascitic fluid bilirubin concentration as a key to choleperitoneum. J Clin Gastroenterol 1987; 9:543.
- Castellote J, López C, Gornals J, et al. Rapid diagnosis of spontaneous bacterial peritonitis by use of reagent strips. Hepatology 2003; 37:893.
- Nousbaum JB, Cadranel JF, Nahon P, et al. Diagnostic accuracy of the Multistix 8 SG reagent strip in diagnosis of spontaneous bacterial peritonitis. Hepatology 2007; 45:1275.
- Mendler MH, Agarwal A, Trimzi M, et al. A new highly sensitive point of care screen for spontaneous bacterial peritonitis using the leukocyte esterase method. J Hepatol 2010; 53:477.
- Sapey T, Mena E, Fort E, et al. Rapid diagnosis of spontaneous bacterial peritonitis with leukocyte esterase reagent strips in a European and in an American center. J Gastroenterol Hepatol 2005; 20:187.
- Koulaouzidis A. Diagnosis of spontaneous bacterial peritonitis: an update on leucocyte esterase reagent strips. World J Gastroenterol 2011; 17:1091.
- Parsi MA, Saadeh SN, Zein NN, et al. Ascitic fluid lactoferrin for diagnosis of spontaneous bacterial peritonitis. Gastroenterology 2008; 135:803.
- Runyon BA, Antillon MR. Ascitic fluid pH and lactate: insensitive and nonspecific tests in detecting ascitic fluid infection. Hepatology 1991; 13:929.
- Albillos A, Cuervas-Mons V, Millán I, et al. Ascitic fluid polymorphonuclear cell count and serum to ascites albumin gradient in the diagnosis of bacterial peritonitis. Gastroenterology 1990; 98:134.
- Runyon BA, Hoefs JC. Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid. Hepatology 1984; 4:447.
- Runyon BA. Bacterial peritonitis secondary to a perinephric abscess. Case report and differentiation from spontaneous bacterial peritonitis. Am J Med 1986; 80:997.
- Garrison RN, Cryer HM, Howard DA, Polk HC Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984; 199:648.
- Pinzello G, Simonetti RG, Craxì A, et al. Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic cirrhotic patients. Hepatology 1983; 3:545.
- Wu SS, Lin OS, Chen YY, et al. Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation. J Hepatol 2001; 34:215.
- Antillon MR, Runyon BA. Effect of marked peripheral leukocytosis on the leukocyte count in ascites. Arch Intern Med 1991; 151:509.
- OVERVIEW OF DIAGNOSTIC APPROACH
- OBTAINING ASCITIC FLUID
- Handling the ascitic fluid
- - Culture
- - Gram stain
- - Cell count
- - Chemistries
- INTERPRETATION OF ASCITIC FLUID TEST RESULTS
- Culture and Gram stain results
- Ascitic fluid cell count
- Ascitic fluid chemistries
- - Serum-ascites albumin gradient
- - Ascitic fluid total protein concentration
- - Ascitic fluid glucose concentration
- - Ascitic fluid lactate dehydrogenase
- - Ascitic fluid amylase
- - Ascitic fluid bilirubin concentration
- Investigational tests
- Unhelpful tests
- DISTINGUISHING SPONTANEOUS FROM SECONDARY BACTERIAL PERITONITIS
- Clinical signs and symptoms
- Ascitic fluid analysis
- Imaging studies
- Response to treatment
- Peritonitis developing during antibiotic treatment
- Other conditions masquerading as secondary bacterial peritonitis
- DISTINCTION FROM ALCOHOLIC HEPATITIS
- SUMMARY AND RECOMMENDATIONS