Clinical review of 23 patients with tuberculous peritonitis: presenting features and diagnosis

OBJECTIVE: To better identify which clinical, laboratory, radiological and invasive procedures were most useful in diagnosing tuberculous peritonitis and to assess the methods in order to reach the diagnosis in future cases. METHODS: Tuberculous peritonitis cases diagnosed between 2000 and 2006 were reviewed retrospectively. Their clinical presentation, physical examination, laboratory and diagnostic methods were evaluated. RESULTS: Twenty‐three cases of tuberculous peritonitis were diagnosed. The mean age of the patients were 30 ± 11 years and 16 were women. The mean duration of symptoms prior to diagnosis was 3.6 months. All patients presented with abdominal pain. Abdominal swelling (91.3%), loss of appetite (87%) and weight loss (82.6%) were the other commonest symptoms. The major physical findings were ascites (78.3%) and fever (60.9%). The serum ascites albumin gradient was <1.1 g/dL in all. An ascites fast bacilli smear was positive in 12 (52.2%) patients. Skin tests with purified protein derivative, adenosine deaminase and polymerase chain reaction were performed in seven, four and five patients, respectively. The tuberculous culture was positive in only two. The most common radiological findings were ascites (100%) and omental involvement (65.2%). A laparoscopy was performed in nine of 23 patients. A total of 22 patients completed anti‐tuberculous therapy successfully and were cured, except one with cirrhosis. CONCLUSION: Tuberculous peritonitis may be fatal but is medically cured if diagnosed in a timely fashion. Although both non‐invasive and invasive tests have additional benefits, clinician suspicion is still the first step for the diagnosis of tuberculous peritonitis.     

Two cases of tuberculous peritonitis with liver cirrhosis complicated by refractory ascites

We present two cases of tuberculous peritonitis with liver cirrhosis complicated by refractory ascites. Case 1 was a 59-year-old female with alcoholic liver cirrhosis. She was admitted to our hospital because of diarrhea, anorexia and inflammatory reactions on a blood test. She had a high fever of 38°C or more and refractory ascites. Tubercle bacilli infection was suspected based on increased levels of serum CA125 and adenosine deaminase (ADA) in ascites. Laparoscopic examination showed white nodules on the peritoneum, and histologic study confirmed tuberculous nodules. The same bacteria were isolated from culture of ascites. Case 2 was a 55-year-old female with hepatitis C virus-infected liver cirrhosis. She was admitted because of high fever and abdominal fullness due to ascites. High levels of serum CA125 and ADA in ascites and ineffectiveness of treatment with antibiotics plus diuretics led us to start anti-tuberculous therapy before definitive diagnosis. Tuberculus bacillus was later isolated from culture of ascites. It is difficult to make early diagnosis of tuberculous peritonitis in cirrhotic patients with ascites due to a lack of specific symptoms. However, determination of serum CA125 and ADA in ascites and the acid-fast bacterial culture of ascites are useful for early diagnosis.     

多功能腹膜检查针的研制及临床应用研究

目的旨在提高腹水病因的诊断率和鉴别诊断率。方法自行研制多功能腹膜检查针并对临床上１５８例腹水患者进行检查。结果这种多功能腹膜检查针对４２例怀疑腹水由结核性腹膜炎引起的病理诊断率达９０．４８％;对４７例不明原因腹水的临床病因确诊率达６３．８３％;对２２例肝硬化伴腹痛和发烧怀疑原发性腹膜炎的确诊率达４０．９％,单纯腹水生化检查的诊断率只占１８．２％,前者明显优于后者;４５例原因不明腹水患者单纯腹水细胞学检查仅５例发现癌细胞,进行腹膜刷检后１３例找到癌细胞,显著优于腹水细胞学检查。结论多功能腹膜检查针对结核性腹水,癌性腹水和肝硬化合并原发性腹膜炎有重要的临床诊断价值,而且操作简单,在病床边即可检查,可在基层医院广泛使用。     

Analysis of clinical course and prognosis of culture-positive spontaneous bacterial peritonitis and neutrocytic ascites

