Skip to content

Spontaneous Bacterial Peritonitis (SBP) and Large-Volume Paracentesis Circulatory Dysfunction (PPCD): Fever or Confusion in Ascites, Ascitic Fluid PMN >= 250/mm3, and Mandatory IV Albumin Replacement

Emergency numbers differ by country. This page uses 911, the number for the United States and Canada. Many other countries use 112, 999, or another number. Find the number for your country.

Spontaneous Bacterial Peritonitis (SBP) and Post-Paracentesis Circulatory Dysfunction (PPCD) are two life-threatening abdominal and hemodynamic emergencies that occur in patients with decompensated liver cirrhosis and portal hypertensive ascites (as well as children or adults with severe nephrotic syndrome). - Spontaneous Bacterial Peritonitis (SBP) dia otrikaretina mahery vaika avy amin'ny fluid ascitic sterile teo aloha izay mitranga ao anatin'ny ** tsy fisian'ny loharanon'ny fandidiana ao anaty kibo** (toy ny appendix mipoitra, fery mipoitra, na abscess diverticular). Ao amin'ny cirrhose decompensate, ny fiakaran'ny tosidrà amin'ny vavahady dia miteraka ** edema mucosal intestinal, tsy fahampian'ny permeability amin'ny tsinay, fitomboan'ny bakteria amin'ny tsinay, ary tsy fahampian'ny fluid ascitic famenoana/opsonic** (indrindra raha $<1.0\text{ hatramin'ny }1.5\text{ ny tontalin'ny fluid ascitic**). Ny bacilli Gram-negatif enteric (Escherichia coli sy Klebsiella pneumoniae) ary ny cocci Gram-positive (Streptococcus pneumoniae sy Enterococcus) dia mandika mivantana ny rindrin'ny tsinainy tsy misy dikany mankany amin'ny tadin'ny lymph mesenterika ary manondraka rano fandroana. Tsy toy ny peritonitis chirurgie (izay miteraka kibon'ny fandidiana mafy toy ny birao), ** rano fandroana 5 ka hatramin'ny 10 litatra misy tsiranoka ascitic dia manasaraka ny peritoneum visceral sy parietal, ka 30 ka hatramin'ny 50 isan-jaton'ny marary SBP mahafaty dia manana fanaintainana ZERO kibo, ZERO rebound tenderness , ary tsy misy fanaintainana miverina , ary tsy misy soritr'aretina. Encephalopathie (fisavoritaka/asterixis), ratra amin'ny voa tsy fantatra (Syndrome Hepatorenal Type 1 / HRS-AKI), jaundice miharatsy, ileus, na fahatafintohinana septika. Isaky ny adiny fahatarana alohan'ny hanaovana Paracentesis Diagnostika sy ny fanomezana ny Cephalosporin Generation fahatelo (Ceftriaxone \(2\text{g}\) IV) dia mampitombo ny fahafatesan'ny hopitaly amin'ny 3.3 isan-jato isan'ora. Ny fitsaboana antibiotika irery dia tsy ampy: ny endotoxine bakteria dia miteraka firongatry ny peritoneal ** oxide nitric (NO) sy ny vasodilation arterial splanchnic ** izay mamono ny voa amin'ny fikorianan'ny rà, ka mahafaty Hepatorenal Syndrome raha tsy hoe mahazo ** Intravenous \(25\%\) $1. \(1,0\text{ g/kg}\) amin'ny Andro faha-3, ny Sort Landmark Protocol), izay mampihena ny fahafatesana efa ho 70 isan-jato. - Post-Paracentesis Circulatory Dysfunction (PPCD) dia iatrogenic hemodynamic collapse ateraky ny mpitsabo iray manao Large-Volume Paracentesis (LVP, mandrotsaka \(> 5\text{ litatra}\) ascites mihenjana ao anatin'ny fotoam-pivoriana iray) tsy misy manome intravenous \(25\%\\\\\\\\'ny soratra {\)25\%$ ny olona albumin isaky ny litatra ascites nesorina). Ny fanerena haingana ny kibo dia mampihena ny tsindry ao anaty kibo ary miteraka reflex ** vasodilation arterial splanchnic **, mihena ny habetsahan'ny arterial mahomby, ny plasma spiking renina sy aldosterone 2 ka hatramin'ny 6 andro aty aoriana, ary mipoitra famerenana haingana ny ascites mihenjana, hyponatremia dilutional mafy, Hepatorenal encephalopathie, hepatorenal encephalitis.

Raha misy marary voan'ny cirrhose sy ascites misy tazo, fanaintainan'ny kibo, fisavoritahana vaovao / rendremana, fihenan'ny urine, na sempotra avy amin'ny kibo mivonto henjana, antsoy ny toerana misy anao. laharana vonjy maika avy hatrany. Avereno jerena ihany koa ny torolàlana momba ny mpiray tam-po amintsika Hepatic encephalopathie kilasy faha-3 sy faha-4 kôma amin'ny aty, asterixis, ary enema lactulose, vaky varices lalankaniny, fandatsahan-drà cirrhose, ary encephalopathie hepatic, ary appendicite, appendix vaky, peritonitis, ary fanaintainan'ny quadrant ambany havanana.

