Spontaneous bacterial peritonitis in extrahepatic portal venous obstruction
A 48-year-old male presented with melena of 2 days duration. He was diagnosed to have idiopathic EHPVO at the age of 14 years and had undergone multiple endotherapies and later splenectomy at the age of 15 years. At admission the vitals were stable and physical examination was normal except for pallor and the presence of abdominal scar. On the fourth day of admission the patient developed fever with abdominal pain and mild abdominal distension due to ascites. Hemogram revealed; hemoglobin 6.1 g/dL, total leukocyte count 6500 cells/mm3, platelet count 3.56 lakhs/mm3, mean corpuscular volume 65.2 fL and International Normalized Ratio (INR) 1.04. Doppler ultrasound abdomen revealed normal liver, multiple tortuous collaterals replacing portal vein and moderate ascites. Upper gastrointestinal endoscopy revealed mucosal tags in the esophagus (post endotherapy), single column of grade 1 esophageal varix and severe portal hypertensive gastropathy. Ascitic fluid analysis revealed a total leukocyte count of 2400 cells/mm3, polymorphonuclear cell count of 1680 cells/mm3, with ascitic fluid protein 1.9 g/dL, albumin 0.8 g/dL and serum ascites albumin gradient (SAAG) 2.3. Culture of ascitic fluid yielded heavy growth of Escherichia coli (E. coli) species.