Ascitic Fluid Analysis Research Articles

Antitumor activity of silver nanoparticles in Dalton’s lymphoma ascites tumor model

Nanomedicine concerns the use of precision-engineered nanomaterials to develop novel therapeutic and diagnostic modalities for human use. The present study demonstrates the efficacy of biologically synthesized silver nanoparticles (AgNPs) as an antitumor agent using Dalton’s lymphoma ascites (DLA) cell lines in vitro and in vivo. The AgNPs showed dose- dependent cytotoxicity against DLA cells through activation of the caspase 3 enzyme, leading to induction of apoptosis which was further confirmed through resulting nuclear fragmentation. Acute toxicity, ie, convulsions, hyperactivity and chronic toxicity such as increased body weight and abnormal hematologic parameters did not occur. AgNPs significantly increased the survival time in the tumor mouse model by about 50% in comparison with tumor controls. AgNPs also decreased the volume of ascitic fluid in tumor-bearing mice by 65%, thereby returning body weight to normal. Elevated white blood cell and platelet counts in ascitic fluid from the tumor-bearing mice were brought to near-normal range. Histopathologic analysis of ascitic fluid showed a reduction in DLA cell count in tumor-bearing mice treated with AgNPs. These findings confirm the antitumor properties of AgNPs, and suggest that they may be a cost-effective alternative in the treatment of cancer and angiogenesis-related disorders.

SOME ASPECTS OF PATHOGENESIS AND DIAGNOSTICS OF SPONTANEOUS BACTERIAL PERITONITIS

Bacterial infections considerably complicate of cirrhosis current, are principal causes of death of such patients. As a rule, infectious complications develop at persons with decompensated cirrhosis. In the medical literature the term «spontaneous bacterial peritonitis» at cirrhosis is often mentioned. This typical infectious complication of cirrhosis about in 25 % of cases is a cause of death of patients. It is connected with absence of the clinically apparent signs. Nonspecific symptoms - abdominal pain, fever, leukocytosis, increase of hepatic encephalopathy. SBP may be asymptomatic or there may be minor symptoms only. Late diagnosis of this complication explains high lethality at SBP. The basic method of diagnostics of SBP- analysis of ascitic fluid. The manual count of polymorphonuclear neutrophils by the traditional hematological method is laborious and, in many instances subjective. In the literature there are developed new methods of diagnostics of SBP. They allow to accelerate search of infectious process. The diagnosis timely improves the prognosis of patients with SBP.

Usefulness of reagent strips for checking cure in spontaneous bacterial peritonitis after short‐course treatment

The usefulness of reagent strips to check cure of spontaneous bacterial peritonitis have not been evaluated to date. To assess the usefulness of ascitic fluid analysis by means of reagent strips to check cure after a 5-day antibiotic course. We prospectively included all cirrhotic patients diagnosed with spontaneous bacterial peritonitis. On day 5, conventional and reagent strip ascitic fluid analyses were performed. Fifty-three episodes of spontaneous bacterial peritonitis in 51 cirrhotic patients were included. Five patients died before the fifth day and in two patients, the control paracentesis yielded no ascitic fluid. In nine out of 46 cases (19.6%), spontaneous bacterial peritonitis had not resolved by day 5. In 32 out of 33 cases in which the ascitic fluid polymorphonuclear count was <250/microL at day five, the reagent strips was negative. The negative predictive value of the reagent strip at fifth day was 97% and the LR- 0.13. Almost 20% of episodes of spontaneous bacterial peritonitis do not resolve with a short-course of antibiotic treatment. In view of the high negative predictive value and low likelihood ratio for a negative test, reagent strips analysis may be an alternative to conventional cytology if a 5-day antibiotic therapy is planned.

Recurrent Ascites Following Laparoscopic Cholecystectomy: Can You Find the Cause?

