Spontaneous bacterial peritonitis in extrahepatic portal venous obstruction
A 58-year-old male presented with melena, abdominal pain and fever. He was diagnosed to have EHPVO and had undergone splenectomy at the age of 19 years when he presented with massive variceal bleeding in 1973. Physical examination revealed pallor and moderate ascites. Laboratory investigations were as follows; hemoglobin 9.1 gm/dL, total leukocyte count 11700 cells/mm3, platelet count 4.04 lakhs/mm3 and INR of 1.1. Ascitic fluid analysis showed a total leukocyte count of 1600 cells/mm3, polymorphonuclear cell count of 1472 cells/mm3, total protein 2.5 g/dL, albumin 1.4 g/dL and SAAG 1.9. Ascitic fluid culture yielded growth of E. coli. Ultrasound abdomen with Doppler study showed normal liver, cavernous transformation of the portal vein and moderate ascites. Upper gastrointestinal endoscopy revealed severe portal hypertensive gastropathy and gastric fundal varix. Computerized tomography of the abdomen was consistent with the diagnosis of EHPVO; there was no evidence of cirrhosis of the liver or any features of perforation or inflammation of other organs.\nThe liver and renal function tests, serum amylase and lipase levels, serum electrolytes and blood glucose levels were normal in both patients. Ascitic fluid glucose, lactate dehy-drogenase, triglycerides and adenosine deaminase were also within normal limits. Both patients did not show any features of perforation or obstruction on plain x-ray of the abdomen.\nBoth patients were managed with infusion of octreotide, proton pump inhibitors, transfusions, hematinics and beta blockers. SBP was treated with Cefotaxime 2 g IV t.i.d. Both patients had relief of fever, abdominal pain and abdominal distension. Repeat ascitic fluid analysis after 48 h of antibiotic therapy showed a decrease in polymorphonuclear cell count to 68 cells/mm3 and 165 cells/mm3 in the first and second case respectively. Antibiotics were continued for 5 days and both patients were discharged in a stable state.