History

A broad range of signs and symptoms are seen in spontaneous bacterial peritonitis (SBP). A high index of suspicion must be maintained when caring for patients with ascites, particularly those with acute clinical deterioration. Completely asymptomatic cases have been reported in as many as 30% of patients.

Fever and chills occur in as many as 80% of patients. Abdominal pain or discomfort is found in as many as 70% of patients.

Other signs and symptoms may include the following:

Worsening or unexplained encephalopathy
Diarrhea
Ascites that does not improve following administration of diuretic medication
Worsening or new-onset renal failure
Ileus

Physical Examination

Abdominal tenderness is found in more than 50% of patients with spontaneous bacterial peritonitis. Findings can range from mild tenderness to overt rebound and guarding. In some cases, the abdominal examination findings mimic an acute intra-abdominal catastrophe requiring emergency surgical evaluation. Physical examination may also disclose hypotension (5-14% of patients) or signs of hepatic failure such as jaundice and angiomata.

Differential Diagnoses

Lata J, Stiburek O, Kopacova M. Spontaneous bacterial peritonitis: a severe complication of liver cirrhosis. World J Gastroenterol. 2009 Nov 28. 15 (44):5505-10. [QxMD MEDLINE Link].
Bert F, Noussair L, Lambert-Zechovsky N, Valla D. Viridans group streptococci: an underestimated cause of spontaneous bacterial peritonitis in cirrhotic patients with ascites. Eur J Gastroenterol Hepatol. 2005 Sep. 17(9):929-33. [QxMD MEDLINE Link].
Cholongitas E, Papatheodoridis GV, Lahanas A, Xanthaki A, Kontou-Kastellanou C, Archimandritis AJ. Increasing frequency of Gram-positive bacteria in spontaneous bacterial peritonitis. Liver Int. 2005 Feb. 25(1):57-61. [QxMD MEDLINE Link].
[Guideline] Runyon BA. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun. 49(6):2087-107. [QxMD MEDLINE Link].
Greenberger NJ et al. Ascites & Spontaneous Bacterial Peritonitis. Current Diagnosis & Treatment: Gastroenterology, Hepatology & Endoscopy. 2nd ed. 2012. Ch 45.
Terg R, Casciato P, Garbe C, et al. Proton pump inhibitor therapy does not increase the incidence of spontaneous bacterial peritonitis in cirrhosis: a multicenter prospective study. J Hepatol. 2015 May. 62 (5):1056-60. [QxMD MEDLINE Link].
Siple JF, Morey JM, Gutman TE, Weinberg KL, Collins PD. Proton pump inhibitor use and association with spontaneous bacterial peritonitis in patients with cirrhosis and ascites. Ann Pharmacother. 2012 Oct. 46(10):1413-8. [QxMD MEDLINE Link].
Deshpande A, Pasupuleti V, Thota P, Pant C, Mapara S, Hassan S. Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. J Gastroenterol Hepatol. 2013 Feb. 28(2):235-42. [QxMD MEDLINE Link].
Ge PS, Runyon BA. Preventing future infections in cirrhosis: a battle cry for stewardship. Clin Gastroenterol Hepatol. 2015 Apr. 13 (4):760-2. [QxMD MEDLINE Link].
Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M. Nonselective ß blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology. 2014 Jun. 146(7):1680-90.e1. [QxMD MEDLINE Link].
Kim JJ, Tsukamoto MM, Mathur AK, Ghomri YM, Hou LA, Sheibani S, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. Am J Gastroenterol. 2014 Sep. 109 (9):1436-42. [QxMD MEDLINE Link].
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 Mar. 12 (3):496-503.e1. [QxMD MEDLINE Link].
Karvellas CJ, Abraldes JG, Arabi YM, Kumar A, Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther. 2015 Apr. 41 (8):747-57. [QxMD MEDLINE Link].
