Jaundice, Secondary bacterial peritonitis

Thanks Sophia for a great case! She presented a case of a young person with a history of alcohol use disorder, hepatitis C and recurrent acute pancreatitis who presents with abdominal pain and jaundice found to have subacute liver failure from alcoholic hepatitis and secondary bacterial peritonitis.

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Main points:

  1. ) One way to think about jaundice is direct vs indirect hyperbilirubinemia? For direct:
    1. a) intrahepatic – alcoholic hepatitis, NAFLD, ischemia, infiltrative diseases, TPN
    2. b) extrahepatic cholestatic – stones, strictures, malignancy/ external compression
      • can be anywhere from the hepatic ducts -> CHD / cystic -> CBD -> ampulla
      • if extrahepatic, look for evidence of cholangitis
    3. c) other – infections, genetic (eg Dubin Johnson)
  2. ) The following imaging tests should guide looking for extrahepatic cholestatic in rising order of sensitivity: ultrasound, CT, MRCP/ ERCP
  3. ) We went over several different workups that were discussed/ blogged about the past few weeks including (1) acute liver injury vs acute liver failure and (2) ascites

Want to learn more?

Secondary vs spontaneous bacterial peritonitis

o Secondary bacterial peritonitis is different from spontaneous bacterial peritonitis there is evidence of an infectious source such as a) perforation of viscera 2) an intra-abdominal abscess or 3) indwelling foreign body eg. peritoneal dialysis catheter

o Other evidence that supports this includes: o WBC peritoneal fluid >10,000, gram stain positive (need many more bacteria to turn a gram stain positive), and culture showing multiple strains of bacteria and application of Runyon’s criteria (see image below)

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