Liver Disease and SBP with Dr. Lagasse

SBP is the most common complication of ascites with 6 month survival of 31%

30% of patients with ascites will have SBP

Pathophysiology of liver disease: hepatocyte death due to toxin or injury

In chronic liver disease there is repeated scarring that disrupts normal liver parenchyma: nodular regeneration and congestion due to portal hypertension

Liver failure: loss of metabolic and synthetic function

Pathophysiology of ascites:

Increased portal pressure drives fluid out of blood vessels

Decrease in albumin production

Na retention through RAS system

Pathophysiology of SBP: translocation of normal gut flora across bowel wall

Due to bowel wall edema and poor immunologic function

SBP features

Diffuse abdominal pain

Consider SBP in all cases of new onset ascites or in ascites + another symptom

Paracentesis is diagnostic: cell count, glucose, protein, gram stain and culture

Consider also getting albumin, LDH, cytology, tumor markers

Criteria for diagnosis: need just 1

Neutrophils > 250

WBC > 1000

Positive gram stain or culture

Treatment: target E.Coli, proteus, Strep pneumo, enterococcus, anaerobes

Recurrence: based on prior culture

New onset: Rocephin, cefotaxime, Zosyn, Unasyn, ticarcillin

Rocephin does not cover pseudomonas

Give albumin if removing > 5 L of ascites

SBP + Cr > 1 should receive albumin, as it will improve their renal function

FFP or platelets prior to paracentesis? Not recommended

No clear cut offs for when you should transfuse prophylactically

Antibiotic prophylaxis should be given to cirrhotic patients who have upper gI bleeding

SBP prophylaxis in patients with ascites without GI bleeding: improves outcomes