Abstract
BackgroundSpontaneous bacterial peritonitis (SBP) is a serious complication in infants and children with chronic liver disease (CLD); however its diagnosis might be difficult. We aimed to study the feasibility of diagnosing SBP by routine ascitic fluid tapping in infants and children with CLD.MethodsWe enrolled thirty infants and children with biopsy-proven CLD and ascites. Ascitic fluid was examined for biochemical indices, cytology and cell count. Aerobic and anaerobic bacteriological cultures of ascitic fluid were preformed. Direct smears were prepared from ascitic fluid deposit for Gram and Zheil-Nelson staining.ResultsPatients were divided into three groups: Group I included five patients with SBP in which the cell count was ≥ 250/mm3 and culture was positive (16.7%), Group II, eight patients with culture negative neutrocytic ascites (CNNA) with cells ≥ 250/mm3 and negative culture (26.7%) and Group III, seventeen negative patients (56.6%) in which cells were <250/mm3 and culture was negative. None of our patients had bacteriascites (i.e. culture positive with cells <250/mm3). Presence of fever was significantly higher in SBP and CNNA. The mean lactate dehydrogenase (LDH) level was significantly higher in ascitic fluid in the infected versus sterile cases (p < 0.002). A ratio of ascitic/serum LDH ≥ 0.5 gave a sensitivity of 80%, specificity of 88%, positive predictive value (PPV) of 66.7%, negative predictive value (NPV) of 93.7% and accuracy of 63.3%. The mean pH gradient (arterial - ascitic) was significantly higher in SBP and CNNA cases when compared to the negative cases (p < 0.001). Ascitic fluid protein level of ≤ 1 gm/dl was found in 13/30 (43.3%) of studied cases with a sensitivity of 100%, specificity of 64.7%, PPV of 45.5%, NPV of 100% and diagnostic accuracy of 53.3% (p = 0.0001).ConclusionsSBP is a rather common complication in children with CLD. Culture of the ascitic fluid is not always diagnostic of infection. Biochemical parameters of the ascitic fluid definitely add to the diagnostic accuracy. LDH ascitic/serum ratio ≥ 0.5, an arterial-ascitic pH gradient ≥ 0.1 and total ascitic fluid protein ≤ 1 gm/dl are the most significant parameters suggesting infection.
Highlights
Spontaneous bacterial peritonitis (SBP) is a serious complication in infants and children with chronic liver disease (CLD); its diagnosis might be difficult
We aimed to study the value of biochemical parameters including ascitic fluid pH, lactate dehydrogenase (LDH), glucose and total proteins compared to their blood levels in diagnosing culture-negative patients
The mean pH gradient was significantly higher in SBP and culture negative neutrocytic ascites (CNNA) cases when compared to the negative cases (p < 0.001) (Figure 1)
Summary
Spontaneous bacterial peritonitis (SBP) is a serious complication in infants and children with chronic liver disease (CLD); its diagnosis might be difficult. We aimed to study the feasibility of diagnosing SBP by routine ascitic fluid tapping in infants and children with CLD. Patients with chronic liver disease (CLD) are susceptible to infections with a higher prevalence in cirrhotics [1]. Spontaneous bacterial peritonitis (SBP) is defined as infected ascites in absence of recognizable secondary cause of infection [2]. CLD patients with ascites because of bacterial overgrowth with translocation through a more permeable small intestinal wall and impaired defense mechanism [3]. Older studies reported 80-100% lethality in SBP, which is probably given partly by the worse therapeutic possibilities in cirrhotic patients and lack of availability of effective antibiotics. Better results with only 20%-40% lethality reported in more recent studies are, to a certain extent, due to early diagnosis and treatment [6,7,8]
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