Ataovy izao izao

  1. **Manaova Paracentesis Diagnostika Ara-drariny amin'ny alàlan'ny Ultrasound ao anatin'ny adiny 6 (Tsara indrindra ao anatin'ny adiny 1 ka hatramin'ny 2) amin'ny marary rehetra voan'ny cirrhose sy ascites nampidirina tany amin'ny hopitaly, na dia tsy manana fanaintainan'ny kibo sy tazo aotra aza izy ireo. global directory of laharana vonjy maika. Hatramin'ny 15 ka hatramin'ny 30 isan-jaton'ny marary cirrhotic rehetra any amin'ny hopitaly miaraka amin'ny ascites dia manana SBP mavitrika rehefa miditra, matetika tsy misy afa-tsy fisafotofotoana (hepatic encephalopathy) na creatinine serum mitombo.
  2. Aza manemotra ny Paracentesis Diagnostika mba hanomezana Plasma Fresh Frozen (FFP) na Platelet ho an'ny INR avo na Isan'ny plateleta ambany.
  3. Ny hadisoan'ny hopitaly maneran-tany dia ny fanemorana 6 ka hatramin'ny 12 ora ny fitiliana ascitic mba hampidirana FFP satria misy marary cirrhotic manana \(\text{INR}\) \(2,2\) na platelets \(45,000/\text{\mu L}\).
  4. AASLD, EASL, and BSG Guidelines state unequivocally: Cirrhotic coagulopathy is rebalanced; the risk of significant bleeding from an ultrasound-guided diagnostic paracentesis is less than \(0.2\%\), and neither an elevated INR nor thrombocytopenia is a contraindication to paracentesis (the only exclusions are clinically evident fibrinolysis or disseminated intravascular coagulation [DIC]). Use bedside ultrasound with Color Doppler to target the Left Lower Quadrant (where the abdominal wall is thinner and the cecum is avoided) and stay at least \(5\text{ cm}\) lateral to the midline to avoid the inferior epigastric artery.
  5. Calculate the Ascitic Fluid Absolute Polymorphonuclear Leukocyte (PMN / Neutrophil) Count AND Inoculate \(10\text{ mL}\) of Ascitic Fluid Directly into Aerobic and Anaerobic Blood Culture Bottles at the Bedside:
  6. The Diagnostic Threshold for SBP: An ascitic fluid Absolute PMN (Neutrophil) Count \(\ge 250\text{ cells/mm}3\) (\(0.25 \times 109\text{/L}\)) confirms Spontaneous Bacterial Peritonitis and mandates immediate empiric intravenous antibiotics + IV albumin without waiting 48 hours for culture results.
  7. Bloody Tap Correction Formula: If a traumatic tap introduces red blood cells (\(\text{RBCs}\)) into the fluid, subtract \(1\text{ PMN}\) for every \(250\text{ RBCs/mm}3\) to get the true corrected PMN count.
  8. Why Bedside Blood Culture Bottles Are Mandatory: Sending ascitic fluid to the lab in a plain sterile syringe or cup yields positive cultures in less than \(40\%\) of SBP cases (because SBP has a very low bacterial colony count of \(\approx 1\text{ organism/mL}\)). Inoculating \(10\text{ mL}\) of ascitic fluid directly into aerobic and anaerobic blood culture bottles at the bedside boosts culture sensitivity above \(80\%\).
  9. Administer Empiric Intravenous Antibiotics Immediately After the Tap:
  10. Community-Acquired SBP (No Septic Shock, No Recent Beta-Lactam Exposure): Administer Intravenous Ceftriaxone \(2\text{ grams}\) IV every 24 hours (or IV Cefotaxime \(2\text{ grams}\) every 8 hours) for 5 to 7 days.
  11. Nosocomial / Healthcare-Associated SBP, Septic Shock, or Recent Hospitalization: Because 30 to 40 percent of hospital-acquired SBP is caused by Extended-Spectrum Beta-Lactamase (ESBL) Gram-negatives or Enterococcus / MRSA, start broad-spectrum Intravenous Meropenem (\(1\text{ g}\) IV every 8 hours) or Piperacillin-Tazobactam (\(4.5\text{ g}\) IV every 6 to 8 hours) PLUS Vancomycin or Daptomycin (or Tigecycline in VRE/MDRO areas).
  12. Administer Mandatory Intravenous \(25\%\) Human Albumin Using the Sort Protocol (\(1.5\text{ g/kg}\) on Day 1 + \(1.0\text{ g/kg}\) on Day 3) and HOLD All Beta-Blockers, Diuretics, and NSAIDs.
  13. In the landmark Sort et al. (NEJM 1999) trial, adding Intravenous \(25\%\) Human Albumin, \(1.5\text{ grams/kg}\) of body weight within 6 hours of SBP diagnosis on Day 1 (maximum \(100\text{ g}\)), followed by \(1.0\text{ gram/kg}\) on Day 3 (maximum \(100\text{ g}\)), slashed the rate of Hepatorenal Syndrome from \(30\%\) down to \(10\%\) and reduced in-hospital mortality from \(29\%\) down to \(10\%\). (Especially critical if baseline Serum Creatinine \(> 1.0\text{ mg/dL}\) [\(88\text{ \mu mol/L}\)], BUN \(> 30\text{ mg/dL}\), or Total Bilirubin \(> 4.0\text{ mg/dL}\) [\(68\text{ \mu mol/L}\)]).
  14. Immediately HOLD Non-Selective Beta-Blockers (Propranolol, Nadolol, Carvedilol), Diuretics (Furosemide, Spironolactone), ACE Inhibitors/ARBs, and Aminoglycosides during active SBP: beta-blockers blunting cardiac output during SBP splanchnic vasodilation markedly increase the risk of Hepatorenal Syndrome and death.
  15. Prevent Post-Paracentesis Circulatory Dysfunction (PPCD) During Any Large-Volume Paracentesis (\(> 5\text{ Liters}\) Removed): Infuse \(6\text{ to }8\text{ Grams}\) of \(25\%\) IV Albumin per Liter Removed.
  16. Never perform a Large-Volume Paracentesis (LVP \(> 5\text{ L}\)) during active Spontaneous Bacterial Peritonitis (draining large volumes during active SBP accelerates acute kidney injury; perform only a small diagnostic tap [\(30\text{ to }50\text{ mL}\)] until SBP is treated, unless tense ascites is causing immediate respiratory failure).
  17. Whenever performing an elective or urgent Large-Volume Paracentesis (\(> 5\text{ L}\) removed in sterile ascites), infuse \(6\text{ to }8\text{ grams}\) of \(25\%\) Intravenous Human Albumin for every liter of ascites removed (for example, if \(8\text{ liters}\) are drained, infuse \(48\text{ to }64\text{ grams}\) [\(200\text{ to }250\text{ mL}\) of \(25\%\) Albumin] IV during or immediately after the procedure).