Purpose: Ascites following laparoscopic cholecystectomy has been described with potential etiologies to include iatrogenic biliary, lymphatic or ureteral disruption. However, this case involves recurrent inflammatory ascites following laparoscopic cholecystectomy without an obvious etiology despite extensive evaluation. Methods: A 36 year old female with a history of chronic hepatitis C was hospitalized at a tertiary referral center due to a one month history of recurrent ascites following laparoscopic cholecystectomy. She was diagnosed from an outside institution with chronic hepatitis C about three months prior. Liver biopsy was performed at that time and demonstrated stage 1-2 fibrosis. One month prior to her transfer to our hospital, she underwent elective cholecystectomy. Postoperatively, she developed significant ascites three days following her procedure. HIDA and abdominal ultrasound with Doppler did not demonstrate any biliary leak or abnormalities of the liver or portal system. Ascitic fluid analysis demonstrated WBC of 6200 (rare PMN, largely lymphocytic), serum-albumin gradient (SAAG) >1.1, and negative urea and fat analysis. She required multiple large volume paracenteses. Given her difficulties she presented to our institution. Results: Repeat ascitic fluid analysis demonstrated 4,700 nucleated cells/uL (83% lymphocytes), SAAG > 1.1, gram stain and culture negative, AFB negative, cytology negative, lipid analysis negative, and no evidence of bile. HIDA was repeated with no evidence of biliary leak. Abdominal ultrasound with Doppler analysis of the portal veins, splenic veins and hepatic veins was unremarkable and without evidence of portal hypertension. CT of the abdomen and pelvis was only notable for ascites. Transthoracic echocardiogram was negative with normal cardiac findings. Venogram with measurement of hepatic vein pressure gradient was unremarkable and without evidence of portal hypertension. Serologic testing with ANA, SPEP, beta-2-microglobulin, and CA-125 were negative. Re-evaluation of outside liver biopsy confirmed absence of cirrhosis. Surgical consultation was obtained and no intervention was recommended. The patient initially required multiple large volume paracenteses. She was started on diuretic regimen with spironolactone and furosemide and afterwards had significant improvement without requiring further paracentesis. Conclusion: Ascites following laparoscopic cholecystectomy has been described with iatrogenic causes being prominent. However, idiopathic postoperative inflammatory ascites has only had limited description in the literature. This case illustrates the complexity involved in these cases, but also supports the use of diuretic therapy in its treatment.

Role of Cholesterol Determination in Ascitic Fluid Analysis†

Role of Cholesterol Determination in Ascitic Fluid Analysis†

Tuberculosis peritoneal por Mycobacterium bovis en paciente cirrótico

Isolated peritoneal tuberculosis is an uncommon extrapulmonary form of presentation of tuberculosis in industrialized countries. In most cases, this disease is the result of reactivation and secondary hematogenous spread of a latent infection. Although the suspected diagnosis is given by clinical manifestations and analysis of ascitic fluid (lymphocytic predominance, albumin gradient between serum and ascitic fluid ⩽1 g/dl and adenosine deaminase concentration ⩾39 U/L), microbiologic assessment is required for the definitive diagnosis. Mycobacterium bovis causes tuberculosis in animals. Transmission to humans is rare in developed areas, given that it usually occurs through ingestion of unpasteurized contaminated milk. We present a patient with cirrhosis who developed ascites caused by an exceptional infection in our setting.

A Positive Breath Hydrogen Test Does Not Predict the Occurrence of a Spontaneous Bacterial Peritonitis in Cirrhotic Patients with Ascites

Background/Aims: A positive breath hydrogen test (BH₂ T) suggesting the presence of a small intestinal bacterial overgrowth (SIBO) might be a factor increasing the risk of spontaneous bacterial peritonitis (SBP) in cirrhotic patients. In this prospective observational study, we aimed to determine whether a positive BH₂ T was associated in time with the development of SBP in cirrhotics with ascites. Methods: During a 3-year period, we prospectively included 29 consecutive cirrhotics with ascites but without previous episodes of SBP or recent antibiotherapy. Every 3 months or before in the event of cirrhosis complications, patients underwent clinical examination, routine laboratory tests, analysis of ascitic fluid and a BH₂ T after ingestion of 50 g D-glucose. Results: During a mean follow-up of 12 months (range 3–33), 11 patients were prematurely withdrawn from the study without SBP (3 transplantations, 2 lost to follow-up, 6 deaths from hepatorenal syndrome, terminal liver failure, variceal bleeding or septic shock) and 9 developed SBP. In the 29 patients, 116 BH₂ T were performed and were positive 12 times in 8 patients; however, in the same patient the positivity was not constant during the follow-up and not related to the clinical presence of ascites. Among the 9 patients who developed SBP, only 2 had a previous transitory positive BH₂ T, which became negative at least 3 months before the occurrence of SBP. Conclusion: In cirrhotics with ascites the diagnosis of SBP is not associated in time with a recent positive BH₂ T.