The clinical significance and prognosis of culture-negative neutrocytic ascites in cirrhotic patients is a controversial topic. In the present study, the clinical and humoral presentation and the short-and long-term prognosis were analyzed in 36 patients with cirrhosis and culture-positive spontaneous bacterial peritonitis and in 28 patients with cirrhosis and ascitic fluid polymorphonuclear count greater than 250/mm³, a negative ascitic fluid culture, and without previous antibiotic therapy. On admission there were no significant differences between groups related to age, sex, alcoholism, fever, abdominal pain, serum albumin, serum urea, serum creatinine, Child-Pugh score, polymorphonuclear count, and total protein concentration in ascitic fluid. A greater frequency of positive blood culture was found in patients with spontaneous bacterial peritonitis (15/21 vs 2/18) (P<0.001). Mortality during the first episode was 36% in patients with spontaneous bacterial peritonitis and 46% in patients with culture-negative neutrocytic ascites (NS). Mortality during follow-up was high and survival probability at 12 months was 32% in spontaneous bacterial peritonitis and 31% in culture-negative neutrocytic ascites. The probability of recurrence at 12 months was 33% in spontaneous bacterial peritonitis and 34% in culture-negative neutrocytic ascites. Our results show that spontaneous bacterial peritonitis and culture-negative neutrocytic ascites are variants of the same disease with a high mortality and poor prognosis.     

Constrictive Pericarditis with Cardiac Ascites Caused Spontaneous Bacterial Peritonitis

Patients with constrictive pericarditis (CP) typically present with symptoms related to right-sided heart failure, such as cardiac ascites. Spontaneous bacterial peritonitis (SBP) usually arises in association with ascites secondary to hepatic cirrhosis. We herein report a rare case of CP in which SBP developed due to cardiac ascites, even in the absence of cirrhosis. In this case, pericardiectomy improved both the hemodynamics and the ascites, while therapy with diuretics alone was insufficient. It is important to consider SBP in the differential diagnosis when any abdominal symptoms or an inflammatory response is found in patients with heart failure and cardiac ascites.     

Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art

ABSTRACT

Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis.

Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed.

Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention.

Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).     

Presentation and role of peritoneoscopy in the diagnosis of tuberculous peritonitis

This study represents the clinical and laboratory features of 135 tuberculous peritonitis cases in whom peritoneoscopic investigation was used routinely. Disease was more common in women than men (1.5:1) and was most frequently encountered in the third and fourth decades in life. The most common presenting symptoms were abdominal distension (96%), abdominal pain (82%), weight loss (80%), weakness (76%), loss of appetite (73%) and fever (69%). The most common physical findings were ascites (96%), fever (75%) and abdominal tenderness (43%). One hundred and twenty-nine cases (95.5%) showed exudative type tuberculous peritonitis with variable amounts of ascites and filmy adhesions. In six patients (4.5%) the disease was of the plastic (dry) type. Peritoneoscopic investigations of 139 patients suggested tuberculous peritonitis but four cases showed histologically proven malignancy (3%). Laparoscopic diagnoses of the remaining cases were confirmed by histology (97%). The laparoscopic appearance of scattered yellowish-white nodules, approximately 1-5 mm in size, on the peritoneal surfaces, and filmy adhesions were suggestive of tuberculous peritonitis. A non-fatal colon perforation occurred as a major complication. After antituberculous therapy patients were followed for at least 1 year. Peritoneoscopy with simultaneous biopsy is the ideal and most accurate diagnostic modality in the diagnosis of tuberculous peritonitis.     

T淋巴细胞亚群检测在腹水鉴别诊断中的价值

目的 :探讨T淋巴细胞亚群检测在腹水鉴别诊断中的价值。方法 :对 92例腹水患者 ,其中结核性腹膜炎腹水 38例 ,肝硬化腹水 2 9例 ,癌性腹水 2 5例 ,用流式细胞仪测定其腹水T淋巴细胞亚群。结果 :腹水中T淋巴细胞 (CD 3+ )、T辅助 /诱导细胞亚群 (CD4+ )、T辅助细胞亚群 /T抑制细胞亚群 (CD 4+ /CD 8+ )由高到低依次为结核性腹膜炎腹水 >癌性腹水 >肝硬化腹水 (P <0 .0 1 ) ;CD 8+ 由高到低依次为癌性腹水 >结核性腹膜炎腹水 >肝硬化腹水 (P <0 .0 1 )。结论 :T淋巴细胞亚群在结核性腹膜炎、肝硬化及癌性腹水中存在明显差异。腹水T淋巴细胞亚群检测可用于腹水的鉴别诊断。     