How to Avoid Operating on SBP, and How to Avoid Missing a Perforated Bowel (Runyon's Criteria for Secondary Bacterial Peritonitis)

Performing an exploratory laparotomy on a decompensated cirrhotic patient who actually has Spontaneous Bacterial Peritonitis (SBP) carries an 80 percent surgical mortality rate from liver failure and bleeding. Conversely, treating a perforated duodenal ulcer, perforated appendix, or perforated diverticulitis (Secondary Bacterial Peritonitis) inside an ascitic belly with medical ceftriaxone alone without surgery is 100 percent fatal. Use Runyon's Ascitic Fluid Criteria on every tap: suspect Secondary Bacterial Peritonitis (Surgical Perforation) and order an immediate Abdominal CT with IV and Oral/Rectal Contrast if the ascitic fluid shows \(\text{PMN} \ge 250/\text{mm}3\) PLUS at least TWO of the following THREE laboratory signs: 1. Ascitic Fluid Total Protein \(> 1.0\text{ g/dL}\) (\(10\text{ g/L}\)); 2. Ascitic Fluid Glucose \(< 50\text{ mg/dL}\) (\(2.8\text{ mmol/L}\)); 3. Ascitic Fluid LDH \(>\) Upper Limit of Normal for Serum LDH (or polymicrobial flora/fungi seen on Gram stain).

Decision tree: diagnostic paracentesis, SBP vs. Secondary Peritonitis triage, and PPCD prevention