Mining the Ovarian Cancer Ascites Proteome for Potential Ovarian Cancer Biomarkers

Current ovarian cancer biomarkers are inadequate because of their relatively low diagnostic sensitivity and specificity. There is a need to discover and validate novel ovarian cancer biomarkers that are suitable for early diagnosis, monitoring, and prediction of therapeutic response. We performed an in-depth proteomics analysis of ovarian cancer ascites fluid. Size exclusion chromatography and ultrafiltration were used to remove high abundance proteins with molecular mass >/=30 kDa. After trypsin digestion, the subproteome (</=30 kDa) of ascites fluid was determined by two-dimensional liquid chromatography-tandem mass spectrometry. Filtering criteria were used to select potential ovarian cancer biomarker candidates. By combining data from different size exclusion and ultrafiltration fractionation protocols, we identified 445 proteins from the soluble ascites fraction using a two-dimensional linear ion trap mass spectrometer. Among these were 25 proteins previously identified as ovarian cancer biomarkers. After applying a set of filtering criteria to reduce the number of potential biomarker candidates, we identified 52 proteins for which further clinical validation is warranted. Our proteomics approach for discovering novel ovarian cancer biomarkers appears to be highly efficient because it was able to identify 25 known biomarkers and 52 new candidate biomarkers that warrant further validation.

Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is a frequent and serious complication of ascites in the presence of advanced cirrhosis. Although SBP can be considered in other conditions associated with the presence of chronic ascites, SBP is most commonly associated with ascites from cirrhosis and its presence correlates with more advanced liver disease (Runyon, Management of adult patient with ascites due to cirrhosis: update 2012. The American Association for the Study of Liver Diseases. AASLD Practice Guideline, 1–87, 2013; Such and Runyon, Clin Infect Dis 27:669–674, 1998). SBP is defined as an ascitic fluid infection in the absence of a surgical etiology. Delay in recognition and appropriate treatment of peritoneal infections such as SBP can lead to sepsis and death. Symptoms include fever, abdominal pain, nausea and altered mental status although patients can be asymptomatic (Runyon, Hepatology 12:710–715, 1990). Translocation of enteric bacteria from the gut into the peritoneal cavity accounts for the majority of SBP cases (Moore and Van Thiel, World J Hepatol 5:251–263, 2013); however, other organisms, (fungal, mycobacteria, and more resistant nosocomial bacteria), can also be pathogenic and lead to peritonitis. The clinical diagnosis of SBP is suspected by the presence of ascites and compatible symptoms and is confirmed by ascitic fluid analysis showing elevated polymorphonuclear cells and a positive microbiologic culture. It is imperative to rule out secondary causes of peritonitis. Treatment primarily includes antibiotics and adjunctive albumin therapy in appropriate patients. Prophylaxis is a cornerstone of therapy for patients meeting criteria. Early identification and management of SBP has transformed this condition from one carrying a high mortality rate to a fairly well managed and treated complication of chronic ascites in cirrhotic patients.

