Introduction: Spontaneous bacterial peritonitis (SBP) as a monomicrobial infection of ASCITES fluid is one of the most important causes of morbidity and mortality in cirrhotic patients. This study was aimed to determine the diagnostic accuracy of ASCITES fluid color in detection of SBP in cirrhotic cases referred to the emergency department.Methods: Cirrhotic patients referred to the ED for the paracentesis of ASCITES fluid were enrolled. For all studied patients, the results of laboratory analysis and gross appearance of ASCITES fluid registered and reviewed by two emergency medicine specialists. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ration of the ASCITES fluid gross appearance in detection of SBP were measured with 95% confidence interval.Results: The present project was performed in 80 cirrhotic patients with ASCITES (52.5 female). The mean of the subjects' age was 56.25±12.21 years (35-81). Laboratory findings revealed SBP in 23 (29%) cases. Fifty nine (73%) cases had transparent ASCITES fluid appearance of whom 17 (29%) ones suffered from SBP. From 21 (26%) cases with opaque ASCITES appearance, 15 (71%) had SBP. The sensitivity and specificity of the ASCITES fluid appearance in detection of SBP were 46.88% (Cl: 30.87-63.55) and 87.50% (95% Cl: 75.3-94.14), respectively.Conclusion: It seems that the gross appearance of ASCITES fluid had poor diagnostic accuracy in detection of SBP and considering its low sensitivity, it could not be used as a good screening tool for this propose.

In this report we have discussed our experience with a special home-made platelet-rich plasma (PRP)-fibrin glue (FG) as a last resort for treatment of a challenging case of postoperative CA. A 25 years old, ill woman was admitted with severe ASCITES and hepatic encephalopathy in our center. She was a known case of autoimmune hepatitis and cirrhosis who had undergone liver transplantation 5 years ago and developed chronic rejection. During the surgery an old organized thrombosis in the portal vein was detected, accordingly an iliac vein graft was used to bypass the superior mesenteric vein. After surgery the patient developed chylous ASCITES. Having no other choice, based on our experience with PRP-FG in similar situations, we decided to use this method as a last resort to treat postoperative chylous ASCITES. It can be concluded that when conservative management is not working for the treatment of postoperative chylous ASCITES in intractable cases, PRP-FG can be considered as a last resort treatment. A special home-made PRP-FG was prepared for the patient and of that, 90 mL was injected to the abdominal cavity via the drainage tube followed by a 25 mL of isotonic saline solution to prevent clot formation within the tube. Few days after treatment, chylous secretion decreased and then completely ceased. It can be concluded that when conservative management is not working for the treatment of postoperative chylous ASCITES in intractable cases, PRP-FG can be considered as a last resort treatment.

Endometriosis is an estrogen dependent disease where active endometrial tissue is present in extra uterine sites. Presence of recurrent massive hemorrhagic ASCITES due to endometriosis is a rare phenomenon which can mislead physicians to other pathological conditions like malignancy and wrong treatment protocol may be applied. For confirming the cause of this huge bloody ASCITES laparoscopy or laparotomy followed by biopsy is significantly essential.

In decompensated cirrhosis, massive ASCITES and pleural effusion (hepatic hydrothorax) can be complicated by infection, which manifests either as spontaneous bacterial peritonitis (SBP) or spontaneous bacterial empyema (SBE). SBE is a distinct and often underdiagnosed complication having different pathogenesis and treatment strategy when compared with parapneumonic empyema. Hepatic hydrothorax in the absence of ASCITES is rare in patients with cirrhosis. The occurrence of SBE without SBP or ASCITES is even more of a rarity in cirrhosis and carries great morbidity and mortality. Here we report a case of an elderly female patient with cirrhosis (Child-Pugh Class B) who had unusual features of isolated right-sided hepatic hydrothorax without clinically evident ASCITES and was later diagnosed as having SBE based on imaging of the thorax, pleural fluid analysis, and cultures. The patient was initially treated conservatively with antibiotics, and diuretics, and later pigtail insertion and drainage was done.

ASCITES is not a usual finding in prehepatic portal hypertension, including portal vein thrombosis, but when portal vein thrombosis is acute and massive, ASCITES can be a presenting feature. We report a 9-year-old boy with tense ASCITES and portal and superior mesenteric vein thrombosis. A 9-year-old boy was evaluated for tense ASCITES which led to umbilical hernia since one month before admission. He did not have any clinical or laboratory stigmata of parenchymal liver disease. Imaging studies showed superior mesenteric and portal vein thrombosis. In laboratory tests for pre-thrombotic states, he suffered from significant protein S deficiency. Thrombophilic states like protein S deficiency predispose patient to vascular thrombosis. This vascular thrombosis can be present with signs and symptoms related to their territories. Prevention of thrombosis and rethrombosis with anticoagulant therapy is recommended.