1. Lab rounds Nadim J Lalani Feb 14 th 2008

2. Objectives  Case  Review of Lab criteria

3. Movie? In which Bogart says “We will always have... a)Whiskey b)Tophi c)Spontaneous bacterial peritonitis d)Paris Significance of this line? # 7 all-time most romantic lines [Daily Mail 2008] Casablanca

4. 1."I'm scared of walking out of this room and never feeling the rest of my whole life the way I feel when I'm with you" – Jennifer Gray, Dirty Dancing 2. "You make me want to be a better man" – Jack Nicholson, As Good As It Gets 3. "I would rather share one lifetime with you than face all the ages of this world alone... I choose a mortal life" – Liv Tyler, Lord of the Rings 4. "The greatest thing you'll ever learn is just to love and be loved in return" – Ewan McGregor, Moulin Rouge 5. "You had me at hello" – Renee Zellweger, Jerry Maguire 6. "I want to tell you with my last breath that I have always loved you" - Chow Yun-Fat, Crouching Tiger, Hidden Dragon The other 6 most romantic quotes are:

5. Case  54 yo M presents to ED with progressive abdominal distension, dypnea, abdo pain and malaise  Likely hx of Etoh abuse  No meds/Allergies

6.  O/e:  38.0, 100, 20, 133/52  Looks dry, ?icteric  Distended abdo with +ve fluid wave and poorly- localisable tenderness.  Lab:  Hb 127, WBC 11, platelets 500, INR 1.4  Doctor?

7. SBP Definition: Infected ascitic fluid  Incidence 10-30% of cirrhotic pts  Mortality 20%  Only 30-50% 1-y survival after 1 st episode Path:  Translocation of gut flora [slow transit & edema in portal HTN]  + impaired immunity  Gm –ves [E coli + Klebsiella]  Gm +ve rarer, but on the rise

8. Clinically:  Abdo pain [acute or insidious]  Peritonitis  Fever[absent in 20-50%]/chills  malaise  ALOC  1-5% asymptomatic [consider in any pt w/ ascites]

9. SBP Diagnostic Paracentesis Perform in the following:  Any new ascites  Known ascites and suggestive sympts  Known liver dis and ALOC  Cirrhotic inpts with GIB What about INR?  Not a contraindication [<1% complication rate]

10. Diagnostic Criteria  Cell count:  PMN > 250 cells/mm 3  Sens 84% ; Spec 90% [pooled]  Pmn > 500 cells/mm 3 [Sens 80% Spec 97% ]  Culture?  Bedside innoculation of Blood Culture bottles  10 ml in each  Sens 80-90% cf 40-50% for conventional  Any other tests?

11. Urine Dipstic? “A positive result from a urine reagent strip for leukocyte esterase has a high degree of correlation with a clinically significant elevation of neutrophil cell count” [Rosen 2007]

12. Dipstick  Rationale: studied in meningitis and peritonitis in pts on receiving peritoneal dialysis.  How it works:  Leukocyte esterase in fluid reacts with compound causing a colour change [purple]

13.  228 Paracentesis  on 128 cirrhotic patients suspected of SBP  Reagent strips read at 90 sec [Aution sticks brand]  2 independent readers  Also did cell count and culture [1 bottle]  SBP defined as >250 PMN/mm 3  Calculated Sens/Spec/LR’s  52 pts SBP +ve  Only 50% culture pos

14. Correlation: GRADE WBC 00 PMN/ml 1 25 PMN/ml 2 75 PMN/ml 3 250 PMN/ml 4500 PMN/ml

16. Authors conclusions:  Reagent strips useful:  Cutoff > 3 or 4  highly specific [96%, PPV 99%]  Cutoff > 0-1  NPV 99% rules out SBP  Cutoff > 2  yields best Sens [96%]  Good correlation b/w strip and PMN count Limitations:  Small study  CHR uses Chemstrip 10

17. Chemstrip 10  Made to be used with analyser/eyeball  Read at 60-120 sec NEG  1+  2+  3+ 10-25 75 >500 leuks/muL  Cost $55/100

18. Rest of Evidence  Only published in abstract form  Mostly from France?!  Small numbers  ?Methods

19. Multistix  Paracentises on 72 cirrhotic pts  SBP [defined as > 250/mm 3 ] positive in 9/72  Multistix defined as: neg, trace, positive  All pts with >250/mm 3 had “positive” Multistix  63 pts with <250/mm 3:  17 had “trace”  46 had negative  State that the 250/mm 3 has 100% sens/spec

20.  2123 paracenteses in cirrhotic pts  117 had SBP  Cutoff 2+  Sens 45% Spec 99%  PPV 76% NPV 97%  Conclude: Can’t use to r/o

21.  Two centres  184 paracenteses in76 cirrhotic pts  [40% of whom were on prophylaxis]  Used Nephur and Multistix  Nephur:  Sens 86%, Spec 100%, PPV100%, NPV99%, Acc99%  Multistix:  Sens 83%, Spec 96%, PPV83%, NPV96%, Acc94%  Conclude can use to screen, but need to send fluid

22.  80 paracenteses  Negative or positive [violet = >500neut/muL]  Sens 80%, Spec 100%, NPV 99%, PPV 100%, Acc 99%  Conclude can use to rule in  Cost effective [strip = 15c VS lab $55]

23. Our Patient:  Reagent read 3+  We started treatment with Cefotaxime 2g Q8h  PMN count came back at 300/mm 3

24. Nadim’s Bottom Line  Really only one good study  PMN count has been validated in several  Value > 3 can rule in  start treatment  Any other value  wait for PMN count

25. More Rosen... “an ascitic fluid pH of less than 7.34 or a pH gradient between arterial blood and ascitic fluid of more than 0.10 is also a reliable early indicator of SBP.” Um... Don’t think so

26. References Risk factors for the development of bacterial infections in hospitalized patients with cirrhosis Marc Deschênes, Jean-Pierre Villeneuve, The American Journal of Gastroenterology Volume 94 Issue 8 Page 2193-2197, August 1999 Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed. Copyright © 2006 Mosby, Inc.

27. QUESTIONS?