flowchart TD
    A["Patient with Cirrhosis and Ascites Presents to Hospital with ANY Decompensation: Fever/Hypothermia, Abdominal Pain, New Hepatic Encephalopathy (Confusion/Asterixis), Rising Creatinine (AKI), GI Bleeding, Leukocytosis, OR Tense Ascites Causing Dyspnea"] --> B["Step 1: Perform Ultrasound-Guided Bedside Diagnostic Paracentesis Within < 6 Hours (Left Lower Quadrant, Avoid Inferior Epigastric Artery; DO NOT Delay for INR or Low Platelets)"]
    B --> C["Step 2: Send Ascitic Fluid STAT for: 1. Cell Count & Differential (Absolute PMN Count); 2. Total Protein & Albumin (Calculate SAAG: Serum Albumin minus Ascites Albumin >= 1.1 g/dL Confirms Portal Hypertension); 3. Glucose, LDH, Gram Stain; 4. Inoculate 10 mL Directly into Aerobic & Anaerobic Blood Culture Bottles at Bedside"]
    C --> D{"Evaluate Ascitic Fluid Absolute Neutrophil (PMN) Count (Subtract 1 PMN per 250 RBCs if Bloody)"}
    D -->|Corrected Ascitic PMN >= 250 cells/mm3| E{"Check Runyon's Criteria for Secondary Surgical Peritonitis: Does Fluid Have >= 2 of 3: 1. Protein > 1.0 g/dL; 2. Glucose < 50 mg/dL; 3. LDH > Serum ULN (or Polymicrobial Gram Stain)?"}
    E -->|YES: Runyon's Criteria Positive| F["SUSPECTED SECONDARY BACTERIAL PERITONITIS (Perforated Ulcer, Appendix, or Diverticulum): Order STAT Abdominal/Pelvic CT + Add Anaerobic Coverage (IV Piperacillin-Tazobactam or Ceftriaxone + Metronidazole) + Emergent Surgical Consultation"]
    E -->|NO: Classic Low-Protein Monomicrobial Ascites| G["CONFIRMED SPONTANEOUS BACTERIAL PERITONITIS (SBP): DO NOT Perform Large-Volume Paracentesis During Active SBP"]
    G --> H["DEFINITIVE SBP RESCUE BUNDLE: 1. Immediate IV Antibiotics: Ceftriaxone 2 g IV q24h (or Meropenem/Pip-Tazo + Vancomycin if Nosocomial/Septic Shock); 2. Mandatory IV 25% Human Albumin (Sort Protocol): 1.5 g/kg Day 1 (within 6h) + 1.0 g/kg Day 3; 3. HOLD All Beta-Blockers (Propranolol/Carvedilol), Diuretics, and NSAIDs; 4. Start Secondary Prophylaxis Before Discharge"]
    D -->|Corrected Ascitic PMN < 250 cells/mm3 (Sterile Ascites on Initial Count)| I{"Check Clinical Status & Subsequent 48-Hour Blood Culture Bottle Result"}
    I -->|Culture Turns Positive at 24-48h ("Monomicrobial Non-Neutrocytic Bacterascites")| J["If Symptomatic (Fever, Pain, Encephalopathy, AKI): Treat Identically to Full SBP; If Completely Asymptomatic: Repeat Diagnostic Paracentesis Immediately"]
    I -->|Patient Has Tense Sterile Ascites Causing Respiratory Distress / Severe Discomfort Requiring Large-Volume Paracentesis (LVP > 5 Liters)| K["LARGE-VOLUME PARACENTESIS (LVP) + PPCD PREVENTION PROTOCOL: Drain Ascites to Dryness in a Single Session AND Infuse 6 to 8 Grams of 25% IV Human Albumin for EVERY Liter Removed (e.g., 50-64 g Albumin for 8 L Removed)"]

Pathophysiology: bacterial translocation, nitric oxide splanchnic vasodilation, and why SBP and Large-Volume Paracentesis trigger Hepatorenal Syndrome

1. Why Cirrhotic Ascitic Fluid Gets Infected Without a Perforated Organ

In advanced cirrhosis, sinusoidal portal hypertension drives protein-poor fluid across the hepatic sinusoids and splanchnic capillaries into the peritoneal cavity (Serum-Ascites Albumin Gradient [SAAG] \(\ge 1.1\text{ g/dL}\) with Ascitic Total Protein \(< 1.5\text{ g/dL}\)). Three defects converge to ignite Spontaneous Bacterial Peritonitis: 1. Intestinal Bacterial Overgrowth & Dysbiosis: Impaired small-bowel motility and reduced bile acid secretion allow Gram-negative Enterobacteriaceae (E. coli, Klebsiella) to overgrow in the small intestine (further worsened by chronic Proton Pump Inhibitor [PPI] use). 2. Gut Barrier Failure & Bacterial Translocation: Portal venous congestion causes subepithelial edema of the intestinal wall and widens intercellular tight junctions, allowing viable bacteria to cross into mesenteric lymph nodes, thoracic duct lymph, and the bloodstream. 3. Deficient Ascitic Fluid Opsonic Activity: Because cirrhotic ascitic fluid has very low total protein (\(< 1.0\text{ to }1.5\text{ g/dL}\)), it lacks Complement C3 and immunoglobulins required to opsonize and kill translocated bacteria. A single bacterium entering the 8-liter fluid bath multiplies unchecked into Spontaneous Bacterial Peritonitis.

HOW SBP & UNPROTECTED LARGE-VOLUME PARACENTESIS CAUSE HEPATORENAL SYNDROME
==========================================================================
 [PATHWAY 1: SPONTANEOUS BACTERIAL PERITONITIS]   [PATHWAY 2: LARGE-VOLUME PARACENTESIS]
 Gram-Negative Endotoxin (LPS) + Cytokines        Draining > 5 Liters of Tense Ascites
 (TNF-alpha, IL-6) flood the peritoneum.          without IV Albumin abruptly drops
                    \                             intra-abdominal pressure.
                     \                                   /
                      v                                 v
      [MASSIVE SPLANCHNIC ARTERIAL VASODILATION (Nitric Oxide Surge)]
      Blood pools inside dilated mesenteric/splanchnic arteries;
      Systemic Vascular Resistance (SVR) and Mean Arterial Pressure (MAP) drop.
                                       |
                                       v
      [EFFECTIVE ARTERIAL HYPOVOLEMIA & BARORECEPTOR ACTIVATION]
      Extreme activation of:
      1. Renin-Angiotensin-Aldosterone System (RAAS)
      2. Sympathetic Nervous System (Norepinephrine)
      3. Non-Osmotic Antidiuretic Hormone (ADH / Vasopressin)
                                       |
         +-----------------------------+-----------------------------+
         |                                                           |
         v                                                           v
 [INTENSE RENAL ARTERIOLAR VASOCONSTRICTION]         [FREE-WATER & SODIUM RETENTION]
 Renal cortical blood flow & GFR collapse            Dilutional Hyponatremia (Na+ < 125)
 --> HEPATORENAL SYNDROME (HRS-AKI)                  + Rapid Re-Accumulation of Ascites
     & Multi-Organ Failure / Death.                    (PPCD).
==========================================================================
 *HOW IV 25% HUMAN ALBUMIN SAVES LIFE IN BOTH EMERGENCIES:*
 1. Oncotic Volume Expansion: Pulls interstitial fluid into the central arterial
    tree, restoring Effective Arterial Blood Volume and shutting off Renin/ADH.
 2. Non-Oncotic Scavenging: Albumin binds bacterial Endotoxin (LPS), Nitric Oxide,
    Prostaglandin E2, and reactive oxygen species, reversing endothelial shock.
==========================================================================