Diagnosis of tuberculous peritonitis using endoscopic ultrasound-guided fine-needle aspiration biopsy of the peritoneum

Tuberculous peritonitis is prevalent in developing countries and its diagnosis is still challenging due to the lack of specific clinical characteristics and the difficulty in obtaining tissue from the peritoneum without laparoscopy. Endoscopic ultrasound - guided fine needle aspiration is emerging as the most effective and safe method for obtaining tissue from the structures surrounding the gut lumen. Our study aimed to elucidate the efficacy of endoscopic ultrasound-fine needle aspiration of the peritoneum in the diagnosis of tuberculous peritonitis. Three patients (2 male and 1 female; aged 38, 25, and 65 years, respectively) suspected of having tuberculous peritonitis were recruited into the study. Clinical evaluation including computed tomography imaging and analysis of ascitic fluid were performed. Endoscopic ultrasound-fine needle aspiration biopsy of the peritoneum was performed trans-gastrically with a 19-gauge ProCore needle in all patients. At least two different areas of the peritoneum suspected to be involved were sampled and paraffin-embedded cell blocks were prepared for each biopsy specimen. Biopsy specimens were positive for Mycobacterium tuberculosis by polimerase chain reaction in 2 patients and positive for multinucleated giant cells in all patients. Treatment for tuberculosis resulted in the resolution of symptoms and ascites. No procedure- related complications occured. Endoscopic ultrasound-fine needle aspiration is an efficacious and safe method to obtain tissue from the peritoneum to use in the diagnosis of tuberculous peritonitis.

Correlation of Tumour Markers in Ascitic Fluid and Serum: Are Measurements of Ascitic Tumour Markers a Futile Attempt?

Correlations between tumour markers in ascitic fluid and serum were investigated to determine whether ascitic fluid analysis had any diagnostic advantage over serum in 91 adults with ascites (55 malign; 36 benign). Serum and ascitic fluid were analysed for carcinoembryonic antigen (CEA), cancer antigen (CA) 125, CA19.9, CA72.4, CA15.3, alpha-fetoprotein (AFP) and cytokeratin-19 fragment (CYFRA). The tumour markers were skewed between the groups so were logarithmically transformed. Correlations between serum and ascitic fluid were tested using Pearson's correlation coefficient. Serum and ascitic fluid levels of CEA, CA125, CYFRA and AFP in the malign group were statistically different and CEA, CA19.9, CA5.3, CYFRA and AFP were statistically different in the benign group. For both groups, all tumour markers were highly correlated in serum and ascitic fluid, with the exception of CYFRA in the malign group. These results indicate that, where malignant ascites is suspected, analysing tumour markers in ascitic fluid does not have any advantage over serum analysis.

Comments on the editorial by Riggio &amp; Ageloni on theascitic fluid analysis

Angeloni et al published a landmark study on the use of Coulter counters in spontaneous bacterial peritonitis (SBP) diagnosis. Riggio and Angeloni have recently published an editorial on the ascitic fluid analysis in diagnosis and monitoring of SBP. Herein, some points of interest are discussed.

Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis

Polymorphonuclear (PMN) cell count in the ascitic fluid is essential for the diagnosis and management of spontaneous bacterial peritonitis (SBP). To date, PMN cell count is routinely performed by traditional manual counting. However, this method is time-consuming, costly, and not always timely available. Therefore, considerable efforts have been made in recent years to develop an alternative test for a more rapid diagnosis and monitoring of SBP. The use of urinary reagent strips was proposed to achieve an "instant" bedside diagnosis of SBP. A series of reports evaluated the urine strip test for SBP diagnosis and reported promising results. However, a recent large multicenter study revealed a surprising lack of diagnostic efficacy of the urine screening test for SBP diagnosis. Another method, more recently proposed as an alternative to the manual PMN count, is the measurement of lactoferrin in ascitic fluid, but the data available on the diagnostic value of this test are limited to a single study. However, both urinary reagent strips and ascitic lactoferrin tests are qualitative methods and need, therefore, to be further confirmed by standard cytology of the ascitic fluid. To date, the only quantitative method proposed as a valid alternative to manual PMN counting is automated blood cell counters, commonly used in all laboratories for blood cell counting. Data available in the literature on the diagnostic performance of this method are limited but very promising, and this tool seems to have the potential to replace the manual counting method.

