Spontaneous bacterial peritonitis

Abstract

Since its initial description in 1964, research has transformed spontaneous bacterial peritonitis (SBP) from a feared disease (with reported mortality of 90%) to a treatable complication of decompensated cirrhosis, albeit with steady prevalence and a high recurrence rate. Bacterial translocation, the key mechanism in the pathogenesis of SBP, is only possible because of the concurrent failure of defensive mechanisms in cirrhosis. Variants of SBP should be treated. Leucocyte esterase reagent strips have managed to shorten the 'tap-to-shot' time, while future studies should look into their combined use with ascitic fluid pH. Third generation cephalosporins are the antibiotic of choice because they have a number of advantages. Renal dysfunction has been shown to be an independent predictor of mortality in patients with SBP. Albumin is felt to reduce the risk of renal impairment by improving effective intravascular volume, and by helping to bind pro-inflammatory molecules. Following a single episode of SBP, patients should have long-term antibiotic prophylaxis and be considered for liver transplantation.

Figures

Figure 1

Algorithm for diffe-rentiating spontaneous from secondary bacterial peritonitis in patients with neutrocytic ascites (i.e. neutrophil count of 250 cells/mm3 or greater) in the absence of hemorrhage into ascitic fluid, tuberculosis, peritoneal carcinomatosis, or pancreatitis. CT: Computed tomography; LDH: Lactate dehydrogenase; PMN: Polymorphonuclear neutrophil; US: Ultrasound (Reproduced with permission from Akriviadis EA, Runyon BA: The value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 98: 127, 1990. Copyright 1990 by the American Gastroenterological Association).