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Xu X, Ding H, Jia J, Wei L, Duan Z, Tang C, Linghu E, Nan Y, Han Y, Xu J, Zhuang H. Chinese guidelines on the management of ascites in cirrhosis : Chinese Society of Hepatology, Chinese Medical Association. Hepatol Int 2024:10.1007/s12072-024-10697-z. [PMID: 38980598 DOI: 10.1007/s12072-024-10697-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/03/2024] [Indexed: 07/10/2024]
Abstract
In 2023, Chinese Society of Hepatology of Chinese Medical Association convened a panel of experts to update the Chinese guidelines on the management of ascites and associated complications in cirrhosis which was launched in 2017 and renamed this guidelines as "Guidelines on the Management of Ascites in Cirrhosis." This comprehensive resource offers essential recommendations for the diagnosis and treatment of cirrhotic ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Gastroenterology, Peking University First Hospital, No. 8, Xishiku St. Xicheng District, Beijing, China.
| | - Huiguo Ding
- Liver Disease and Digestive Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Jidong Jia
- Liver Disease Center, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong'an Road, Xicheng District, Beijing, China
| | - Lai Wei
- Hepatobiliary and Pancreatic Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, No. 168, Litang Road, Changping District, Beijing, China
| | - Zhongping Duan
- Liver Disease Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, Sichuan Province, China
| | - Enqiang Linghu
- Digestive Department, First Medical Center of Chinese, PLA General Hospital, No. 28, Fuxing Road, Haidian District, Beijing, China
| | - Yuemin Nan
- Department of Integrated Traditional Chinese and Western Medicine for Liver Diseases, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang, Hebei Province, China
| | - Ying Han
- Liver Disease and Digestive Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Jinghang Xu
- Department of Infectious Diseases, Peking University First Hospital, No. 8, Xishiku St. Xicheng District, Beijing, China
| | - Hui Zhuang
- Department of Pathogenic Biology, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, China
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Beran A, Mohamed MFH, Vargas A, Aboursheid T, Aziz M, Hernaez R, Patidar KR, Nephew LD, Desai AP, Orman E, Chalasani N, Ghabril MS. Early Diagnostic Paracentesis Improves Outcomes of Hospitalized Patients With Cirrhosis and Ascites: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2024:00000434-990000000-01206. [PMID: 38916217 DOI: 10.14309/ajg.0000000000002906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Diagnostic paracentesis is recommended for patients with cirrhosis admitted to the hospital, but adherence is suboptimal with unclear impact on clinical outcomes. The aim of this meta-analysis was to assess the outcomes of early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. METHODS We searched multiple databases for studies comparing early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. The pooled odds ratio (OR) and mean difference with confidence intervals (CIs) for proportional and continuous variables were calculated using the random-effects model. Early diagnostic paracentesis was defined as receiving diagnostic paracentesis within 12-24 hours of admission. The primary outcome was in-hospital mortality. Secondary outcomes were length of hospital stay, acute kidney injury, and 30-day readmission. RESULTS Seven studies (n = 78,744) (n = 45,533 early vs n = 33,211 delayed diagnostic paracentesis) were included. Early diagnostic paracentesis was associated with lower in-hospital mortality (OR 0.61, 95% CI 0.46-0.82, P = 0.001), length of hospital stay (mean difference -4.85 days; 95% CI -6.45 to -3.20; P < 0.001), and acute kidney injury (OR 0.62, 95% CI 0.42-0.92, P = 0.02) compared with delayed diagnostic paracentesis, with similar 30-day readmission (OR 1.11, 95% CI 0.52-2.39, P = 0.79). Subgroup analysis revealed consistent results for in-hospital mortality whether early diagnostic paracentesis performed within 12 hours (OR 0.51, 95% CI 0.32-0.79, P = 0.003, I2 = 0%) or within 24 hours of admission (OR 0.67, 95% CI 0.45-0.98, P = 0.04, I2 = 82%). Notably, the mortality OR was numerically lower when diagnostic paracentesis was performed within 12 hours, and the results were precise and homogenous ( I2 = 0%). DISCUSSION Findings from this meta-analysis suggest that early diagnostic paracentesis is associated with better patient outcomes. Early diagnostic paracentesis within 12 hours of admission may be associated with the greatest mortality benefit. Data from large-scale randomized trials are needed to validate our findings, especially if there is a greater mortality benefit for early diagnostic paracentesis within 12 hours.
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Affiliation(s)
- Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Mouhand F H Mohamed
- Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, Rhode Island, USA
| | - Alejandra Vargas
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Tarek Aboursheid
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, Illinois, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, Bon Secours Mercy Health, Toledo, Ohio, USA
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kavish R Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Badal J, Badal B, Nawras M, Lee-Smith W, Stanley S, Hassan M, Ahmed Z. Diagnostic Paracentesis Within 1 Day Is Associated With Reduced Mortality and Length of Hospital Stay in Patients with Cirrhosis and Ascites. Dig Dis Sci 2024; 69:1454-1466. [PMID: 38217676 DOI: 10.1007/s10620-023-08249-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/09/2023] [Indexed: 01/15/2024]
Abstract
Spontaneous bacterial peritonitis (SBP) is the most common infection in patients with cirrhosis and is associated with high mortality. Although recent literature reports mortality benefits to early diagnostic paracentesis, current guidelines do not offer specific recommendations for how quickly diagnostic paracentesis should be performed in patients with cirrhosis and ascites who are admitted to the hospital. Therefore, we conducted a systematic review and meta-analysis to evaluate outcomes among patients admitted to the hospital with cirrhosis and ascites receiving paracentesis within ≤ 12, ≤ 1 day, and > 1 day. Eight studies with 116,174 patients were included in the final meta-analysis. The pooled risk of in-hospital mortality was significantly lower in patients who underwent early (≤ 12 h or ≤ 1 day) compared to delayed (> 12 h or > 1 day) paracentesis (RR: 0.69, p < 0.00001), and in patients who underwent paracentesis compared to no paracentesis (RR: 0.74, p < 0.00001). On subgroup analysis, in-hospital mortality was significantly lower in both paracentesis within ≤ 12 h (RR: 0.61, p = 0.02) vs. > 12 h, and within ≤ 1 day (RR: 0.70, p < 0.00001) vs. > 1 day. While there was a trend towards decreased mortality in those undergoing paracentesis within ≤ 12 h compared to ≤ 1 day, the difference did not reach statistical significance. The length of hospital stay was significantly shorter by 5.38 days in patients who underwent early (≤ 12 h) compared to delayed (> 12 h) paracentesis (95% CI 4.24-6.52, p < 0.00001). Early paracentesis is associated with reduced mortality and length of hospital stay. We encourage providers to perform diagnostic paracentesis in a timely manner, at least within 1 day of hospital admission, for all patients with cirrhosis and ascites.