In-hospital mortality in spontaneous bacterial peritonitis: a new predictive model

Spontaneous bacterial peritonitis (SBP) is a severe complication in cirrhotics with ascites. Early identification of high-risk patients is crucial for prognostic improvement. Model for end-stage liver disease (MELD) relies on a few objective variables and predicts short-term survival. We aimed to determine the predictive value of MELD score, at admission, in the short-term mortality of SBP patients. We conducted a retrospective study of 73 SBP episodes admitted in our department between January 2002 and April 2006. Diagnosis (neutrophil count in ascitic fluid >or=250/mm3) was established within 24 h and cefotaxime was immediately started. Data collected included age, sex, etiology of liver disease, severity of ascites and hepatic encephalopathy, serum creatinine, total bilirubin and albumin, prothrombin time with international normalized ratio, and ascitic fluid analysis. Student's t-test, chi2 test, univariate analysis, logistic regression model, and receiver operating characteristic curves. In-hospital mortality rate was 37%. In multivariate analysis, MELD score (P<0.001), and advanced age (P<0.05) were independent predictors of mortality. Receiver operating characteristic curve for MELD score revealed an excellent discriminatory ability to predict death, with an area under curve of 0.84. Age increased the predictive ability of MELD score, represented by an increment of area under curve to 0.88. MELD score and older age were independent predictors of mortality. Age increased the discriminatory ability of MELD score to predict death. This new model may be useful for stratifying patients in future therapeutic trials, deserving further validation.

Color Doppler ultrasonography in detecting transdiaphragmatic flow of hepatic hydrothorax: Correlation with thoracoscopic findings

Many mechanisms have been proposed for hepatic hydrothorax (HH), pleural effusion seen in cirrhotic patients, and the transdiaphragmatic flow of ascitic fluid through the diaphragmatic defects is considered the most probable.1,2 There are several methods for diagnosis of HH, including biochemical analysis of ascitic and pleural fluids, conventional radiography, radioisotopic imaging, magnetic resonance imaging, and thoracoscopy. Among these, ultrasonography may be considered the easiest method and has the benefit of real-time diagnosis of anatomic integrity.

Ascitic Fluid Lactoferrin for Diagnosis of Spontaneous Bacterial Peritonitis

The diagnosis of spontaneous bacterial peritonitis (SBP) is based on a manual count of ascitic fluid polymorphonuclear cells (PMNs). This procedure is operator-dependent and lysis of PMNs during transport to the laboratory may lead to false-negative results. Furthermore, ascitic fluid culture is insensitive and leads to delays in diagnosis. The aim of this study was to assess the utility of ascitic fluid lactoferrin (AFLAC) for the diagnosis of SBP and to identify a cut-off level that can be used for future development of a rapid bedside test. A total of 218 consecutive ascites samples from 148 patients (1-8 samples per patient) with cirrhosis at 2 tertiary care medical centers were examined for PMN count, bedside culture, and lactoferrin concentration. AFLAC concentrations were determined using a polyclonal antibody-based enzyme-linked immunosorbent assay. An ascitic fluid PMN count of 250 cells/mL or greater with or without a positive culture was used for diagnosis of SBP. Twenty-two (10.1%) samples fulfilled diagnostic criteria for SBP. Samples with SBP had a significantly higher lactoferrin concentration (median, 3744 ng/mL; 25th-75th percentiles [P25-P75], 788-9617) compared with non-SBP samples (median, 31 ng/mL; P25-P75, 12-67; P < .001). By using a cut-off level of 242 ng/mL, the sensitivity and specificity of the assay for diagnosis of SBP were 95.5% and 97%, respectively. The area under the receiver operating characteristic curve was 0.98. AFLAC can serve as a sensitive and specific test for diagnosis of SBP. Qualitative bedside assays for the measurement of AFLAC can be developed easily and may serve as a rapid and reliable screening tool for SBP in patients with cirrhosis.

Does This Patient Have Bacterial Peritonitis or Portal Hypertension? How Do I Perform a Paracentesis and Analyze the Results?