Complete Diagnostic Classification of Ascitic Fluid Infections: SBP vs. Culture-Negative Neutrocytic Ascites vs. Bacterascites vs. Secondary Peritonitis

Every ascitic fluid tap must be classified into one of five distinct entities based on the Corrected Absolute PMN Count (\(\text{Total WBC} \times \%\text{Neutrophils}\)), Bedside Blood-Culture Bottle Result, and Runyon's Biochemistry:

Ascitic Fluid Category Corrected Ascitic PMN Count (\(\text{cells/mm}3\)) Ascitic Fluid Bacterial Culture Result Ascitic Protein, Glucose & LDH (Runyon's Criteria) Clinical Meaning & Mandatory Emergency Action
1. Classic Spontaneous Bacterial Peritonitis (SBP) \(\ge 250/\text{mm}3\) Positive for a SINGLE organism (E. coli, Klebsiella pneumoniae, or Streptococcus pneumoniae) Protein usually \(< 1.0\text{ g/dL}\); Glucose \(\ge 50\text{ mg/dL}\); LDH \(<\) Serum ULN. Active SBP: Start IV Ceftriaxone \(2\text{ g}\) q24h (or Meropenem if nosocomial) + IV \(25\%\) Albumin (\(1.5\text{ g/kg}\) Day 1, \(1.0\text{ g/kg}\) Day 3).
2. Culture-Negative Neutrocytic Ascites (CNNA) \(\ge 250/\text{mm}3\) Negative (often due to prior antibiotic dose or poor culture technique; rule out pancreatitis, peritoneal carcinomatosis, or tuberculous peritonitis) Same as Classic SBP (low protein, normal glucose, low LDH). Treat 100% Identically to Classic SBP: Carries the exact same mortality and hepatorenal risk as culture-positive SBP; give IV Ceftriaxone + IV Albumin.
3. Monomicrobial Non-Neutrocytic Bacterascites (MNB) \(< 250/\text{mm}3\) Positive for a SINGLE organism (detected 24 to 48 hours later when lab calls with positive blood culture bottle) Normal / baseline transudative cirrhotic ascites. Two Paths:
- If Symptomatic (fever, pain, confusion/HE, or AKI): Treat immediately as full SBP.
- If Completely Asymptomatic: Repeat diagnostic paracentesis immediately (60% clear spontaneously; if repeat \(\text{PMN} \ge 250\) or culture stays positive, treat as SBP).
4. Secondary Bacterial Peritonitis (Perforated Viscus or Abscess) \(\ge 250/\text{mm}3\) (often \(> 1,000\text{ to }10,000/\text{mm}3\)) Polymicrobial (multiple enteric Gram-negatives + anaerobes + Enterococcus or Candida) Runyon's Positive (\(\ge 2\) of 3):
1. Protein \(> 1.0\text{ g/dL}\)
2. Glucose \(< 50\text{ mg/dL}\)
3. LDH \(>\) Serum ULN
(Also check Ascitic CEA \(> 5\text{ ng/mL}\) or Alk Phos \(> 240\text{ U/L}\) for hollow viscus perforation).		 SURGICAL EMERGENCY: Order STAT Abdominal/Pelvic CT with contrast, add anaerobic coverage (IV Piperacillin-Tazobactam or Ceftriaxone + Metronidazole), and consult General Surgery immediately.
5. Polymicrobial Bacterascites (Needle Bowel Puncture) \(< 250/\text{mm}3\) Polymicrobial (multiple gut organisms + air bubbles/particulate matter aspirated during tap) Normal baseline PMN count because the paracentesis needle accidentally entered a loop of bowel. Most resolve without surgery; repeat paracentesis from opposite quadrant and cover with broad-spectrum IV antibiotics (Ceftriaxone + Metronidazole) if symptoms develop.