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Affiliation(s)
- Joyce Badal
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA.
- UNC Faculty Physicians Center, 100 Eastowne Drive, Chapel Hill, NC, 27514, USA.
| | - Bryan Badal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, VA, USA
| | - Mohamad Nawras
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | | | - Sara Stanley
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Mona Hassan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Zohaib Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
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Pereira RA, Virella D, Perdigoto R, Marcelino P, Saliba F, Germano N. Continuous passive paracentesis versus large-volume paracentesis in the prevention and treatment of intra-abdominal hypertension in the critically ill cirrhotic patient with ascites (COPPTRIAHL): study protocol for a randomized controlled trial. Trials 2023; 24:534. [PMID: 37582719 PMCID: PMC10426145 DOI: 10.1186/s13063-023-07541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Critically ill patients with cirrhosis and ascites are at high risk for intra-abdominal hypertension (IAH) which increases mortality. Clinical guidelines recommend maintaining intra-abdominal pressure (IAP) below 16 mmHg; nonetheless, more than three quarters of critically ill patients with cirrhosis develop IAH during their first week of ICU stay. Standard-of-care intermittent large-volume paracentesis (LVP) relieves abdominal wall tension, reduces IAP, optimizes abdominal perfusion pressure, and is associated with short-term improvement in renal and pulmonary dysfunction. However, there is no evidence of the superiority of different paracentesis strategies in the prevention and treatment of IAH in critically ill patients with cirrhosis. This trial aims to compare the outcomes of continuous passive paracentesis versus LVP in the prevention and treatment of IAH in patients with cirrhosis and ascites. METHODS An investigator-initiated, open label, randomized controlled trial, set in a general ICU specialized in liver disease, was initiated in August 2022, with an expected duration of 36 months. Seventy patients with cirrhosis and ascites will be randomly assigned, in a 1:1 ratio, to receive one of two methods of therapeutic paracentesis. A stratified randomization method, with maximum creatinine and IAP values as strata, will homogenize patient baseline characteristics before trial group allocation, within 24 h of admission. In the control group, LVP will be performed intermittently according to clinical practice, with a maximum duration of 8 h, while, in the intervention group, continuous passive paracentesis will drain ascitic fluid for up to 7 days. The primary endpoint is serum creatinine concentration, and secondary endpoints include IAP, measured creatinine clearance, daily urine output, stage 3 acute kidney injury and multiorgan dysfunction assessed at day 7 after enrollment, as well as 28-day mortality rate and renal replacement therapy-free days, and length-of-stay. Prespecified values will be used in case of renal replacement therapy or, beforehand ICU discharge, liver transplant and death. Safety analysis will include paracentesis-related complication rate and harm. Data will be analyzed with an intention-to-treat approach. DISCUSSION This is the first trial to compare the impact of different therapeutic paracentesis strategies on organ dysfunction and outcomes in the prevention and treatment of IAH in critically ill patients with cirrhosis and ascites. TRIAL REGISTRATION ClinicalTrials.gov NCT04322201 . Registered on 20 December 2019.
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Affiliation(s)
- Rui Antunes Pereira
- Unidade de Cuidados Intensivos Polivalente 7, Hospital de Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Daniel Virella
- Unidade Funcional de Neonatologia, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Rui Perdigoto
- Unidade de Transplante, Hospital de Curry Cabral, Centro Hospitalar Universitário Lisboa Central; Nova Medical School, Lisboa, Portugal
| | - Paulo Marcelino
- Unidade de Cuidados Intensivos Polivalente 4, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Faouzi Saliba
- Hôpital Paul Brousse, Hepato-Biliary Center, Université Paris Saclay, INSERM Unit 1193, Villejuif, France
| | - Nuno Germano
- Unidade de Cuidados Intensivos Polivalente 7, Hospital de Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
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Wang Y, Chung H, Xie M, Sun C, Bansal P, Huang Y. The Trend of Paracentesis Utilization in Hospitalized Patients with Cirrhosis and Ascites in the US, 2004 to 2019. J Gen Intern Med 2023; 38:2215-2217. [PMID: 36631684 PMCID: PMC10361931 DOI: 10.1007/s11606-023-08032-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/30/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, MA, USA
| | - Howard Chung
- Department of Medicine, NYU Grossman School of Medicine, New York City, NY, USA
| | - Mengdan Xie
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH, USA
| | - Chenyu Sun
- AMITA Health Saint Joseph Hospital, Chicago, IL, USA
| | - Pardeep Bansal
- Division of Gastroenterology, Mercy Health - St. Vincent Medical Center, Toledo, OH, USA
| | - Yuting Huang
- Department of Gastroenterology and Hepatology, Mayo Clinic in Florida, Jacksonville, FL, USA.