The use of adenosine deaminase as a diagnostic tool for peritoneal tuberculosis

SETTING: Tygerberg Hospital, an academic hospital in the Western Cape, South Africa.Objective: To determine the diagnostic utility of ascitic fluid adenosine deaminase (ADA) in the diagnosis of tuberculous peritonitis. DESIGN: A prospective study, carried out from February 1995 to February 1998, resulted in 178 paired ascites and serum specimens being collected from adult patients. Specimens were evaluated for biochemistry, ADA, microbiology and cytology; further investigations were done at the treating clinician's discretion. Diagnoses were made according the pre-determined criteria. RESULTS: The median (range) ADA activity in the tuberculous group was 61.6 (17.5--115.0) U/L and was significantly higher than in any other diagnostic group (p<0.05). Using ROC curves, a cut-off level of 30 U/L for the diagnosis of tuberculous peritonitis was found to yield the best results; corresponding sensitivity and specificity was 94% and 92%, respectively. No statistically significant difference in ADA activity was observed when tuberculous ascites occurred in the absence or presence of cirrhosis. CONCLUSIONS: Ascitic fluid ADA activity is useful in identifying those patients in whom the diagnosis of tuberculous peritonitis should be actively pursued to justify its routine use, at least in areas such as South Africa where TB is endemic. The presence or absence of underlying cirrhosis does not appear to distract from its diagnostic utility.     

The value of ascitic fluid polymorphonuclear cell count determination during therapy of spontaneous bacterial peritonitis in patients with liver cirrhosis

BACKGROUND/AIMS: Spontaneous bacterial peritonitis is one of the most common complications attending the onset of ascites in patients with liver cirrhosis. The aim of this study was to demonstrate whether it is possible, on the basis of ascitic fluid polymorphonuclear cell count in patients with liver cirrhosis and spontaneous bacterial peritonitis, to determine the optimal duration of cefotaxime therapy, as the most frequently applied empirical therapy, and possibly anticipate the disease recurrence. METHODOLOGY: In 16 patients with alcoholic liver cirrhosis and confirmed diagnosis of spontaneous bacterial peritonitis, cefotaxime therapy was administered 2g t.i.d. during 5 days. Before the therapy, at 48 hours, 5 days and 15-20 days after the cefotaxime therapy was started, in all patients with spontaneous bacterial peritonitis diagnostic abdominal paracentesis was performed, each time determining the ascitic fluid polymorphonuclear cell count together with microbiological analysis. RESULTS: In the course of the "primary" spontaneous bacterial peritonitis attack, 3 patients died (18.8%). In 4 patients the recurrence of spontaneous bacterial peritonitis was observed within 15-20 days after therapy was discontinued. Two patients died during the therapy of spontaneous bacterial peritonitis recurrence. After 48 hours of therapy, 11 patients with the "primary" spontaneous bacterial peritonitis attack were without any symptoms (68.8%). Out of these 11, 10 patients (62.5%) had the ascitic fluid polymorphonuclear cell count lower than 250/mm3. After 5 days of therapy, 12 patients (75%) were free of symptoms, and the number of ascitic fluid polymorphonuclear cell count < 250/mm3 was still found in 10 (62.5%) patients. No association between the presence of symptoms 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis was established. A significant association was found between the ascitic fluid polymorphonuclear cell count determined 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis. A recurrence occurred in only 1 patient with the number of ascitic fluid polymorphonuclear cell count < 250/mm3, 48 hours after the therapy was started. A recurrence of spontaneous bacterial peritonitis occurred in all the patients who had an ascitic fluid PMN cell count > or = 250/mm3, 48 hours after the therapy was started. CONCLUSIONS: By monitoring the ascitic fluid PMN cell count it seems to be possible to determine the efficacy and optimal duration of cefotaxime therapy in patients with spontaneous bacterial peritonitis when it is of most importance that the number of ascitic fluid PMN cell count should decrease below 250/mm3 during the therapy.     