Abdominal paracenteses are performed in patients with ascites, most commonly to assess for infection or portal hypertension and to manage refractory ascites. To systematically review evidence for paracentesis methods that may decrease risk of adverse events or improve diagnostic yield and to determine the accuracy of ascitic fluid analysis for spontaneous bacterial peritonitis or portal hypertension. Relevant English-language studies from Medline (1966-April 2007) and EMBASE (1980-April 2007). Paracentesis studies evaluating interventions (use of preprocedure coagulation parameters, needle type, insertion location, ultrasound guidance, bedside inoculation into blood culture bottles, and use of plasma expanders in therapeutic taps) for reducing adverse events or improving the diagnostic yield, and studies assessing the accuracy of ascitic fluid biochemical analyses for spontaneous bacterial peritonitis or portal hypertension. For technique studies, data on intervention and outcome; and for diagnostic studies, data on parameters for diagnosing spontaneous bacterial peritonitis and portal hypertension (ie, ascitic fluid white blood cell and polymorphonuclear leukocyte [PMN] count, ascitic fluid pH, blood-ascitic fluid pH gradient, and serum-ascites albumin gradient). Thirty-seven studies met inclusion criteria: 2 showed that obtaining preprocedure coagulation was likely unnecessary prior to paracentesis; 1 showed the 15-gauge, 3.25-inch needle-cannula results in less multiple peritoneal punctures [P = .05] and termination due to poor fluid return [P = .02] vs a 14-gauge needle in therapeutic paracentesis; 1 showed immediate inoculation of culture bottles improves diagnostic yield vs delayed (from 77% to 100% [95% CI for the difference, 5.3%-40.0%]); 9 evaluated therapeutic paracentesis, performed with or without albumin or nonalbumin plasma expanders, and found no consistent effect on morbidity or mortality; 16 showed the accuracy of biochemical analysis of ascitic fluid in patients suspected of having spontaneous bacterial peritonitis to increase the likelihood of spontaneous bacterial peritonitis (PMN count >250 cells/microL [summary likelihood ratio {LR}, 6.4] 95% CI, 4.6-8.8; ascitic fluid leukocyte count >1000 cells/microL [summary LR, 9.1] 95% CI, 5.5-15.1; pH < 7.35 [summary LR, 9.0] 95% CI, 2.0-40.6; or a blood-ascitic fluid pH gradient > or = 0.10 [LR, 11.3] 95% CI, 4.3-29.9) and other levels lowered the likelihood (PMN count < or = 250 cells/microL [summary LR, 0.2] 95% CI, 0.11-0.37; or a blood-ascitic fluid pH gradient < 0.10 [summary LR, 0.12] 95% CI, 0.02-0.77); and 4 showed the diagnostic accuracy of the serum-ascites albumin gradient lowers the likelihood of portal hypertension (< 1.1 g/dL [summary LR, 0.06] 95% CI, 0.02-0.20). Ascitic fluid should be inoculated into blood culture bottles at the bedside. Spontaneous bacterial peritonitis is more likely at predescribed parameters of ascitic PMN count or blood-ascitic fluid pH, and portal hypertension is less likely below a predescribed serum-ascites albumin gradient.

Tuberculous peritonitis in children: Report of nine patients and review of the literature

To present our experience with tuberculous peritonitis treated in our hospital from 2002-2007. We reviewed the medical records of 9 children with tuberculous peritonitis. Nine patients (5 boys, 4 girls) of mean age 14.2 years were diagnosed with peritoneal tuberculosis. All patients presented with abdominal distention. Abdominal pain was seen in 55.5% and fever in 44.4% of the patients. Four cases had coexisting pleural effusion and two had pulmonary tuberculosis with parenchymal consolidation. Ultrasonography found ascites with septation in 7 patients. Two patients had only ascites without septation. Ascitic fluid analysis of 8 patients yielded serum-ascite albumin gradients of less than 1.1 gr/dL. Laparoscopy and laparotomy showed that whitish tuberculi were the most common appearance. Adhesions were also seen in three cases. The diagnosis of peritoneal tuberculosis was confirmed histo-pathologically in 7 patients and microbiologically in two. Two patients had been diagnosed by ascitic fluid diagnostic features and a positive response to antituberculous treatment. All patients completed the antituberculous therapy without any complications. Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain. Laparoscopy and peritoneal biopsy are still the most reliable, quick and safe methods for the diagnosis of tuberculous peritonitis.