Step-by-Step Hospital Protocol for Performing Ultrasound-Guided Paracentesis, Treating SBP, and Preventing PPCD

Step 1: Safe Ultrasound-Guided Technique (The Left Lower Quadrant & "Z-Track" Method)

  1. Nahoana no tiana ny efamira havia ambany (LLQ) noho ny efamira ambany havanana:
  2. Ny rindrin'ny kibo ao amin'ny Quadrant ambany havia (\(2\text{ fingerbreadths}\) [\(3\text{ cm}\)] cephalad ary \(2\text{ fingerbreadths}\) medial mankany anterior superior iliac spine [ASIS]) dia manify kokoa ary manana dobo ranom-boankazo ascitic lalindalina kokoa noho ny afovoany, ary misoroka ny tsipika ambany kokoa noho ny afovoany. mivelatra miaraka amin'ny entona avy amin'ny fitsaboana lactulose) ary koa ny hepatomegali-kavanana ambony.
  3. Tsy maintsy ultrason-drongony eo am-pandriana + Fijerena Doppler loko:
  4. Identify the deepest pocket of free-floating anechoic fluid free of bowel loops or omentum.
  5. Ampiasao ny Color Doppler hitadiavana sy hialana amin'ny Arterie Epigastric Inferior (izay mitsangana mitsangana ao anatin'ny fonon'ny rectus \(4\text{ hatramin'ny }8\text{ cm}\) lateral amin'ny umbilicus) sy izay mety ho caput medusae / rindrin'ny kibo portosystemic collateral veins.
  6. The "Z-Track" Needle Insertion Technique (Prevents Post-Tap Ascitic Fluid Leak):
  7. After sterile chlorhexidine prep and \(1\%\) lidocaine wheal down to the peritoneum, pull the skin \(2\text{ centimeters}\) caudally (downward) with your non-dominant hand while advancing the paracentesis needle perpendicular to the abdominal wall, aspirating continuously until peritoneal fluid enters the syringe. When the needle is withdrawn at the end of the tap, the skin slides back to its original position, creating an offset "Z-track" seal so ascitic fluid does not leak onto the bed. (If a persistent post-paracentesis ascitic leak ever occurs, place a sterile ostomy bag over the site to quantify losses or close the skin pinhole with a single figure-of-eight suture or tissue adhesive while having the patient lie on the opposite side).

Step 2: The Complete SBP Hospital Treatment Bundle (Antibiotics, Albumin, Medication Hold, and 48-Hour Tap Check)

Component of SBP Bundle Exact Regimen & Timing Clinical Rationale & Guideline Evidence
1. Empiric IV Antibiotics (Within 1 Hour of Diagnosis) - Community-Acquired SBP: IV Ceftriaxone \(2\text{ g}\) every 24 hours (or IV Cefotaxime \(2\text{ g}\) every 8 hours) for 5 to 7 days.
(If severe beta-lactam anaphylaxis: IV Levofloxacin \(500\text{ mg}\) q24h or IV Ciprofloxacin \(400\text{ mg}\) q12h ONLY if patient was NOT already taking fluoroquinolone SBP prophylaxis; otherwise use Aztreonam + Vancomycin).
- Nosocomial / ICU / Septic Shock SBP: IV Meropenem \(1\text{ g}\) q8h (or Piperacillin-Tazobactam) + IV Vancomycin or Daptomycin.		 A 5-day course of third-generation cephalosporin is equal in efficacy to a 10-day course in uncomplicated SBP. Strictly avoid Aminoglycosides (Gentamicin, Tobramycin, Amikacin), which cause catastrophic nephrotoxicity in cirrhosis.
2. Intravenous 25% Human Albumin (Sort Protocol) - Day 1 (Within 6 Hours of Diagnosis): \(1.5\text{ grams/kg}\) of \(25\%\) Human Albumin IV (max \(100\text{ g}\), infused over 4 to 6 hours).
- Day 3 (48 Hours Later): \(1.0\text{ gram/kg}\) of \(25\%\) Human Albumin IV (max \(100\text{ g}\)).		 Proven by Sort et al. (NEJM) to cut Type-1 Hepatorenal Syndrome from \(30\%\) to \(10\%\) and reduce mortality from \(29\%\) to \(10\%\). Highest benefit when Serum Creatinine \(> 1.0\text{ mg/dL}\), BUN \(> 30\text{ mg/dL}\), or Bilirubin \(> 4.0\text{ mg/dL}\). (Use \(25\%\) concentrated hyperoncotic albumin, not \(5\%\) albumin in saline, to avoid sodium/fluid overload; infuse slowly if underlying heart failure or portopulmonary hypertension is present).
3. Mandatory Medication Audit (Hold Beta-Blockers, Diuretics & PPIs) - STOP Non-Selective Beta-Blockers (Propranolol, Nadolol, Carvedilol) immediately during active SBP (permanently discontinue if SBP is complicated by hypotension [\(\text{SBP} < 90\text{ mmHg}\) or \(\text{MAP} < 65\text{ mmHg}\)] or Hepatorenal Syndrome).
- HOLD Furosemide & Spironolactone until SBP and AKI resolve.
- Discontinue Unnecessary Proton Pump Inhibitors (PPIs) (omeprazole, pantoprazole) unless there is an active peptic ulcer/GI bleed.		 Mandorfer et al. (Gastroenterology) proved that continuing beta-blockers during active SBP prevents compensatory tachycardia, doubling the rate of Hepatorenal Syndrome and mortality. Chronic PPIs destroy the gastric acid barrier and triple recurrent SBP risk.
4. When to Perform a 48-Hour Repeat Diagnostic Paracentesis Repeat a diagnostic tap at 48 hours if the patient fails to improve clinically OR has atypical/nosocomial SBP. In properly treated SBP, the 48-hour ascitic PMN count must drop by at least \(25\%\) from baseline. If the 48-hour PMN count is static or rising, immediately broaden antibiotics for MDRO / ESBL / Enterococcus AND order a CT scan to rule out Secondary Surgical Peritonitis.
5. Lifelong Secondary Oral Antibiotic Prophylaxis Before Discharge Start Oral Trimethoprim-Sulfamethoxazole (Bactrim DS, 1 double-strength tablet [\(160/800\text{ mg}\)] PO once daily) OR Oral Ciprofloxacin \(500\text{ mg}\) PO once daily (or Norfloxacin \(400\text{ mg}\) PO daily where available) upon completing IV therapy, plus Urgent Liver Transplant Evaluation. Without daily oral prophylaxis, 70 percent of SBP survivors suffer a recurrent episode within 1 year, and 1-year survival after a first episode of SBP is only \(30\%\text{ to }50\%\) without liver transplantation.

