Liver disease

Primary peritonitis.

Think of this in any patient with ascites (even that due to nephrotic syndrome) who deteriorates.

Tap ascites and send the fluid for MC&S. Also inoculate 10 ml at the bedside into a blood culture bottle (23% absolute difference in yield¹ versus delaying inoculation by 4 hours) – i.e. for every 5 bedside inoculations, 1 extra infection will be diagnosed.

A differential count on the fluid is the quickest route to the diagnosis – finding any polymorphs is suggestive, and the presence of more than 500 cells/mm³ of fluid is strongly in favour of infection. Do a blood culture as well.

Treat with an intravenous third generation cephalosporin if available, and if not with ampicillin. Gentamicin is a logical addition to the latter but exercise extreme caution and try to avoid it in any patient with renal failure.

There is some evidence² that prophylaxis with co-trimoxazole 2 tabs/day, 5 days/week may reduce the risk of peritonitis (NNT = 4.)

Perspective – dipsticks for identifying infected ascites

The ability of a urinary dip sticks with a leukocyte esterase strip to identify ascitic fluid with a WCC > 250/microlitre is reasonable – in one study,³ sensitivity was 83%, and specificity was 99% (hence LR+ = 83.0 and LR- = 0.17).

Nutrition in liver disease

Nutritional advice historically was about protein restriction as worse encephalopathy was associated with higher protein diets. Most patients with liver failure are hypoalbuminaemic and malnourished. In the non-encephalopathic patient rigorous protein restriction is probably unnecessary and may be disadvantageous.

Iron overload syndromes.

Iron overload associated with the chronic ingestion of beer brewed in iron containers may become less common with the ready availability of alternative containers for brewing and storage, but it typically presents with features of hyperpigmentation and cardiac failure. There may be associated gum bleeding and soft tissue bruising suggestive of scurvy, and occasional patients have back pain due to osteoporosis. Do a serum ferritin. If this is very high it is probably unnecessary to proceed to liver biopsy, and in a symptomatic patient the simple remedy of regular venesection is appropriate. To perform venesection, take off a unit of blood (get the bag from a blood bank) fortnightly until you have removed 5 to 6 units. Re-check the ferritin.

Liver abscess

Suspect in a sick patient with right upper quadrant tenderness or hepatomegaly. Fever is common but not always present. Amoebic and pyogenic abscesses are not always easy to differentiate clinically; the former are often single in previously healthy individuals who become acutely ill; the latter are often multiple and occur in patients with another underlying illness such as diabetes, colonic carcinoma or other causes for portal pyaemia. Inflammatory bowel disease is not a common cause. Amoebic serology often doesn’t return in time to guide therapy. If in doubt and the ultrasound shows a lesion that is unlikely to be a hepatoma, then go ahead and aspirate it. If the pus is odourless (or at least inoffensive) then it is likely to be amoebic.

Therapy – pyogenic abscesses usually settle with amoxycillin-clavulanate 1.2 g IV 12 hourly (change to oral amoxyclav 1 g 12 hourly when tolerated); you may need to treat for two or three months – resolution likely when patient clinically well and CRP normal.

Amoebic liver abscess usually settles with metronidazole alone (800 mg 3x/d PO for 10 days.) Response should be determined clinically rather than by ultrasound, as ultrasonographic changes may persist for several months.

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1. Runyon BA, Antillon KR, Akriviadis EA, et al. Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J Clin Microbiol. 1990;28:2811-12 ↩

2. Singh N, Gayowski T, Yu VL, et al, Trimethoprim-sulphamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis in a randomised trial. Ann Intern Med. 1995;122:595-8 ↩

3. Butani RC, Shaffer RT, Szyjkowski RD, et al. Rapid diagnosis of infected ascitic fluid using leukocyte esterase dipstick testing. Am J Gastroenterol. 2004;99:532 ↩

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