Routine analysis of cirrhotic ascites for evidence of infection – not worth the effort?

Abstract

Spontaneous bacterial peritonitis (SBP) is a serious complication of advanced cirrhosis of the liver. Usually patients with SBP show symptoms such as fever, abdominal pain, worsening of renal function, hypotension or development of encephalopathy. The frequency of SBP among hospitalised patients with advanced cirrhosis varies from 10% to 30% [1]. The mortality of SBP was 80% to 100% in the 1960s, but has declined to 30% to 40% with early diagnosis and effective therapy with broad-spectrum antibiotics [2, 3]. A high index of suspicion followed by analysis of ascitic fluid for evidence of infection is helpful in making an early diagnosis of SBP, and is today considered the standard of care in patients with cirrhosis and symptoms listed above. The International Ascites Club recommends mandatory analysis of ascitic fluid in all cases of new onset of ascites, worsening of ascites, and in all other cases whenever there is a suspicion of SBP [1]. The recommendations of the American Association for the Study of Liver Disease (AASLD) differ from those of the International Ascites Club. The AASLD thus recommends testing of ascitic fluid for cell count and differential count, but not necessarily culture, for patients undergoing serial outpatient therapeutic paracentesis, each time the fluid is removed [4]. Given the low prevalence of SBP in asymptomatic patients, the question is whether we need to undertake ascitic fluid cell count routinely in all cases of paracentesis. This issue is of particular importance for gastroenterologists and physicians in India and other developing countries, since such