Step 3: Performing Large-Volume Paracentesis (LVP) Safely and Preventing Post-Paracentesis Circulatory Dysfunction (PPCD)

When a patient has sterile tense ascites (\(\text{PMN} < 250/\text{mm}3\)) causing diaphragmatic splinting, dyspnea, or early satiety: 1. Can You Drain All the Fluid in One Single Session ("Total Paracentesis to Dryness")? - Yes, provided Intravenous \(25\%\) Albumin is co-administered. Modern randomized trials (Ginès, Tito et al.) prove that draining 8, 10, or 15 liters of sterile ascites completely to dryness in a single 1-to-2-hour session is safer, faster, and causes fewer local complications than repeated small taps, IF and ONLY IF you replace intravascular oncotic pressure with \(25\%\) Intravenous Human Albumin. 2. Exact Albumin Replacement Rules by Volume Removed (AASLD / EASL): - Volume Removed \(< 4\text{ to }5\text{ Liters}\): Risk of PPCD is low; intravenous albumin is not strictly required unless the patient has concomitant Acute-on-Chronic Liver Failure (ACLF) or Acute Kidney Injury. - Volume Removed \(\ge 5\text{ Liters}\) (Large-Volume Paracentesis): Administer \(6\text{ to }8\text{ grams}\) of \(25\%\) Intravenous Human Albumin for EVERY liter of ascitic fluid removed (calculated on the entire volume removed, or every liter above \(5\text{ L}\) per local institutional protocol; AASLD and EASL recommend \(6\text{ to }8\text{ g}\) per liter of total fluid removed when \(> 5\text{ L}\) is drained). - Practical Example: For a \(10\text{-liter}\) Large-Volume Paracentesis, administer \(60\text{ to }80\text{ grams}\) of \(25\%\) Human Albumin (for example, three \(100\text{-mL}\) vials of \(25\%\) Albumin [\(25\text{ g/vial} = 75\text{ g}\) total]), infusing \(50\%\) during the drainage and \(50\%\) over the 1 to 2 hours immediately after removing the catheter.

Laharana vonjy taitra isam-paritra sy torolàlana momba ny klinika

  • United States and Canada: Dial 911 for any patient with cirrhosis and ascites who develops fever, abdominal pain, confusion, gastrointestinal bleeding, or severe shortness of breath. Management follows the American Association for the Study of Liver Diseases (AASLD) 2021 Practice Guidance on the Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome (Biggins SW et al., Hepatology).
  • United Kingdom: Dial 999 or attend an NHS Emergency Department. Clinicians follow the British Society of Gastroenterology (BSG) and BASL Guidelines on the Management of Ascites in Cirrhosis (Aithal GP et al., Gut) and the BSG Decompensated Cirrhosis Care Bundle (mandatory diagnostic ascitic tap within 6 hours of admission, immediate antibiotics + albumin, and \(8\text{ g}\) albumin per liter in LVP \(> 5\text{ L}\)).
  • European Union: Dial 112. Clinicians follow the European Association for the Study of the Liver (EASL) Clinical Practice Guidelines for the Management of Patients with Decompensated Cirrhosis (Journal of Hepatology).
  • Australia and New Zealand: Dial 000 in Australia or 111 in New Zealand and follow Gastroenterological Society of Australia (GESA) cirrhosis and SBP management guidelines.

Fanontaniana apetraka matetika

Why do up to half of all patients with life-threatening Spontaneous Bacterial Peritonitis (SBP) have zero stomach pain and zero fever?

