Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid. Despite published guidelines, an inappropriate diagnosis of SBP is frequent. In this study, we aim to evaluate guideline adherence in diagnosing SBP. This is a retrospective study conducted between January 2015 and January 2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL), two authors judged guideline adherence in SBP diagnosis and management. One hundred and six patients were included in the study, and 93% were hospitalized. The mean age was 56.9 years, and 62 patients were males. In addition, Caucasians were the most common ethnicity (86.8%). The authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with proper treatment. Inpatient mortality was documented in five patients, and the readmission rate within 30-days after discharge was 29.3%. In conclusion, SBP is a common complication of cirrhosis, which can be managed with adherence to published guidelines. In our population, guidelines were not implemented in diagnosing nearly half the SBP patients, mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even giving broad-coverage antibiotics when not indicated. Further efforts are needed to enhance adherence to guidelines in clinical practice.

Small intestinal hemangiomas are uncommon tumors that frequently present with gastrointestinal bleeding (GIB). Diagnosis, detection, and treatment can be challenging and may require surgical intervention. An 81-year-old female presented with melena. Video capsule endoscopy revealed active bleeding in the proximal jejunum and push enteroscopy identified a polypoid nodule with central umbilication. The patient underwent laparoscopic resection and jejunal submucosal hemangioma was detected. Submucosal hemangiomas are a rare cause of GIB. As the most common site of submucosal hemangiomas is the mid-jejunum, they are not easy to detect. Surgical intervention is usually required for a definitive diagnosis and definitive treatment.

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid when there is no evidence of intra-abdominal surgically treatable source of infection. It has an estimated in-hospital mortality rate of 20%. Despite the published guidelines, inappropriate diagnosis of SBP is frequent. In this study, we aim to measure the percentage of inappropriate diagnosis and treatment of SBP. METHODS: A retrospective study was conducted between Jan-2015 and Jan-2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL) two authors judged the adherence to the guidelines in diagnosis and management of SBP. A third author resolved conflicts. Data was analyzed by chi-square analysis/Mann Whitney U Tests, ANOVA, and t-tests. RESULTS: One hundred six patients were included in the study. 93.3% (98/106) of them were hospitalized. Mean age was 56.9 years (range 32-87). 58.5% (62/106) of the patients were males. Caucasian was the most common ethnicity, with 86.8% (92/106). Smoking use was present in 41.5%, and alcohol use was present in 28.3% of our sample. Alcohol was the most common cause of cirrhosis in 50% of the patients, and viral hepatitis was the second (21.7%). Prior SBP was found in 24.5% of the population. Mean WBC 11.1, Mean MELD-Na score 23.5 (range 8-42), and mean Albumin 2.8 (1.6-4.9). Polymorphonuclear neutrophils (PMN) was neutrocytic (>250) in 54.8% (46/106). 81.8% of the ascitic cultures were negative. 16.2% of the cultures grew one organism, and 1.9% of them were polymicrobial. Albumin was given in 62.1%, and 52.4% on day 1 and day 3, respectively. Hepatology was consulted on 80.2% of the patients. Authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with appropriate treatment. Inpatient mortality documented in 5 patients. The readmission rate was 29.3%. CONCLUSION: SBP is a common complication of cirrhosis, that can be easily managed if we adhere to the published guidelines. In our population, nearly half of the patients were diagnosed and treated inappropriately; this was mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even given broader antibiotics when it is not needed. Further efforts should stress to adopt the guidelines in clinical practice.

INTRODUCTION: Small intestinal hemangiomas are uncommon tumors that usually present with gastrointestinal bleeding (GIB). Hemangiomas account for only 0.05% of all intestinal tumors. The most common location in the small intestine is the mid-jejunum. Diagnosis, detection, and treatment can be challenging and may require surgery. CASE DESCRIPTION/METHODS: An 81-year-old female presented to the emergency department with a one-week history of melena, associated with fatigue and palpitations. She denied hematemesis, hematochezia, NSAIDs use, or the use of anticoagulants or antiplatelet agents. Her vital signs were stable, and her physical examination was unremarkable except for lower limb edema. Hemoglobin was 4.7 g/dl, which was lower than her baseline of 8 g/dl. The patient was transfused to maintain her hemoglobin above 7 g/dl, and a proton pump inhibitor infusion was initiated. Esophagogastroduodenoscopy was performed, and benign-appearing and non-bleeding polyps were detected in the gastric fundus and body. Colonoscopy did not detect significant abnormalities other than moderate diverticulosis, internal hemorrhoids and old melenic liquid throughout the colon but no active bleeding. Due to continued blood transfusion requirements, a video capsule endoscopy was performed, and active bleeding was detected. Push enteroscopy was performed, and a polypoid nodule with central umbilication and red spot was detected in the proximal jejunum [Figure 1]. The lesion was biopsied, and post-biopsy bleeding developed. Hemostasis was achieved by injection of epinephrine (1:10000 concentration) and application of three hemoclips. Subsequently, the patient underwent a laparoscopic segmental jejunal resection. Histologic examination of the resected specimen demonstrated a jejunal submucosal hemangioma with surrounding hemorrhage, an organizing hematoma, and no evidence of dysplasia or malignancy. DISCUSSION: Submucosal hemangiomas are a rare cause of GIB. They can present with melena and severe anemia. As the most common site is mid-jejunum, it is difficult to detect submucosal hemangiomas. In this case, the lesion was detected by video capsule endoscopy and was reached by push enteroscopy. Surgery is usually required for a definitive diagnosis and definitive treatment.

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