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Pereira RA, Esteves AF, Cardoso FS, Perdigoto R, Marcelino P, Saliba F. Abdominal perfusion pressure in critically ill cirrhotic patients: a prospective observational study. Sci Rep 2023; 13:8550. [PMID: 37237113 DOI: 10.1038/s41598-023-34367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/28/2023] [Indexed: 05/28/2023] Open
Abstract
In critical patients, abdominal perfusion pressure (APP) has been shown to correlate with outcome. However, data from cirrhotic patients is scarce. We aimed to characterize APP in critically ill cirrhotic patients, analyze the prevalence and risk factors of abdominal hypoperfusion (AhP) and outcomes. A prospective cohort study in a general ICU specialized in liver disease at a tertiary hospital center recruited consecutive cirrhotic patients between October 2016 and December 2021. The study included 101 patients, with a mean age of 57.2 (± 10.4) years and a female gender proportion of 23.5%. The most frequent etiology of cirrhosis was alcohol (51.0%), and the precipitant event was infection (37.3%). ACLF grade (1-3) distribution was 8.9%, 26.7% and 52.5%, respectively. A total of 1274 measurements presented a mean APP of 63 (± 15) mmHg. Baseline AhP prevalence was 47%, independently associated with paracentesis (aOR 4.81, CI 95% 1.46-15.8, p = 0.01) and ACLF grade (aOR 2.41, CI 95% 1.20-4.85, p = 0.01). Similarly, AhP during the first week (64%) had baseline ACLF grade (aOR 2.09, CI 95% 1.29-3.39, p = 0.003) as a risk factor. Independent risk factors for 28-day mortality were bilirubin (aOR 1.10, CI 95% 1.04-1.16, p < 0.001) and SAPS II score (aOR 1.07, CI 95% 1.03-1.11, p = 0.001). There was a high prevalence of AhP in critical cirrhotic patients. Abdominal hypoperfusion was independently associated with higher ACLF grade and baseline paracentesis. Risk factors for 28-day mortality included clinical severity and total bilirubin. The prevention and treatment of AhP in the high-risk cirrhotic patient is prudential.
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Affiliation(s)
- Rui Antunes Pereira
- Unidade de Cuidados Intensivos Polivalente 7 (UCIP7), Hospital de Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal.
| | - André F Esteves
- Serviço de Medicina, Hospital Garcia de Orta, Almada, Portugal
| | - Filipe S Cardoso
- Unidade de Transplante, Hospital de Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Nova Medical School, Lisbon, Portugal
| | - Rui Perdigoto
- Unidade de Transplante, Hospital de Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Nova Medical School, Lisbon, Portugal
| | - Paulo Marcelino
- Unidade de Cuidados Intensivos Polivalente 4 (UCIP4), Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Hepato-Biliary center, Université Paris Saclay, INSERM unit Nº 1193, Villejuif, France
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Long B, Gottlieb M. Emergency medicine updates: Spontaneous bacterial peritonitis. Am J Emerg Med 2023; 70:84-89. [PMID: 37244043 DOI: 10.1016/j.ajem.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition. OBJECTIVE This paper evaluates key evidence-based updates concerning SBP for the emergency clinician. DISCUSSION SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm3 is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality. CONCLUSIONS An understanding of literature updates can improve the care of patients with suspected SBP.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Brown C, Aksan N, Chang P, Jagannathan P, Ochi MG, Pignone M, Feagins L. Delayed Diagnostic Paracentesis Is Associated with Increased Preventable Healthcare Utilization in Disadvantaged Patient Populations with Advanced Liver Disease and Elevated INR. Dig Dis Sci 2023:10.1007/s10620-023-07937-x. [PMID: 37052775 DOI: 10.1007/s10620-023-07937-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/25/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Patients hospitalized with cirrhosis, ascites, and elevated INR often experience delays in timely diagnostic paracentesis. AIMS Identify whether delays in diagnostic paracentesis were associated with adverse outcomes in a hospital system serving a large disadvantaged population. METHODS Retrospective cohort analysis of patients admitted from January 2017 to October 2019 with cirrhosis, ascites, and INR ≥ 1.5 across a multi-hospital health system in central Texas. We examined demographic and clinical characteristics of patients with diagnostic paracentesis (1) ≤ 24 h; (2) > 24 h; (3) therapeutic only or no paracentesis. We used logistic regression to examine differences in clinical outcomes controlling for confounders. RESULTS 479 patients met inclusion criteria. 30.0% (N = 143) were Latino, 6.7% (N = 32) African American, and 67.8% (N = 325) under or uninsured. 54.1% of patients received a diagnostic paracentesis ≤ 24 h of admission and 21.1% did not receive a diagnostic paracentesis during the hospitalization. Undergoing diagnostic paracentesis > 24 h of admission was associated with a 2.3 day increase in length of stay (95% CI 0.8-3.8), and OR 1.7 for an Emergency Room visit within 30 days of discharge (95% CI 1.1-2.7) compared to receiving a diagnostic paracentesis ≤ 24 h. Patients receiving diagnostic paracentesis in radiology were more likely to have a delay in procedure OR 5.8 (95% CI 2.8-8.6). CONCLUSION Delayed diagnostic paracentesis is associated with increased preventable healthcare utilization compared with timely diagnostic paracentesis. Health systems should support efforts to ensure timely diagnostic paracentesis for patients with advanced liver disease, including performance at the bedside.
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Affiliation(s)
- Cristal Brown
- Dell Medical School, University of Texas at Austin, Austin, USA.
