title: Diagnosis of spontaneous bacterial peritonitis in infants and children with chronic liver disease: A cohort study.
abstract: BACKGROUND
  Spontaneous 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.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  Patients 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).
  
  
  CONCLUSIONS
  SBP 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.
authors: Pediatric Department, Faculty of Medicine, Cairo University, Cairo, Postcode 12411, Egypt. melshabrawi@medicine.cu.edu.eg
authors: Mortada H F
authors: MH
authors: El-Shabrawi
authors: Ola
authors: O
authors: El-Sisi
authors: Sawsan
authors: S
authors: Okasha
authors: Mona
authors: M
authors: Isa
authors: Sayed Abou
authors: SA
authors: Elmakarem
authors: Iman
authors: I
authors: Eyada
authors: Zainab
authors: Z
authors: Abdel-Latif
authors: Gamal
authors: G
authors: El-Batran
authors: Naglaa
authors: N
authors: Kamal
references: Gastroenterol Clin Biol. 2005 Mar;29(3):275-9
references: 15864178
references: South Med J. 2002 Oct;95(10):1158-62
references: 12425501
references: World J Gastroenterol. 2006 Sep 28;12(36):5890-2
references: 17007059
references: Pediatr Transplant. 2007 Feb;11(1):21-3
references: 17239119
references: Gut. 1985 Apr;26(4):325-31
references: 3884467
references: BMJ. 2000 Aug 12;321(7258):442-5
references: 10938059
references: Dis Mon. 1985 Sep;31(9):1-48
references: 3899555
references: J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):289-94
references: 15735482
references: Am J Gastroenterol. 1999 Oct;94(10):2972-6
references: 10520854
references: J Hepatol. 2000 Jan;32(1):142-53
references: 10673079
references: Gastroenterology. 1993 Apr;104(4):1133-8
references: 8462803
references: Am J Gastroenterol. 2001 Apr;96(4):1232-6
references: 11316175
references: Med Clin North Am. 1975 Jul;59(4):963-81
references: 1095846
references: Am J Gastroenterol. 2007 Jul;102(7):1510-7
references: 17509025
references: Scand J Gastroenterol Suppl. 2006;(243):79-84
references: 16782626
references: Kathmandu Univ Med J (KUMJ). 2007 Jan-Mar;5(1):48-59
references: 18603986
references: World J Gastroenterol. 2009 Nov 28;15(44):5505-10
references: 19938187
references: Przegl Epidemiol. 2004;58(4):597-607
references: 15810501
references: BMC Infect Dis. 2009 Apr 12;9:41
references: 19361340
references: Eur J Gastroenterol Hepatol. 2004 Jun;16(6):571-7
references: 15167159
references: J Hepatol. 2004 Sep;41(3):384-90
references: 15336440
references: J Gastroenterol Hepatol. 2007 Feb;22(2):177-81
references: 17295868
references: JAMA. 2008 Mar 12;299(10):1166-78
references: 18334692
references: Hepatology. 2003 Apr;37(4):897-901
references: 12668984