– Spontaneous bacterial peritonitis (SBP) is a serious and potentially life-threatening infection of the fluid that accumulates in the abdomen (ascites) due to liver disease, such as cirrhosis.

– SBP occurs when bacteria from the intestines or other sources enter the bloodstream and reach the peritoneum, the thin layer of tissue that lines the abdominal cavity and covers the organs. SBP can cause inflammation, damage, and dysfunction of the peritoneum and other organs, such as the kidneys, lungs, and brain.

What is the triad of SBP?

– The triad of SBP is a combination of three clinical features that are suggestive of spontaneous bacterial peritonitis (SBP), a serious infection of the ascitic fluid in patients with liver disease.

– The triad consists of:

🔅 Fever or Hypothermia

– A body temperature that is higher or lower than normal, indicating a systemic inflammatory response to the infection. Fever is more common than hypothermia, but both can occur in SBP.

🔅 Abdominal Pain or Tenderness

– A sensation of discomfort or soreness in the abdomen, especially in the lower right quadrant where the liver is located. Abdominal pain or tenderness may be caused by the inflammation and damage of the peritoneum and other organs by the infection.

🔅 Altered Mental Status or Confusion

– A change in the level of consciousness, cognition, or behavior, ranging from mild disorientation to coma. Altered mental status or confusion may be caused by the accumulation of toxins in the blood that are normally cleared by the liver, leading to hepatic encephalopathy.

– The triad of SBP is not specific or sensitive for the diagnosis of SBP, as some patients may have no symptoms or only mild symptoms. Therefore, it is important to perform a paracentesis, a procedure that involves withdrawing some fluid from the ascitic cavity and analyzing it for signs of infection, such as high white blood cell count, positive bacterial culture, low pH, or low glucose.

The causes of SBP are not fully understood, but some factors that may increase the risk of developing SBP are:

• Advanced liver disease with portal hypertension and ascites.

• Low protein levels in the ascitic fluid.

• Previous episodes of SBP or other bacterial infections.

• Gastrointestinal bleeding or procedures.

• Use of proton pump inhibitors or nonsteroidal anti-inflammatory drugs.

The symptoms of SBP may vary depending on the severity and extent of the infection, but they usually include:

• Abdominal pain or tenderness, Fever and chills/peritonitis.

• Nausea and vomiting.

• Loss of appetite.

• Diarrhea or constipation.

• Decreased urine output.

• Difficulty passing stool or gas.

• Fatigue and weakness.

• Altered mental status or confusion.

• Worsening of ascites or edema.

– Some patients with SBP may have no symptoms or only mild symptoms, which can delay the diagnosis and treatment. Therefore, it is important to monitor the ascitic fluid regularly for signs of infection, especially in patients with high-risk factors.

The diagnosis of SBP requires a procedure called paracentesis, which involves inserting a needle into the abdomen and withdrawing some fluid from the ascitic cavity. The fluid is then analyzed for signs of infection, such as:

• High white blood cell count (>250 cells/µL), especially neutrophils (>250 cells/µL).

• Positive bacterial culture.

• Low pH (<7.35) or low glucose (<60 mg/dL).

Other tests that may be done to confirm the diagnosis and assess the severity and complications of SBP are:

• Blood tests to measure liver function, kidney function, electrolytes, blood count, and inflammatory markers.

• Urine tests to Bing, 7:37 PM check for signs of kidney injury or infection.

• Chest X-ray or ultrasound to look for signs of pleural effusion or pneumonia.

• Abdominal ultrasound to evaluate the liver, spleen, and ascites.

The treatment of SBP consists of antibiotics to kill the bacteria and prevent their spread, and albumin infusion to restore the fluid balance and prevent kidney failure.

The choice and duration of antibiotics may depend on the type and sensitivity of the bacteria, the severity of the infection, and the presence of any allergies or side effects. Some common antibiotics used for SBP are cefotaxime, ceftriaxone, amoxicillin-clavulanate, levofloxacin, or moxifloxacin. Albumin infusion is usually given at a dose of 1.5 g/kg on day 1 and 1 g/kg on other days.

The prevention of SBP is based on reducing the risk factors and avoiding potential triggers of infection.

Some preventive measures are:

• Treating the underlying liver disease and its complications, such as portal hypertension, variceal bleeding, hepatic encephalopathy, or hepatorenal syndrome.

