Board Review: In from one END out the OTHER

A  55 year old male with a history of cirrhosis and HTN presents to the ED with progressively worsening abdominal pain and distension for the past week. Vitals are as follows: T101F HR110 BP150/95 SpO297% RR20. You notice significant ascites on exam and decide to perform a paracentesis, although he reports he isn’t “due for another tap” until next week. To support your suspected diagnosis, you are searching for what cutoff of PMNs in the ascitic fluid?


  1. >100 cells/mm3

  2. >150 cells/mm3

  3. >200 cells/mm3

  4. >250 cells/mm3

















Answer: D. This patient with ascites has a concerning history for spontaneous bacterial peritonitis (SBP) with the characteristic triad of abdominal pain, fever, and increasing ascites. However, patients often do not present with these classical symptoms, therefore it is up to you as their EM physician to keep this diagnosis in mind! Ascitic fluid with PMNs >250 cells/mm3 is diagnostic of SBP. You should order a 3rd generation cephalosporin to cover the most typical causes of SBP - E.coli, strep pneumo, and enterococcus.