Symptoms of Spontaneous Bacterial Peritonitis (SBP)
Up to one-third of patients with spontaneous bacterial peritonitis (SBP) may be entirely asymptomatic or present only with worsening of liver function or hepatic encephalopathy. 1
Common Clinical Presentations
SBP presents with a wide spectrum of symptoms ranging from asymptomatic to severe systemic inflammation:
Cardinal Symptoms
Other Common Manifestations
- Altered mental status/worsening hepatic encephalopathy
- Vomiting
- Diarrhea
- Ileus
- Tachycardia
- Tachypnea
- Unexplained deterioration in clinical condition
- Acute kidney injury 1, 2
High-Risk Scenarios
SBP should be strongly suspected in any patient with cirrhosis and ascites who presents with:
- New-onset fever
- Abdominal pain or tenderness
- Unexplained clinical deterioration
- Worsening encephalopathy
- Acute kidney injury
- Gastrointestinal bleeding 1
Diagnostic Approach
The diagnosis of SBP requires a high index of suspicion, as clinical symptoms may be subtle or absent. Diagnostic paracentesis should be performed immediately in all patients with cirrhosis and ascites who:
- Are admitted to the hospital emergently for any reason
- Develop signs of infection
- Show worsening liver or renal function
- Present with hepatic encephalopathy
- Have gastrointestinal bleeding 1
The diagnosis is confirmed by an ascitic fluid neutrophil count >250/mm³ in the absence of an intra-abdominal surgically treatable source of infection 1.
Clinical Pitfalls to Avoid
Delayed diagnosis: Each hour of delay in diagnosis is associated with a 3.3% increase in mortality. Do not wait for culture results to initiate treatment 1.
Missing asymptomatic cases: Remember that up to one-third of patients may be asymptomatic or present with only subtle signs like worsening encephalopathy 1, 2.
Overlooking SBP in patients with GI bleeding: All cirrhotic patients with gastrointestinal bleeding should undergo diagnostic paracentesis 1.
Withholding paracentesis due to coagulopathy concerns: Despite abnormal coagulation panels in many cirrhotic patients, routine transfusion before paracentesis is not recommended 2.
Failing to differentiate from secondary peritonitis: SBP is typically monobacterial with neutrophil count >250/mm³ but <1000/mm³, while secondary peritonitis is often polymicrobial with neutrophil count >1000/mm³ 1.
Early recognition of symptoms and prompt diagnostic paracentesis are critical for improving outcomes in patients with SBP, as mortality without prompt treatment can be as high as 20-40% 1.