- Gastroenterology and Hepatology, The University of Texas at Austin Dell Medical School, Health Discovery Building, 1601 Trinity St Z0900, Austin, TX, 78712, USA.
| | - Nazan Aksan
- Dell Medical School, University of Texas at Austin, Austin, USA
| | - Patrick Chang
- Dell Medical School, University of Texas at Austin, Austin, USA
| | | | | | - Michael Pignone
- Dell Medical School, University of Texas at Austin, Austin, USA
| | - Linda Feagins
- Dell Medical School, University of Texas at Austin, Austin, USA
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Smith-Hanratty B. Performing Abdominal Paracentesis. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2022.104534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Gupta K, Khan A, Goyal H, Cal N, Hans B, Martins T, Ghaoui R. Weekend admissions with ascites are associated with delayed paracentesis: A nationwide analysis of the 'weekend effect'. Ann Hepatol 2021; 19:523-529. [PMID: 32540327 DOI: 10.1016/j.aohep.2020.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/10/2020] [Accepted: 05/20/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Weekend admissions has previously been associated with worse outcomes in conditions requiring specialists. Our study aimed to determine in-hospital outcomes in patients with ascites admitted over the weekends versus weekdays. Time to paracentesis from admission was studied as current guidelines recommend paracentesis within 24h for all patients admitted with worsening ascites or signs and symptoms of sepsis/hepatic encephalopathy (HE). PATIENTS We analyzed 70 million discharges from the 2005-2014 National Inpatient Sample to include all adult patients admitted non-electively for ascites, spontaneous bacterial peritonitis (SBP), and HE with ascites with cirrhosis as a secondary diagnosis. The outcomes were in-hospital mortality, complication rates, and resource utilization. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models. RESULTS Out of the total 195,083 ascites/SBP/HE-related hospitalizations, 47,383 (24.2%) occurred on weekends. Weekend group had a higher number of patients on Medicare and had higher comorbidity burden. There was no difference in mortality rate, total complication rates, length of stay or total hospitalization charges between the patients admitted on the weekend or weekdays. However, patients admitted over the weekends were less likely to undergo paracentesis (OR 0.89) and paracentesis within 24h of admission (OR 0.71). The mean time to paracentesis was 2.96 days for weekend admissions vs. 2.73 days for weekday admissions. CONCLUSIONS We observed a statistically significant "weekend effect" in the duration to undergo paracentesis in patients with ascites/SBP/HE-related hospitalizations. However, it did not affect the patient's length of stay, hospitalization charges, and in-hospital mortality.
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Affiliation(s)
- Kamesh Gupta
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA.
| | - Ahmad Khan
- Department of Internal Medicine, West Virginia University-Charleston Division, Charleston, WV, USA
| | - Hemant Goyal
- Department of Gastroenterology, Wright Center, Scranton, PA, USA
| | - Nicholas Cal
- Department of Gastroenterology, UMMS-Baystate Medical Center, Springfield, MA, USA
| | - Bandhul Hans
- Depatment of Medicine, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Tiago Martins
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA
| | - Rony Ghaoui
- Department of Gastroenterology, UMMS-Baystate Medical Center, Springfield, MA, USA
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Ritter E, Malik M, Qayyum R. Impact of a Hospitalist-Run Procedure Service on Time to Paracentesis and Length of Stay. J Hosp Med 2021; 16:476-479. [PMID: 34347583 DOI: 10.12788/jhm.3582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022]
Abstract
Hospitals are establishing procedure services to address resident training and patient safety. We examined whether a hospitalist procedure service affects a patient's hospital length of stay (LOS) and the time from admission to paracentesis (A2P). We queried our electronic medical records for all inpatient peritoneal fluid samples from July 1, 2016, to May 31, 2019. LOS and A2P time were compared among patients who had paracentesis by the procedure service, by residents, or by radiology. Of the 1,321 procedures, 509 (38.5%) were performed by the procedure service. In the adjusted analysis, as compared with procedure service, the group that underwent paracentesis by the radiology service had a 27% longer LOS (95% CI, 2%-58%) and 40% longer A2P time (95% CI, 5%-87%). The resident group had shorter A2P (-19%; 95% CI, -33% to 0.2%; P = .05) than the procedure service group but similar LOS. To our knowledge, this is the first study that suggests patient-centered benefits of a hospitalist procedure service.
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Affiliation(s)
- Evan Ritter
- Division of Hospital Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Manpreet Malik
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rehan Qayyum
- Division of Hospital Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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12
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Spontaneous bacterial peritonitis: update on diagnosis and treatment. ACTA ACUST UNITED AC 2021; 59:345-350. [PMID: 34182617 DOI: 10.2478/rjim-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Indexed: 11/21/2022]
Abstract
Spontaneous bacterial peritonitis (SBP) is a common complication in patients with liver cirrhosis, with an increased risk of mortality. For this reason, a diagnostic paracentesis should be performed in all patients with ascites and clinical features with high diagnostic suspicion. Although literature data abound in identifying new diagnostic markers in serum or ascites, they have not yet been validated. The final diagnosis requires the analysis of ascites and the presence of > 250 mm3 neutrophil polymorphonuclear (PMN) in ascites. If previous data showed that the most common microorganisms identified were represented by gram-negative bacteria, we are currently facing an increase in gram-positive bacteria and multi-drug resistant bacteria. Although prompt and effective treatment is required to prevent outcomes, this becomes challenging as first-line therapies may become ineffective leading to worsening prognosis and increased inhospital mortality. In this paper we will make a brief review of existing data on the diagnosis and treatment of SBP.
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Tocia C, Dumitru A, Alexandrescu L, Popescu R, Dumitru E. Timing of paracentesis and outcomes in hospitalized patients with decompensated cirrhosis. World J Hepatol 2020; 12:1267-1275. [PMID: 33442453 PMCID: PMC7772729 DOI: 10.4254/wjh.v12.i12.1267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/03/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ascites is one of the most common complications of cirrhosis, placing a significant burden on the healthcare system. Data regarding the optimal time of paracentesis and outcomes among patients with cirrhosis and ascites are scarce.
AIM To assess the outcomes of patients who underwent paracentesis within 12 h after admission compared to patients who underwent paracentesis later than 12 h.