Tuberculous peritonitis: a study comparing cirrhotic and noncirrhotic patients

Tuberculous peritonitis is a rare disease, which often goes unrecognized because of the subtle clinical clues and its insidous onset. We retrospectively analyzed the records of 37 cases of tuberculous peritonitis diagnosed over a 15-year period, and compared the clinical and diagnostic features of cirrhotic and noncirrhotic patients. In cirrhotic patients, tuberculous peritonitis can simulate ascites from liver disease or spontaneous bacterial peritonitis. The diagnosis is difficult in these patients because the ascitic fluid may not be of the exudative type as a result of the low albumin level in serum, and lymphocytes do not predominate in all cases. Adenosine deaminase (ADA) activity in ascitic fluid was elevated (higher than 40 U/L) in all 11 patients (four patients with hepatic cirrhosis). The time required to achieve a correct diagnosis was significantly longer in cirrhotic than in noncirrhotic patients. The overall mortality was 13%, with deaths occurring exclusively among cirrhotic patients. We emphasize that tuberculous peritonitis in cirrhotic patients can present an atypical picture. A considerable element of suspicion is necessary.     

Spontan bakterielle Peritonitis bei Leberzirrhose

Spontaneous bacterial peritonitis is the most common bacterial infection in patients with liver cirrhosis and ascites. The diagnosis is based on a cell count of more than 250 polymorphonuclear granulocytes per mm³ ascites. Spontaneous bacterial peritonitis results from bacterial translocation from the gut lumen and an altered immune response in cirrhotic patients. Clinically, spontaneous bacterial peritonitis often presents as deterioration of liver function and development of hepatic encephalopathy. In certain cases, the disease can also lead to sepsis with organ failure. Spontaneous bacterial peritonitis has a limited prognosis and antibiotic therapy is mandatory. Antibiotic treatment is usually initiated with third generation cephalosporins or chinolons. The success of antibiotic therapy should be validated by a decrease in ascitic neutrophil count after 48 hours. A secondary prophylaxis is an established treatment after survival of the first episode of spontaneous bacterial peritonitis. A primary prophylaxis of the disease is effective in patients with low ascites protein levels and reduced liver and/or kidney function. Cirrhotic patients with gastrointestinal hemorrhage also benefit from prophylactic antibiotic treatment.     

Tuberculous peritonitis in an endemic area

BACKGROUND: Tuberculous peritonitis is a fatal disease if not diagnosed in time. AIMS: To identify the clinical, laboratory, and diagnostic features of tuberculous peritonitis in Iranian patients. PATIENTS: Included in the study were all cases of tuberculous peritonitis with a definite diagnosis confirmed by pathology in four referral University Hospitals in Tehran between 1989 and 1999. METHODS: All clinical, laboratory, and radiological findings as well as invasive procedures were reviewed. RESULTS: A total of 50 patients (30 female, 20 male), mean age 33.5 years were studied. Main presenting symptoms included abdominal pain (84%), weight loss (72%) and fever (50%). In 24% of patients a positive tuberculin test was found. Erythrocyte sedimentation rate >50 mm/h was detected in 60% of patients and 4.4% had an Erythrocyte sedimentation rate >100 mm/h. Laparoscopy or laparotomy showed peritoneal seeding in 74% of patients. CONCLUSIONS: Exudative ascites should give rise to clinical suspicion of tuberculous peritonitis in endemic areas or in immigrants from endemic areas. Laparoscopy is the most sensitive and specific diagnostic method.     

Prognosis of patients with liver cirrhosis and spontaneous bacterial peritonitis

BACKGROUND/AIMS: Patients with liver cirrhosis and ascites have a high risk of spontaneous bacterial peritonitis, but the prognostic impact of spontaneous bacterial peritonitis has not been well examined. METHODOLOGY: Patients with liver cirrhosis and ascites were included at the time of their first paracentesis during hospitalization in the Department of Hepatology, Aarhus University Hospital, Denmark, between September 1992 and September 2000. Cox regression was used to estimate the mortality of patients with spontaneous bacterial peritonitis (ascites leukocyte count > or = 250 per mm3) relative to controls without spontaneous bacterial peritonitis. Furthermore, we used Cox regression to estimate the change in mortality when controls developed spontaneous bacterial peritonitis during follow-up. RESULTS: Of 286 patients, 76 (27%) had spontaneous bacterial peritonitis at the first paracentesis. The mortality ratio of patients with spontaneous bacterial peritonitis relative to controls was 1.0 (95% confidence interval 0.7-1.5) after adjustment for age, gender, comorbidity, and alcohol abuse. Of the 210 controls, 42 (20%) were found to have spontaneous bacterial peritonitis at a later paracentesis. Their mortality rate more than doubled with the onset of spontaneous bacterial peritonitis. CONCLUSIONS: Spontaneous bacterial peritonitis at the first paracentesis did not affect the prognosis of patients with liver cirrhosis, whereas development of spontaneous bacterial peritonitis during follow-up doubled the mortality risk. This may be due to a longer diagnostic delay in those who developed spontaneous bacterial peritonitis during follow-up.     

