Figure 59-16. LeVeen peritoneovenous shunt used for routing ascitic fluid into the systemic circulation. The shunt consists of

fenestrated tubing for insertion into the peritoneal cavity, a one-way valve, and a length of venous tubing for insertion into the

superior vena cava.

12 Spontaneous bacterial peritonitis is a potentially lethal complication of portal hypertension with

ascites that occurs in up to 10% of patients. The cause of spontaneous bacterial peritonitis is unknown.

Antecedent gastrointestinal hemorrhage is common, and spontaneous bacterial peritonitis in this setting

may be related to bacterial translocation from the gut. Deficits in immune function, both systemically

and within the abdomen, including depressed272 reticuloendothelial function,273–275 low ascitic protein

concentration, and deficient ascitic opsonic activity, may play a role. Patients often present with

abdominal pain and fever, but 10% to 20% of cases are discovered on routine paracentesis.276–278 In

addition, patients may present with other signs not clearly related to spontaneous bacterial peritonitis,

including worsening encephalopathy and deteriorating renal function. The diagnosis is easily made by

examination of the ascitic fluid obtained by paracentesis. An elevated number of white blood cells

(>250/mm3) are diagnostic. The vast majority of cases of spontaneous bacterial peritonitis are caused

by a single organism, most commonly gram-negative enteric bacteria. Hematogenous spread may lead

to infection with Streptococcus pneumoniae (Table 59-14). If more than one organism is present, the

diagnosis of spontaneous bacterial peritonitis must be questioned, and a search for intra-abdominal

disease (secondary peritonitis), such as a perforated viscus or diverticulitis, should be performed.

Table 59-14 Bacteriology of Spontaneous Bacterial Peritonitis

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The treatment of spontaneous bacterial peritonitis consists of supportive care and broad-spectrum

antibiotics, most commonly cefotaxime, a third-generation cephalosporin. Protein replacement has been

shown to significantly reduce mortality in patients with spontaneous bacterial peritonitis and is

complementary to other interventions as established in the landmark publication from Barcelona.279

Other antibiotics with proven efficacy include ofloxacin, a quinolone. This antibiotic has potent activity

against gram-negative organisms and reaches high levels in ascitic fluid. For patients who are clinically

stable and able to take oral medications, this is the drug of choice. Cure can be achieved in 75% to 90%

of cases, but mortality rates are high, ranging from 20% to 40%.280,281 The poor prognosis associated

with spontaneous bacterial peritonitis warrants consideration of liver transplantation.

Prophylactic oral or intravenous antibiotics are indicated for three distinct groups of patients with

cirrhosis with ascites: (a) those with gastrointestinal hemorrhage, (b) those with low protein counts in

the ascitic fluid (<10 to 15 g/L), and (c) those who have survived an episode of SBP.282,283 The

preferred antibiotics used in patients with hemorrhage are 7 days of either intravenous ceftriaxone or

oral norfloxacin.283 These antibiotics reduce the incidence of spontaneous bacterial peritonitis from

approximately 15% to 20% to 3% to 9% and cause few side effects.284–286 A meta-analysis evaluating

the use of prophylactic antibiotics in patients with gastrointestinal hemorrhage confirmed the utility of

prophylaxis, with an approximately 30% decrease in the incidence of infection, a 20% decrease in the

incidence of spontaneous bacterial peritonitis and bacteremia, and a 10% improvement in overall

survival.287 In patients with low protein levels in the ascitic fluid, multiple regimens have proved

effective in reducing the incidence of spontaneous bacterial peritonitis, from approximately 20% to less

than 5%.287–289

Hernias and Ascites

Hernias of the anterior abdominal wall occur in up to 20% of patients with cirrhosis. The causes include

increased intra-abdominal pressure and nutritional deficits, with muscular wasting and thinning of the

fascia. If the hernias are left untreated, complications include incarceration, rupture, strangulation, and

leakage. Patients with hernias and decompensated cirrhosis need to be evaluated for liver

transplantation. In patients with stable liver function, hernias should be treated electively, with

preoperative paracentesis to decrease intra-abdominal pressure. No increase in complication rates was

noted in a study comparing the outcome of umbilical hernia repair in patients with and without ascites.

A longer hospital stay and a significantly higher recurrence rate (73% vs. 14%) were noted, however, in

the group of patients with ascites.290–292 We favor the use of abdominal drains to remove the ascites

until the incision is healed, thereby preventing ascites from leaking through the wound. Meticulous fluid

management is essential during the postoperative period to prevent early reaccumulation of ascites.

In patients with severe ascites, TIPS should be performed before hernia repair to ensure a good result.

Emergency repair of hernias complicated by skin breakdown with ascites leak or incarceration or

strangulation is managed in a similar fashion with preoperative large-volume paracentesis, and

aggressive control of ascites postoperatively.

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