METHODS The study included 185 patients with cirrhosis and ascites who underwent paracentesis. The early paracentesis group was defined as paracentesis performed < 12 h after admission (65 patients) and the delayed paracentesis group was defined as paracentesis performed > 12 h after admission (120 patients). New-onset complications of cirrhosis, length of hospital stay, weekday or weekend admission, in-hospital mortality rate, and 90-d readmission rates were assessed and compared between the groups.
RESULTS Significantly more patients in the delayed paracentesis group than in the early paracentesis group developed hepatic encephalopathy (45% vs 21.5%, P < 0.01), hepato-renal syndrome (21.6% vs 9.2%, P = 0.03) and infections (25% vs 10.7%, P = 0.02) during hospitalization. There were no statistically significant differences in the occurrence of spontaneous bacterial peritonitis and upper gastrointestinal bleeding between the two groups. Length of stay was shorter in the early paracentesis group than in the delayed paracentesis group (6.7 d vs 12.2 d) and in-hospital mortality was lower among patients in the early paracentesis group. Patients in the delayed paracentesis group had a higher risk of developing complications during hospitalization.
CONCLUSION Early paracentesis (within 12 h after admission) could be a new inpatient quality metric among patients hospitalized with cirrhosis and ascites as it is associated with fewer complications of cirrhosis, lower in-hospital mortality and shorter length of stay.
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Affiliation(s)
- Cristina Tocia
- Department of Gastroenterology, Constanta County Clinical Emergency Hospital, Constanta 900647, Romania
| | - Andrei Dumitru
- Department of Gastroenterology, Constanta County Clinical Emergency Hospital, Constanta 900647, Romania
| | - Luana Alexandrescu
- Department of Gastroenterology, Constanta County Clinical Emergency Hospital, Constanta 900647, Romania
| | - Razvan Popescu
- Department of General Surgery, Constanta County Clinical Emergency Hospital, Constanta 900647, Romania
| | - Eugen Dumitru
- Department of Gastroenterology, Constanta County Clinical Emergency Hospital, Constanta 900647, Romania
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Gorgone M, McNichols B, Li D, Quill C. Resident-Driven Procedure Team and Speed of Obtaining Diagnostic Paracentesis. Jt Comm J Qual Patient Saf 2020; 47:137-139. [PMID: 33121890 DOI: 10.1016/j.jcjq.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
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Abstract
The prevalence of cirrhosis is increasing despite advances in therapeutics, and it remains an expensive medical condition. Studies examining the healthcare burden of inpatient cirrhosis-related care regardless of etiology, stage, or severity are lacking. This study aims to describe the current drivers of cost, length of stay (LOS), and mortality in hospitalized patients with cirrhosis.
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Townsend L, Blais P, Huh A, Nayak L, Elwing JE, Sayuk GS. Survival benefit associated with early detection of spontaneous bacterial peritonitis in veteran inpatients with cirrhotic ascites. JGH Open 2020; 4:503-506. [PMID: 32514461 PMCID: PMC7273690 DOI: 10.1002/jgh3.12290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 12/01/2019] [Indexed: 01/23/2023]
Abstract
Background Spontaneous bacterial peritonitis (SBP) is common in hospitalized cirrhotic patients with ascites and carries high mortality. This study aimed to determine whether early diagnostic paracentesis (EDP) <12 h of hospitalization conveys an intermediate‐term (6‐month) survival benefit in cirrhotic patients diagnosed with SBP. Methods Consecutive US veterans with cirrhosis diagnosed with SBP over 13 years at a single VA medical center were reviewed retrospectively. Kaplan‐Meyer analyses assessed the effects of EDP on survival. Results A total of 79 cirrhotic patients were diagnosed with SBP (61.8 ± 8.8 years, n = 77 male, n = 52 [66.8%] Caucasian, n = 23 [29.1%] African‐American). Underlying liver diseases included hepatitis c viral infection (HCV) (17.5%), alcohol (28.6%), alcohol and HCV (30.1%), and cryptogenic/metabolic (15.9%). Median baseline model for end‐stage liver disease (MELD) was 12 (range 6–34), and median MELD at presentation was 18. Seven subjects had a history of hepatocellular carcinoma (11.1%), and 26 (41.3%) presented with sepsis. Thirty‐three (52.4%) subjects died within 6 months after the SBP admission. Of the subjects, 41 (65.1%) underwent EDP, of which 23 (56.0%) survived at least 6 months, compared to only 7 of the 22 patients (31.8%) undergoing paracentesis >12 h from presentation (P = 0.057). The maximal benefit of EDP on survival was observed beyond days 14 and 30; at these time points, no statistical difference in mortality was discernable (P = 0.55 and 0.71). In a multivariate model including age, MELD at admission, hepatocellular cancer, and sepsis criteria, EDP (p 0.034) positively impacted patient survival at 6 months. Conclusions EDP is associated with improved 6‐month mortality in cirrhotic patients with ascites. In this veteran cohort, EDP was as important as MELD as a predictor of intermediate‐term survival.