• Reducing or eliminating ascites by using diuretics, salt restriction, paracentesis, or transjugular intrahepatic portosystemic shunt (TIPS).

• Taking prophylactic antibiotics, such as norfloxacin, ciprofloxacin, or rifaximin, in patients with high-risk factors, such as low protein levels in the ascitic fluid, previous episodes of SBP, gastrointestinal bleeding, or peritoneal dialysis.

• Practicing good hygiene and avoiding infections, such as urinary tract infections, respiratory infections, or skin infections.

• Avoiding the use of proton pump inhibitors or nonsteroidal anti-inflammatory drugs, unless prescribed by a doctor.

The prognosis of SBP depends on several factors, such as the type and cause of the infection, the response to treatment, and the presence of any complications or underlying conditions.

SBP has a high mortality rate of about 30% to 50%, especially if not treated promptly and effectively.

Some of the possible complications of SBP are:

• Sepsis: A condition that occurs when the infection spreads to the bloodstream and causes a systemic inflammatory response that can affect multiple organs and systems. Sepsis can lead to shock, organ failure, and death.

• Hepatorenal Syndrome: A condition that occurs when the kidney function deteriorates rapidly due to reduced blood flow to the kidneys caused by severe liver disease and portal hypertension. Hepatorenal syndrome can cause oliguria, azotemia, hyponatremia, and hypotension. It is a serious complication of SBP that has a poor prognosis.

• Hepatic Encephalopathy: A condition that occurs when the brain function is impaired due to the accumulation of toxins in the blood that are normally cleared by the liver. Hepatic encephalopathy can cause confusion, disorientation, drowsiness, coma, and death. It is a common complication of SBP that can worsen the outcome.

• Pleural Effusion: A condition that occurs when excess fluid accumulates in the pleural space, which is the area between the lungs and the chest wall. Pleural effusion can cause shortness of breath, chest pain, cough, and fever. It can be a complication of SBP due to the translocation of bacteria or ascitic fluid from the peritoneum to the pleura.

– SBP is a serious condition that requires immediate medical attention and treatment. By understanding its causes, symptoms, diagnosis, treatment and prevention methods, you can better manage your health and reduce your risk of complications.

What is the difference between SBP and Secondary Peritonitis?

– The difference between SBP and Secondary Peritonitis is mainly based on the source and location of the infection.

SBP is caused by an infection of the fluid in the peritoneal cavity, which is the space between the peritoneum and the abdominal organs. SBP usually occurs in people who have liver or kidney failure, especially those who are on peritoneal dialysis.

Secondary Peritonitis is caused by an infection that spreads from another part of the digestive tract or from an abdominal injury or surgery. Secondary peritonitis can result from conditions such as a ruptured appendix, a perforated ulcer, diverticulitis, pancreatitis, or pelvic inflammatory disease.

– SBP and Secondary Peritonitis may have different symptoms, diagnosis methods, treatment options, and prognosis depending on the cause and severity of the infection.

For example, SBP may cause cloudy or discolored dialysis fluid, white flecks or clumps in the dialysis fluid, redness or pain around the catheter site, or an unusual odor from the dialysis fluid.

Secondary peritonitis may cause abdominal pain or tenderness, abdominal bloating or distension, fever and chills, nausea and vomiting, loss of appetite, diarrhea or constipation, decreased urine output, difficulty passing stool or gas, or fatigue. SBP is diagnosed by analyzing the dialysis fluid for signs of infection, such as bacteria, fungi, white blood cells, or protein. Secondary peritonitis is diagnosed by various tests that can help identify the cause and extent of the infection, such as blood tests, paracentesis, X-ray, CT scan, or ultrasound.

– SBP is treated with antibiotics that are given intravenously or through the dialysis fluid. Secondary peritonitis may require surgery to remove any infected tissue or foreign objects, drain any abscesses or collections of pus, repair any perforations or holes in the peritoneum or other organs, and wash out any contaminated fluid from the abdominal cavity.

SBP has a high mortality rate of about 30% to 50%, especially if not treated promptly and effectively. Secondary peritonitis has a lower mortality rate of about 10% to 20%, but it can increase if complications such as sepsis, abscesses, adhesions, or organ failure occur.