Cohen MJ, Sahar T, Benenson S, Elinav E, Brezis M, Soares-Weiser K. Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding. Cochrane Database Syst Rev 2009; 15:CD004791. Available at https://read.qxmd.com/doi//10.1002/14651858.CD004791.pub2. 2009; Accessed: 3/21/2021.
Dirk Foell 1, Michael Frosch, Clemens Sorg, Johannes Roth. Phagocyte-specific calcium-binding S100 proteins as clinical laboratory markers of inflammation. Clin Chim Acta. June 2004. 344(1-2):37-51. [QxMD MEDLINE Link]. [Full Text].
Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology. 2012 May. 55 (5):1551-61. [QxMD MEDLINE Link].
Muhammad S Soyfoo 1, Johannes Roth, Thomas Vogl, Roland Pochet, Guy Decaux. Phagocyte-specific S100A8/A9 protein levels during disease exacerbations and infections in systemic lupus erythematosus. J Rheumatol. Oct 2009. 36(10):2190-4. [QxMD MEDLINE Link]. [Full Text].
A G Røseth 1, P N Schmidt, M K Fagerhol. Correlation between faecal excretion of indium-111-labelled granulocytes and calprotectin, a granulocyte marker protein, in patients with inflammatory bowel disease. Scand J Gasterenterol. Jan 1999. 34(1):50-4. [QxMD MEDLINE Link]. [Full Text].
Riggio O, Angeloni S. Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis. World J Gastroenterol. 2009 Aug 21. 15(31):3845-50. [QxMD MEDLINE Link]. [Full Text].
Chinnock B, Gomez R, Hendey GW. Peritoneal fluid cultures rarely alter management in patients with ascites. J Emerg Med. 2011 Jan. 40(1):21-4. [QxMD MEDLINE Link].
Gaya DR, David B Lyon T, et al. Bedside leucocyte esterase reagent strips with spectrophotometric analysis to rapidly exclude spontaneous bacterial peritonitis: a pilot study. Eur J Gastroenterol Hepatol. 2007 Apr. 19(4):289-95. [QxMD MEDLINE Link].
Emanuel Burri 1, Felix Schulte, Jürgen Muser, Rémy Meier, Christoph Beglinger. Measurement of calprotectin in ascitic fluid to identify elevated polymorphonuclear cell count. World J Gastroenterol. Apr 7 2013. 19(13):2028-36. [QxMD MEDLINE Link]. [Full Text].
Téllez-Ávila FI, Chávez-Tapia NC, Franco-Guzmán AM, Uribe M, Vargas-Vorackova F. Rapid diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips in emergency department: uri-quick clini-10SG® vs. Multistix 10SG®. Ann Hepatol. 2012 Sep-Oct. 11(5):696-9. [QxMD MEDLINE Link].
Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology. 1990 Oct. 12(4 Pt 1):710-5. [QxMD MEDLINE Link].
[Guideline] Runyon BA. 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 Apr. 57(4):1651-3. [QxMD MEDLINE Link].
Mazer L, Tapper EB, Piatkowski G, Lai M. The need for antibiotic stewardship and treatment standardization in the care of cirrhotic patients with spontaneous bacterial peritonitis - a retrospective cohort study examining the effect of ceftriaxone dosing. F1000Res. 2014. 3:57. [QxMD MEDLINE Link]. [Full Text].
Pande C, Kumar A, Sarin SK. Addition of probiotics to norfloxacin does not improve efficacy in the prevention of spontaneous bacterial peritonitis: a double-blind placebo-controlled randomized-controlled trial. Eur J Gastroenterol Hepatol. 2012 Jul. 24(7):831-9. [QxMD MEDLINE Link].
Salerno F, Navickis RJ, Wilkes MM. Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials. Clin Gastroenterol Hepatol. 2013 Feb. 11 (2):123-30.e1. [QxMD MEDLINE Link].
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 Apr. 57 (4):1651-3. [QxMD MEDLINE Link].
Runyon BA, Borzio M, Young S, Squier SU, Guarner C, Runyon MA. Effect of selective bowel decontamination with norfloxacin on spontaneous bacterial peritonitis, translocation, and survival in an animal model of cirrhosis. Hepatology. 1995 Jun. 21 (6):1719-24. [QxMD MEDLINE Link].
Fernández J, Navasa M, Planas R, Montoliu S, Monfort D, Soriano G, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007 Sep. 133 (3):818-24. [QxMD MEDLINE Link].