In a person without liver disease, an abdominal infection (like a burst appendix) causes the inflamed bowel to rub directly against the pain-sensitive lining of the outer abdominal wall (the parietal peritoneum), triggering agonizing pain and a rigid, board-like belly whenever a doctor presses down. In a patient with cirrhosis and ascites, 5 to 15 liters of fluid act as a liquid cushion that physically separates the internal organs from the outer abdominal wall, preventing peritoneal friction and masking abdominal pain and rebound tenderness. At the same time, cirrhotic patients have impaired immune cytokine responses and low baseline body temperatures, so they frequently cannot mount a fever. Instead of pain or fever, their very first sign of SBP is often sudden confusion (Hepatic Encephalopathy), low blood pressure, or kidney failure, which is why doctors must perform a needle tap on the belly of every cirrhotic patient admitted to the hospital.

Why is it a dangerous mistake to wait for Fresh Frozen Plasma (FFP) or platelet transfusions before doing a diagnostic paracentesis?

Patients with advanced cirrhosis almost always have an abnormal blood-clotting test (an elevated INR of 1.8 to 2.5) and a low platelet count (40,000 to 70,000) because their liver makes fewer clotting factors and their enlarged spleen traps platelets. However, modern hematology proves that cirrhotic patients also make fewer natural blood thinners (Protein C and antithrombin), so their blood clotting is actually "rebalanced." Studies of thousands of ultrasound-guided paracenteses prove that the risk of bleeding is less than 1 in 500 regardless of the INR or platelet count, whereas delaying the diagnostic tap and antibiotics by just 6 hours to thaw and transfuse unnecessary plasma increases death from SBP septic shock by nearly 20 percent.

How does Intravenous Albumin save lives in SBP when Ceftriaxone is already killing the bacteria?

Even when intravenous Ceftriaxone rapidly kills the E. coli or Klebsiella bacteria in the ascitic fluid, the dying bacteria release endotoxin (lipopolysaccharide) that triggers a massive burst of nitric oxide in the blood vessels of the intestines. That nitric oxide causes all the blood vessels in the abdomen to dilate wide open, pooling blood in the gut and starving the kidneys of blood flow, which triggers fatal Hepatorenal Syndrome (acute kidney failure) in 30 percent of patients. Infusing concentrated 25% Human Albumin on Day 1 (1.5 g/kg) and Day 3 (1.0 g/kg) does two life-saving things that saltwater IV fluids cannot do: its powerful oncotic pressure holds fluid inside the central arteries to keep the kidneys perfused, and the albumin protein molecule directly binds and neutralizes bacterial endotoxin, nitric oxide, and inflammatory cytokines, cutting death rates by two-thirds.

What happens if a doctor drains 8 liters of fluid from a swollen belly (Large-Volume Paracentesis) without giving IV Albumin?

When a doctor drains more than 5 liters of tense ascitic fluid in a single session without giving intravenous 25% Albumin, the sudden drop in pressure inside the abdomen causes the arteries feeding the intestines to dilate rapidly. Over the next 24 to 72 hours, fluid rushes out of the bloodstream back into the belly to refill the space, causing the patient's effective arterial blood volume to collapse, a condition called Post-Paracentesis Circulatory Dysfunction (PPCD). The kidneys respond by releasing massive surges of renin, aldosterone, and antidiuretic hormone (ADH), causing severe low blood sodium (hyponatremia), acute kidney failure (Hepatorenal Syndrome), rapid return of the ascites, and higher mortality. Infusing 6 to 8 grams of 25% IV Albumin for every liter of fluid removed completely prevents PPCD.

Loharano sy tari-dalana ofisialy

  • American Association for the Study of Liver Diseases (AASLD 2021 Practice Guidance, Biggins SW, Angeli P, Garcia-Tsao G et al., Hepatology): Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis, Post-Paracentesis Circulatory Dysfunction, and Hepatorenal Syndrome.
  • New England Journal of Medicine (Sort Landmark Trial, Sort P, Navasa M, Arroyo V et al., NEJM 1999): Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis.
  • European Association for the Study of the Liver (EASL): EASL Clinical Practice Guidelines for the Management of Patients with Decompensated Cirrhosis (Journal of Hepatology).
  • British Society of Gastroenterology (BSG) and BASL (Aithal GP et al., Gut): Guidelines on the Management of Ascites in Cirrhosis and the BSG Decompensated Cirrhosis 6-Hour Care Bundle.
  • Runyon's Ascitic Fluid Criteria (Runyon BA, Hepatology): Differentiation of Spontaneous Bacterial Peritonitis from Secondary Bacterial Peritonitis (Perforated Viscus) Using Ascitic Fluid Protein, Glucose, and LDH.

Manaova taranja fanampiana voalohany voamarina ary manaova hevitra amin'ny matihanina

This guide provides emergency recognition and hospital triage education and does not replace professional hepatology, gastroenterology, interventional radiology, or emergency medical care. To build practical skills in recognizing sepsis, shock, and altered mental status and performing basic life support, take a certified first aid course through the Red Cross, St John Ambulance, or a local provider.

Mpitarika mifandraika