Ascites and Spontaneous Bacterial Peritonitis in Fulminant Hepatic Failure Radha K. Dhiman, M.D., Govind K. Makharia, M.D., Sanjay Jain, M.D., and Yogesh Chawla, M.D. Departments of Hepatology and Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India OBJECTIVE: Although presence of ascites has been reported in patients with fulminant hepatic failure (FHF), spontane- ous bacterial peritonitis (SBP) has not been studied in a large group of such patients. Hence, the present study was conducted to evaluate the prevalence and prognostic signif- icance of ascites and SBP in FHF patients. METHODS: Two hundred ninety-eight consecutive patients (mean age 32.9  14.8 yr) with FHF were studied. There were 133 (44.6%) men and 165 (55.4%) women. Acute viral hepatitis accounted for 91.6% of the patients and were analyzed in the present study. RESULTS: Ascites was clinically detected in 79 (28.9%) patients. The patients with ascites were older (p = 0.005), had longer jaundice– encephalopathy interval (p  0.0000001), lesser grade of encephalopathy on admission (p = 0.0000043), and a lower incidence of raised intracra- nial pressure on admission (p = 0.0007). Patients with ascites had significantly lower serum albumin (p = 0.021), ALT (p = 0.0005), AST (p = 0.00017), and PT (p = 0.002) on admission than in patients without ascites. Multivariate logistic regression analysis showed that jaundice– encepha- lopathy interval (14 days) and serum albumin (2.5 g/dl) were the only independent predictors of ascites. SBP was detected in 14 (17.7%) patients (neutrocytic culture positive, 4; neutrocytic culture negative, 9; and monomicrobial bacterascites, 1). Escherichia coli was identified in three patients. Survival was no different between patients with and those without ascites and also between patients with and those without SBP. CONCLUSIONS: Ascites is a frequent accompaniment of FHF and is complicated by SBP. Jaundice– encephalopathy interval of 14 days or more and serum albumin (2.5 g/dl) on admission predicts the development of ascites in these patients. (Am J Gastroenterol 2000;95:233–238. © 2000 by Am. Coll. of Gastroenterology) INTRODUCTION Although ascites is an important feature of decompensated chronic liver disease, it has been reported infrequently in patients with severe acute hepatitis (1, 2). Portal hyperten- sion has been implicated in the pathogenesis of ascites both in cirrhosis of the liver as well as in fulminant hepatic failure (FHF) (2– 4). Spontaneous bacterial peritonitis (SBP) is a well-recognized complication of ascites in cirrhotic patients. Recent prospective studies have shown the prevalence of SBP in cirrhotic ascites as 15% to 25% (5– 8). SBP has also rarely been reported in patients with FHF with ascites (9, 10). Recently, Chu et al. (1) reported SBP in 31.7% of patients with severe acute hepatitis and ascites. However, the majority of patients in this series had underlying chronic liver disease. There is no large study in the literature on the occurrence of ascites and SBP in FHF and its prognostic significance. The current study was performed to evaluate the prevalence and prognostic significance of ascites and SBP in patients with FHF due to acute viral hepatitis. MATERIALS AND METHODS For the purpose of this study, acute liver failure or FHF was defined according to the criteria of O’Grady et al. (11), that is, onset of hepatic encephalopathy occurring within 12 wk of onset of jaundice and further subclassified depending on the interval between the onset of jaundice and the onset of encephalopathy into hyperacute (HALF; interval 0 –7 days), acute (ALF; interval 8 –28 days), and subacute liver failure (SALF; interval 29 days to 12 wk) (11, 12). A viral etiology was presumed when a history of exposure to drugs or toxins was absent. A typical prodromal illness was present in the majority of patients. Patients with a history of intake of hepatotoxic drugs and absence of viral markers were diag- nosed as having drug-induced FHF. Patients who consumed 50 g/day of alcohol for 5 yr and those with evidence of chronic liver disease based on clinical, biochemical, or on abdominal ultrasound examination or at autopsy were ex- cluded. Standard criteria were used for the diagnosis of Wilson’s disease (13), whereas the diagnosis of malignant infiltration of liver leading to FHF was confirmed at au- topsy. Two hundred ninety-eight consecutive patients with FHF were studied. There were 133 (44.6%) men and 165 (55.4%) women. The mean age was 32.9  14.8 yr (range 12– 82 yr). Acute viral hepatitis accounted for 91.6% of the patients. All 22 (7.2%) patients with drug-induced hepatitis and FHF were related to antitubercular regimens containing rifampi- THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 95, No. 1, 2000 © 2000 by Am. Coll. of Gastroenterology ISSN 0002-9270/00/$20.00 Published by Elsevier Science Inc. PII S0002-9270(99)00750-9