P1027 - A Rare Case of Spontaneous Bacterial Peritonitis in a Patient With Cardiac Ascites

Mudassar Sandozi, DO, Ahmet Sakiri, MD, Thayer Hamoudah, MD, Altaf Dawood, MD, MBBS, Naser Khan, MD
MercyHealth, Rockford, IL

Introduction: Ascitic fluid accumulates due to conditions such as cirrhosis, heart failure, malignancy, and renal disease. Spontaneous bacterial peritonitis (SBP) is a concerning complications of ascites. We report a rare case of SBP occurring in a patient with cardiac ascites.



Case Description/Methods: A 71-year-old male with chronic heart failure (CHF), coronary artery disease, obstructive sleep apnea, and chronic kidney disease (CKD), presented to GI clinic for evaluation of abdominal distention in the setting of CHF exacerbation. Patient underwent paracentesis, and subsequent ascitic fluid analysis revealed a fluid protein of 4.1 and serum-ascites albumin gradient (SAAG) of 2.0 gm/dL (serum albumin of 4.6 gm/dL, ascites albumin 2.6 gm/dL), suggestive of cardiogenic ascites. Cell count yielded 520 PMN count (1,736 /mm3 Nucleated Cells, 30% Neutrophils), consistent with SBP. Patient was directed to the ED for further management. On admission patient was afebrile and hemodynamically stable. Labs were notable for a creatinine of 1.8 on baseline of 1.5 mg/dL, high sensitivity troponin trend of 30, 31, 28, and 31 ng/L, elevated BNP of 3828 pg/mL, and INR 1.4. CT abdomen/pelvis revealed cirrhosis with small volume ascites. Empiric IV Ceftriaxone was started, along with albumin and IV Furosemide. Patient underwent repeat paracentesis that drained 2L of fluid. Ascitic fluid analysis revealed SAAG of 2.0 (Serum Albumin of 4.9, Ascites Albumin of 2.9), ascitic protein of 4.4, PMN of 1,399 /mm3 (nucleated cells 2,533, 55% neutrophils), and negative fluid cultures. In the setting of worsening PMN count, patient was continued on IV antibiotics and treated as culture-negative neutrocytic ascites.

Discussion: Cardiac ascites is suggested by a SAAG > 1.1 g/dL and total protein > 2.5 g/dL. Cardiac ascites occurs in 5% of ascites case. SBP in cardiac ascites is even more rare, with under 10 cases reported to date. The treatment strategy remains an area of exploration given its rarity, but timely management is essential for this potentially fatal phenomena. Our approach to treatment was inferred from treatment of culture-negative neutrocytic ascites, which is defined by an ascitic fluid polymorphonuclear count greater than 250/mm3, a negative ascitic fluid culture, and the absence of previous antibiotic therapy and intra-abdominal source of infection. This case gives credence to the metabolic effects of CHF on the microbiota, and should increase clinical suspicion of SBP in patients with cardiac ascites.


Disclosures:


Mudassar Sandozi, DO, Ahmet Sakiri, MD, Thayer Hamoudah, MD, Altaf Dawood, MD, MBBS, Naser Khan, MD. P1027 - A Rare Case of Spontaneous Bacterial Peritonitis in a Patient With Cardiac Ascites, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.