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Affiliation(s)
- Luke Townsend
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
| | - Pierre Blais
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
| | - Alex Huh
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
| | - Leela Nayak
- St. Louis Veterans Affairs Medical CenterJohn Cochran Division St. Louis Missouri USA
| | - Jill E Elwing
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
- St. Louis Veterans Affairs Medical CenterJohn Cochran Division St. Louis Missouri USA
| | - Gregory S Sayuk
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
- St. Louis Veterans Affairs Medical CenterJohn Cochran Division St. Louis Missouri USA
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Sobotka LA, Spitzer C, Hinton A, Michaels A, Hanje AJ, Mumtaz K, Conteh LF. Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission. J Gastroenterol Hepatol 2020; 35:641-647. [PMID: 31441096 DOI: 10.1111/jgh.14842] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 07/02/2019] [Accepted: 08/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Carleen Spitzer
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Anthony Michaels
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - A James Hanje
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Khalid Mumtaz
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Lanla F Conteh
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
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Sherman Z, Soltani A, Steel P, Jesudian A. Time-Sensitive Interventions in Hospitalized Patients With Cirrhosis. Clin Liver Dis (Hoboken) 2020; 15:36-39. [PMID: 32104576 PMCID: PMC7041954 DOI: 10.1002/cld.869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/23/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
| | - Amin Soltani
- Department of MedicineWeill Cornell MedicineNew YorkNY
| | - Peter Steel
- Department of Emergency MedicineWeill Cornell MedicineNew YorkNY
| | - Arun Jesudian
- Division of Gastroenterology and HepatologyWeill Cornell MedicineNew YorkNY
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Gottumukkala RV, Prabhakar AM, Hemingway J, Hughes DR, Duszak R. Disparities over Time in Volume, Day of the Week, and Patient Complexity between Paracentesis and Thoracentesis Procedures Performed by Radiologists versus Those Performed by Nonradiologists. J Vasc Interv Radiol 2019; 30:1769-1778.e1. [PMID: 31422023 DOI: 10.1016/j.jvir.2019.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/01/2019] [Accepted: 04/11/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To compare the disparities between the paracenteses and thoracenteses performed by radiologists with those performed by nonradiologists over time. Variables included the volume of procedures, the days of the week, and the complexity of the patient's condition. MATERIALS AND METHODS Using carrier claims files for a 5% national sample of Medicare beneficiaries from 2004 to 2016, paracentesis and thoracentesis examinations were retrospectively classified by physician specialty (radiologist vs nonradiologist), day of the week (weekday vs weekend), and the complexity of the patient's condition (using Charlson comorbidity index scores). The Pearson chi-square and independent samples t-test were used for statistical analysis. RESULTS Between 2004 and 2016, the proportion of all paracentesis and thoracentesis procedures performed by radiologists increased from 70% to 80% and from 47% to 66%, respectively. Although radiologists increasingly performed more of both services on both weekends and weekdays, the share performed by radiologists was lower on weekends. For most of the first 9 years across the study period, radiologists performed paracentesis in patients with more complex conditions than those treated by nonradiologists, but the complexity of patients' conditions was similar during recent years. For thoracentesis, the complexity of patients' conditions was similar for both specialty groups across the study period. CONCLUSIONS The proportion of paracentesis and thoracentesis procedures performed in Medicare beneficiaries by radiologists continues to increase, with radiologists increasingly performing most of both services on weekends. Nonetheless, radiologists perform disproportionately more on weekdays than on weekends. Presently, radiologists and nonradiologists perform paracentesis and thoracentesis procedures in patients with similarly complex conditions. These interspecialty differences in timing and complexity of the patient's condition differ from those recently described for several diagnostic imaging services, reflecting the unique clinical and referral patterns for invasive versus diagnostic imaging services.
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Affiliation(s)
- Ravi V Gottumukkala
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.
| | - Anand M Prabhakar
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | | | - Danny R Hughes
- Harvey L. Neiman Health Policy Institute, Reston, Virginia; School of Economics, Georgia Institute of Technology, Atlanta, Georgia; Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Jesudian A, Barraza L, Steel P, Shen N, Schneider Y, Bodnar D, Farmer B, Dargar S, Del Toro C, Sharma R, Brown, Jr. RS, Lee JI. Quality improvement initiative increases total paracentesis and early paracentesis rates in hospitalised cirrhotics with ascites. Frontline Gastroenterol 2019; 11:22-27. [PMID: 31885836 PMCID: PMC6914287 DOI: 10.1136/flgastro-2019-101199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/27/2019] [Accepted: 04/12/2019] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Early paracentesis (EP) for rapid diagnosis of spontaneous bacterial peritonitis is considered best practice in the care of admitted patients with cirrhosis and ascites, but inpatient paracentesis is frequently not performed or delayed. We developed a quality improvement (QI) initiative aimed at increasing the proportion of admitted patients with cirrhosis who undergo paracentesis and EP. DESIGN Pre-post study of a QI initiative. SETTING A tertiary care hospital in a major metropolitan area. PATIENTS Hospitalised patients with cirrhosis and ascites. INTERVENTIONS We targeted care providers in the emergency department (ED) by raising awareness of the importance of EP, developing criteria to identify patients at highest risk of SBP who were prioritised for EP by ED providers and restructuring the ED environment to enable timely paracentesis. RESULTS 76 patients meeting inclusion criteria were admitted during the postintervention 9-month study period. Of these, 91% (69/76) underwent paracentesis during admission versus 71 % (77/109) preintervention (p=0.001). 81% (56/69) underwent EP within 12 hours of presentation or after a predefined acceptable reason for delay versus 48% (37/77) preintervention (p=0.001). There were no significant differences in in-hospital mortality or length of stay before and after intervention. CONCLUSION A multidisciplinary QI intervention targeting care in the ED successfully increased the proportion of patients with cirrhosis and ascites undergoing diagnostic paracentesis during admission and EP within 12 hours of presentation.
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Affiliation(s)
- Arun Jesudian
- Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Luis Barraza
- Division of Digestive and Liver Diseases, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Peter Steel
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Nicole Shen
- Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Yecheskel Schneider
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Bodnar
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Brenna Farmer
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Savira Dargar
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Cristina Del Toro
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Rahul Sharma
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Robert S Brown, Jr.
- Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
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Sarwar S, Tarique S, Waris U, Khan AA. Cephalosporin resistance in community acquired spontaneous bacterial peritonitis. Pak J Med Sci 2019; 35:4-9. [PMID: 30881387 PMCID: PMC6408669 DOI: 10.12669/pjms.35.1.17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To determine 3rd generation cephalosporin resistance in patients with community-acquired spontaneous bacterial peritonitis (SBP) using early response assessment. Methods: This prospective quasi-experimental study was carried out at Doctors Hospital & Medical Center from January 2016 to September 2018. Patients with cirrhosis and SBP were included. Third generation cephalosporins i.e. cefotaxime/ceftriaxone were used for treatment of SBP. Response after 48 hours was assessed and decline in ascitic fluid neutrophil count of < 25% of baseline was labelled as cephalosporin resistant. Carbapenem were used as second line treatment. Recovery and discharge or death of patients were primary end points. Results: Male to female ratio in 31 patients of SBP was 1.2/1 (17/14). Hepato-renal syndrome was diagnosed in 11(37.9%) patients. Cefotaxime was used for 16(51.6%) patients whereas ceftriaxone for 15(48.3%) patients. Early response of SBP was noted in 26(83.8%) patients while 5 (16.2%) were non-responders to cephalosporins. SBP resolved in all non-responding patients with i/v carbapenem. In-hospital mortality was 12.9% and had no association with cephalosporin resistance. High bilirubin (p 0.04), deranged INR (p 0.008), low albumin (p 0.04), high Child Pugh (CTP) score (p 0.03) and MELD scores (p 0.009) were associated with in-hospital mortality. Conclusion: Cephalosporin resistance was present in 16.2% of study patients with community-acquired SBP. Mortality in SBP patients is associated with advanced stage of liver disease.
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Affiliation(s)
- Shahid Sarwar
- Shahid Sarwar MBBS, FCPS (Medicine), (Gastroenterology) MCPS-HPE. Associate Professor, Services Institute of Medical Sciences, Consultant Gastroenterologist, Doctors Hospital & Medical Center, Doctors Hospital & Medical Center Lahore, Pakistan
| | - Shandana Tarique
- Shandana Tarique, MBBS, FCPS (Medicine). Professor of Medicine, King Edward Medical University, Lahore, Pakistan. Doctors Hospital & Medical Center Lahore, Pakistan
| | - Umaima Waris
- Dr. Umaima Waris Post-Graduate Resident Medicine, Services Institute of Medical Sciences, Doctors Hospital & Medical Center Lahore, Pakistan
| | - Anwaar A Khan
- Anwaar A. Khan, MACP, FACG, FRCP, FCPS. Consultant Gastroenterologist, Doctors Hospital & Medical Center Ex- Dean and Professor of Gastroenterology, Shaikh Zayed Post Graduate Medical Institute, Lahore, Pakistan
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Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E7-E15. [PMID: 30604780 PMCID: PMC8021127 DOI: 10.12788/jhm.3095] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.
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Affiliation(s)
- Joel Cho
- Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA.
| | - Trevor P Jensen
- Division of Hospital Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
| | - Kreegan Reierson
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
| | - Benji K Mathews
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Anjali Bhagra
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ricardo Franco-Sadud
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Michael Mader
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Ria Dancel
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brian P Lucas
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | | | - Nilam J Soni
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
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Xu X, Duan Z, Ding H, Li W, Jia J, Wei L, Linghu E, Zhuang H. Chinese guidelines on the management of ascites and its related complications in cirrhosis. Hepatol Int 2019; 13:1-21. [PMID: 30656520 DOI: 10.1007/s12072-018-09923-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/20/2018] [Indexed: 12/12/2022]
Abstract
The Chinese Society of Hepatology developed the current guidelines for the Management of Ascites and Its Related Complications in Cirrhosis based on the published evidences and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of cirrhotic ascites emphasizing a step-wise approach with the first-, second-, and third-line therapy. For refractory ascites, vasoconstrictors and albumin are recommended for splanchnic vasodilation and selective vasopressin (V2) receptor antagonists for moderate-to-severe hyponatremia. For spontaneous bacterial peritonitis, empirical anti-infection treatment was recommended based on the local microbiological examination of community- or hospital-acquired infections. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing, 100034, China.
| | - Zhongping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Center for Hepatology and Gastroenterology, Beijing You-An Hospital, Capital Medical University, Beijing, China
| | - Wengang Li
- Liver Tumor Diagnosis, Treatment and Research Center, 302 Military Hospital of China, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lai Wei
- Institute of Hepatology, Peking University People's Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, China
| | - Hui Zhuang
- Department of Pathogen Biology, Peking University Health Science Center, Beijing, China
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Sadat Mazloom S, Khoramian MK, Mohsenian L. Spontaneous Bacterial Peritonitis in Afebrile Cirrhotic Patients; Report from a Referral Transplantation Center. Bull Emerg Trauma 2018; 6:363-366. [PMID: 30402527 PMCID: PMC6215066 DOI: 10.29252/beat-060415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a complication of liver cirrhosis with adverse effect on patient prognosis. Early diagnosis and treatment is highly important, especially in patients without remarkable manifestations. We designed this study to determine the prevalence of SBP among afebrile cirrhotic patients and identify high-risk subgroups in a referral center in southern Iran. This cross-sectional study evaluated all afebrile cirrhotic patients, admitted to the gastroenterology ward of Namazi hospital (affiliated with Shiraz University of Medical Sciences, Shiraz, Iran) over a 6-month period in 2017, for the presence and correlates of SBP. Demographic data, clinical findings, and comorbidities were recorded. Ascitic fluid white blood cells (WBC) count >500 and neutrophil count >250 indicated bacterial peritonitis. In total, 97 afebrile cirrhotic patients comprising of 63 (64.9%) men and 34 (35.1%) women were included. All patients had ascites and 89 (91.8%) had abdominal tenderness. Accordingly, abdominal distension was the top presentation. Confirmed etiologies or comorbidities such as HBS, HCV, and liver cancer or metastasis existed in 46 patients. Thirteen (13.4%) had SBP. The correlations of gender (p=0.331), decreased level of consciousness (p=0.145), tenderness (p=0.315). With regards to the type of presentations, only DLOC showed to be significantly higher in SBP negative patients (p=0.022, OR=0.09. 95%CI=0.01–0.62). Also, using binary logistic regression, the correlation of age with SBP was statistically non-significant (coefficient= ⎼0.013, p=0.595). Our findings indicated that routine paracentesis in all cirrhotic patients regardless of fever can help diagnose a number of potentially neglected patients and improve their outcome.