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE: To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis. METHODS: Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features. RESULTS: The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment. CONCLUSION: Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.     

Spontaneous bacterial peritonitis in cirrhotic patients: Is prophylactic propranolol therapy beneficial?

Background and Aim: It has been suggested that propranolol may have a protective effect on the development of spontaneous bacterial peritonitis by increasing the motility of the bowel and lowering the pressure of the portal vein. The aim of this study is to evaluate the association between the use of propranolol and development of spontaneous bacterial peritonitis in patients with cirrhosis and ascites. Methods: We retrospectively evaluated 134 patients with cirrhosis and ascites admitted consecutively for a period of 2 years. Diagnosis of spontaneous bacterial peritonitis was based on an ascitic fluid neutrophilic count of >250/mm³ and/or a positive culture without evidence of secondary peritonitis. Results: Spontaneous bacterial peritonitis was diagnosed in 39 of 134 (29%) patients and 12 of 39 (31%) patients died in hospital compared to only 4% (four of 95) of those without spontaneous bacterial peritonitis (P < 0.001). At admission, patients with spontaneous bacterial peritonitis, as compared to those without, had significantly more encephalopathy (28 vs 11%, P = 0.02) or fever (18 vs 4%, P = 0.01) and less frequently tense ascites (33 vs 57%, P = 0.02). Spontaneous bacterial peritonitis was diagnosed in six of 33 (18%) patients who did and in 33 of 101 (33%) who did not receive propranolol therapy (OR = 0.46, 95% CI: 0.17–1.22, P = 0.17). Conclusion: Our data indicate that spontaneous bacterial peritonitis significantly increases mortality in patients with cirrhosis. Propranolol therapy was not found to be associated with a significantly lower risk for spontaneous bacterial peritonitis, but a Type II statistical error cannot be definitely excluded. The potential protective effect of propranolol on the incidence of spontaneous bacterial peritonitis might deserve evaluation in properly designed prospective studies.     

Effects of pentoxifylline on intestinal bacterial overgrowth, bacterial translocation and spontaneous bacterial peritonitis in cirrhotic rats with ascites

BackgroundProphylaxis of spontaneous bacterial peritonitis with norfloxacin has been associated to development of antibiotic resistance. We investigated whether pentoxifylline compared to norfloxacin reduces bacterial translocation and spontaneous bacterial peritonitis in rats with CCl₄-induced cirrhosis and ascites.MethodAfter development of cirrhosis and ascites, animals were randomly allocated to receive pentoxifylline (16 mg/kg/d every 8 h, oral route, n = 13) or placebo (n = 12) for 15 days. An additional group of 8 cirrhotic rats was given norfloxacin (5 mg/kg/d for 15 days). Six healthy rats served as controls. Cecal flora and the prevalence of bacterial translocation and spontaneous bacterial peritonitis were analysed. Serum and ascitic fluid levels of TNF-alpha and cecal levels of malondialdehyde were also measured.ResultsPentoxifylline in comparison to placebo reduced intestinal bacterial overgrowth (21% vs. 67%, p = 0.04), bacterial translocation to cecal lymph nodes (23% vs. 75%, p = 0.03) and prevented spontaneous bacterial peritonitis (0% vs. 33%, p = 0.04) by Enterobacteriaceae. Norfloxacin administration induced similar results. Pentoxifylline (0.18 ± 0.10 nmol/mg), but not norfloxacin (0.25 ± 0.13; p = 0.02), significantly reduced cecal mucosal levels of malondialdehyde compared to placebo (0.33 ± 0.16; p = 0.03).ConclusionIn cirrhotic rats with ascites: (a) pentoxifylline as well as norfloxacin reduced intestinal bacterial overgrowth and bacterial translocation and prevented spontaneous bacterial peritonitis; (b) pentoxifylline, but not norfloxacin, reduced oxidative stress in cecal mucosal.     