Graves' Disease with Intractable Diarrhea, Chylous Ascites, and Chylothorax: A Case Report

A 50-year-old woman was admitted to our hospital because of severe diarrhea, irritableness, and severe pitting edema of the legs. The patient had been well until 5 years before admission, when a tremor and tachycardia developed and a diagnosis of Graves' disease was made. Treatment with methimazole was effective in reducing her tremor and tachycardia; however, she was often nonadherent with her antithyroid medication because of improvement of her symptoms. On admission, a thyroid swelling, exophthalmos, a pleural effusion, and ascites were observed. The results of thyroid function tests (free triiodothyronine: 21.5 pg/mL; free thyroxine: 7.17 ng/dL; thyroid-stimulating hormone (TSH): <0.01 microIU/mL; TSH receptor antibodies: 95.9%) were consistent with Graves' disease. Biochemical analysis of pleural and ascitic fluid was consistent with chylothorax and chylous ascites, respectively. Serum calcium, total protein, and albumin were very low. Her symptoms and signs except severe diarrhea, edema, pleural effusion, and ascites disappeared after receiving intravenous drip infusion of fluid replacement, and methimazole and iodine. Because of malnutrition, she was given a high-calorie intravenous infusion. Three months after admission, her pleural effusion and ascites began to improve, as did her diarrhea and hypoalbuminemia. An appropriate treatment of Graves' disease is crucial to avoid serious sequelae of longstanding, poorly controlled hyperthyroidism.

Spontaneous bacterial peritonitis and reagent strips

I read with interest the article by Nousbaum et al.1 about the diagnostic accuracy of the Multistix 8 SG reagent strip (Bayer HealthCare) for the diagnosis of spontaneous bacterial peritonitis (SBP). A test sensitivity of 45.3% is disappointing for an infectious complication with a still high mortality. The test was read by an investigator and a nurse; when there was discordance between the 2 readers, the highest value was registered. If we need to increase the sensitivity, it may be better to register the lowest value because the majority of the patients were free of SBP. Because concordance was good but not perfect, to recalculate statistics in this other way may substantially change the sensitivity and specificity. It would be interesting to know the sensitivity and specificity found in the study if a different cutoff were considered. In our study using Aution sticks (Menarini Diagnostics),2 the sensitivity increased to 89%-96% when the cutoff passed from ≥3 to ≥2 on a scale of 0-4, with only a slight decrease in specificity. Contrary to what the authors state in their discussion, only patients with cirrhosis were included in our study, and in only 1 of 228 cases did the patient have peritoneal carcinomatosis, but it was correctly classified by the reagent strip as a true negative. In 2 of 3 studies comparing Multistix with other reagent strips,1 the sensitivity was clearly lower with Multistix. We can conclude that Multistix is not enough sensitive and may be not used to diagnose SBP. Results with other strips are encouraging, although every dipstick should be tested and compared with others before its use is recommended. I agree with the authors that reagent strips should not systematically replace standard fluid analyses. However, they can be very useful when analyses are not quickly available or are unavailable. A clearly positive test is highly indicative of SBP and is an indication of antibiotic therapy; a clearly negative test excludes SBP with confidence because the negative predictive value has ranged from 96%-100% in all the studies reported until now. In those cases with intermediate results, a conventional polymorphonuclear leukocyte count is mandatory if it is available, and if it is not, empirical antibiotic therapy should be initiated. Finally, Nousbaum et al.1 reported a low prevalence of SBP in asymptomatic outpatients (0.57%). To the best of our knowledge, 5 studies have prospectively studied SBP prevalence in outpatients with asymptomatic cirrhosis undergoing large-volume paracentesis.3-7 Only 1 of 834 cases was diagnosed with SBP. In view of this figure, I think that ascitic fluid analysis may be not necessary in this clinical context. Jose Castellote*, * Servicio de Aparato Digestivo, IDIBELL—Hospital Universitario de Bellvitge, Barcelona, Spain.