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Affiliation(s)
- Sara Sadat Mazloom
- Department of Emergency Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Leila Mohsenian
- Department of Emergency Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Impact of Performing Nonurgent Interventional Radiology Procedures on Weekends. J Am Coll Radiol 2018; 15:1246-1253. [DOI: 10.1016/j.jacr.2018.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/22/2018] [Accepted: 05/28/2018] [Indexed: 11/20/2022]
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Maraolo AE, Gentile I, Pinchera B, Nappa S, Borgia G. Current and emerging pharmacotherapy for the treatment of bacterial peritonitis. Expert Opin Pharmacother 2018; 19:1317-1325. [PMID: 30071176 DOI: 10.1080/14656566.2018.1505867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is the quintessential model of bacterial infection in cirrhotic patients. In these particularly frail subjects, infections clearly worsen prognosis increasing substantially mortality. Furthermore, treatment of SBP has become more challenging because of the growing impact of multidrug-resistant (MDR) bacteria. AREAS COVERED This review addresses the reasons behind the change in therapeutic recommendations for SBP that have occurred in the past few years, by focusing on the following aspects: the importance of an early appropriate empirical treatment, the difference between nosocomial and non-nosocomial forms and the overall microbiological shift (rise of Gram-positive bacteria and MDR strains) that have affected SBP. EXPERT OPINION Until recently, third-generation cephalosporins have represented the cornerstone of SBP treatment, a safe choice covering the most important causative agents, namely Enterobacteriaceae. Unfortunately, massive exposure to health systems makes cirrhotic patients prone to MDR infections, which poses significant challenges, all the while not forgetting to strike a balance between effective antimicrobial activity and the risk of toxicity in these fragile subjects. Moreover, there is sparse information about new antibiotics in cirrhotic patients and about drugs levels in ascitic fluid. Therefore, further research is needed to optimize the treatment of SBP.
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Affiliation(s)
- Alberto Enrico Maraolo
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Ivan Gentile
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Biagio Pinchera
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Salvatore Nappa
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Guglielmo Borgia
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
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Sobotka LA, Modi RM, Vijayaraman A, Hanje AJ, Michaels AJ, Conteh LF, Hinton A, El-Hinnawi A, Mumtaz K. Paracentesis in cirrhotics is associated with increased risk of 30-day readmission. World J Hepatol 2018; 10:425-432. [PMID: 29988878 PMCID: PMC6033715 DOI: 10.4254/wjh.v10.i6.425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/13/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites. METHODS A retrospective analysis of the nationwide readmission database (NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission. RESULTS Of the 59597 patients included in this study, 18319 (31%) were readmitted within 30 d. Majority (58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832 (50%) patients on index admission. Independent predictors of 30-d readmission included age < 40 (OR: 1.39; CI: 1.19-1.64), age 40-64 (OR: 1.19; CI: 1.09-1.30), Medicaid (OR: 1.21; CI: 1.04-1.41) and Medicare coverage (OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity (OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis (OR: 1.16; CI: 1.10-1.23), paracentesis on index admission (OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma (OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted (P-value: 0.34); however cost of care was significantly more on 30 d readmission ($30959 ± 762) as compared to index admission ($12403 ± 378), P-value: < 0.001. CONCLUSION Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Rohan M Modi
- Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Akshay Vijayaraman
- Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - A James Hanje
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Anthony J Michaels
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Lanla F Conteh
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, the Ohio State University, Columbus, OH 43210, United States
| | - Ashraf El-Hinnawi
- Department of Surgery, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States.
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MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus 2018; 10:e2253. [PMID: 29721399 PMCID: PMC5929973 DOI: 10.7759/cureus.2253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/16/2018] [Indexed: 12/11/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) has a high mortality rate; early antimicrobial therapy is essential for improving patient outcomes. Given that cirrhotic patients are often coagulopathic, the perceived risk of bleeding may prevent providers from performing a paracentesis and ruling out this potentially deadly disease. We examine the pathophysiology and risk factors for SBP, and current guidelines for its diagnosis and treatment. We then review the time-sensitive nature of performing a paracentesis, and the current controversies and contraindications for performing this procedure in patients at risk for SBP. Cirrhotic patients with ascites and clinical suspicion for SBP-abdominal pain or tenderness, fever or altered mental status-should have a diagnostic paracentesis. Although most patients with cirrhosis and liver dysfunction will have prolonged prothrombin time, paracentesis is not contraindicated. Limited data support platelet administration prior to paracentesis if <40,000-50,000/μL. Timely antimicrobial therapy includes a third-generation cephalosporin for community-acquired infection; nosocomial infections should be treated empirically with a carbapenem or with piperacillin-tazobactam, or based on local susceptibility testing. Patients with gastrointestinal (GI) hemorrhage should receive ceftriaxone prophylactically for GI hemorrhage. SBP has a high mortality rate. Early diagnosis and antimicrobial therapy are essential for improving patient outcomes. Cirrhotic patients with ascites with clinical suspicion for SBP, abdominal pain or tenderness, altered mental status or fever should have a diagnostic paracentesis performed prior to admission unless platelets <40,000-50,000/μL.
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Cirrhosis with ascites in the last year of life: a nationwide analysis of factors shaping costs, health-care use, and place of death in England. Lancet Gastroenterol Hepatol 2018; 3:95-103. [DOI: 10.1016/s2468-1253(17)30362-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 01/02/2023]
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