Ascites: Aetiology,mortality and the prevalence of spontaneous bacterial peritonitis

Objective. To assess the aetiology, prognosis and prevalence of spontaneous bacterial peritonitis (SBP) in patients hospitalized for ascites. The validity of an elevated (>11 g/l) serum-ascites albumin gradient (SAAG) in the diagnostic work-up was evaluated. Mortality trends were observed over two periods of time. Material and methods. A total of 231 consecutive patients who underwent diagnostic paracentesis between February 1994 and December 1998 and January 2005 and March 2007 were included in the study. The definition of SBP comprised polymorphonuclear cell count >250/mm³ without evidence of other intra-abdominal source of infection. SAAG was obtained and the Child-Pugh classification applied. Survival rates were obtained from medical records. Results. The most common causes of ascites were alcohol liver cirrhosis (n=143; 62%), malignancy (n=30; 13%), non-alcoholic cirrhosis (n=11; 5%) and malignancy with cirrhosis (n=11; 5%). The prevalence of SBP in cirrhosis was 6.7% (95% CI 2.8–10.5%). Overall mortality rates at 1 month, 6 months and 1 year were 22%, 40% and 48%, respectively, and remained unchanged between the intervals. Patients with grade C liver disease had higher 1-month (26% versus 6%), and 6-month (44% versus 27%) mortality rates than grade B patients, but commensurate 1-year mortality (49% versus 47%). SAAG was ≥11 g/l in 85% of patients with obvious portal hypertension and in 30% with malignancy, ascites albumin level ≤9 g/l in 69% and 20%, respectively. Conclusions. Mortality in patients with ascites was high. The occurrence of SBP was relatively low in our series, with a high proportion of alcoholic cirrhosis. SAAG was inaccurate in differentiating ascites caused by portal hypertension or malignancy.     

Weekend admissions with ascites are associated with delayed paracentesis: A nationwide analysis of the ‘weekend effect’

Introduction and objectivesWeekend admissions has previously been associated with worse outcomes in conditions requiring specialists. Our study aimed to determine in-hospital outcomes in patients with ascites admitted over the weekends versus weekdays. Time to paracentesis from admission was studied as current guidelines recommend paracentesis within 24 h for all patients admitted with worsening ascites or signs and symptoms of sepsis/hepatic encephalopathy (HE).PatientsWe analyzed 70 million discharges from the 2005–2014 National Inpatient Sample to include all adult patients admitted non-electively for ascites, spontaneous bacterial peritonitis (SBP), and HE with ascites with cirrhosis as a secondary diagnosis. The outcomes were in-hospital mortality, complication rates, and resource utilization. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.ResultsOut of the total 195,083 ascites/SBP/HE-related hospitalizations, 47,383 (24.2%) occurred on weekends. Weekend group had a higher number of patients on Medicare and had higher comorbidity burden. There was no difference in mortality rate, total complication rates, length of stay or total hospitalization charges between the patients admitted on the weekend or weekdays. However, patients admitted over the weekends were less likely to undergo paracentesis (OR 0.89) and paracentesis within 24 h of admission (OR 0.71). The mean time to paracentesis was 2.96 days for weekend admissions vs. 2.73 days for weekday admissions.ConclusionsWe observed a statistically significant “weekend effect” in the duration to undergo paracentesis in patients with ascites/SBP/HE-related hospitalizations. However, it did not affect the patient's length of stay, hospitalization charges, and in-hospital mortality.     

Ascitic pH and infection in alcoholic cirrhosis

The pH values of 108 samples of ascitic fluid in 94 alcoholic cirrhotic patients were analyzed in order to assess their diagnostic and prognostic value. The mean pH value of ascitic fluid was significantly lower (p less than 0.001) in patients with spontaneous bacterial peritonitis (7.23 +/- 0.22) or with suspected diagnosis of spontaneous bacterial peritonitis (7.29 +/- 0.15) than in patients with sterile ascites (7.45 +/- 0.06). However, there was an important overlap between these groups. In patients with and without spontaneous bacterial peritonitis, measurement of the difference between blood and ascitic pH was more discriminative than the ascitic pH alone: a difference of 0.10 or more was detected in all patients with spontaneous bacterial peritonitis, in 2 of 5 patients with suspected diagnosis of spontaneous bacterial peritonitis and in 3 of 97 patients with sterile ascites. When the ascitic pH value was lower than 7.15, death occurred rapidly. Ascitic pH rapidly increased when treatment of spontaneous bacterial peritonitis was clinically effective. These results suggest that measurement of pH in ascitic fluid is contributive to the diagnosis and prognosis of spontaneous bacterial peritonitis in alcoholic cirrhosis.