Elsevier

Journal of Hepatology

Volume 52, Issue 1, January 2010, Pages 39-44
Journal of Hepatology

Research Article
Secondary bacterial peritonitis in cirrhosis: A retrospective study of clinical and analytical characteristics, diagnosis and management

https://doi.org/10.1016/j.jhep.2009.10.012Get rights and content

Background & Aims

Secondary bacterial peritonitis in cirrhotic patients is an uncommon entity that has been little reported. Our aim is to analyse the frequency, clinical characteristics, treatment and prognosis of patients with secondary peritonitis in comparison to those of patients with spontaneous bacterial peritonitis (SBP).

Methods

Retrospective analysis of 24 cirrhotic patients with secondary peritonitis compared with 106 SBP episodes.

Results

Secondary peritonitis represented 4.5% of all peritonitis in cirrhotic patients. Patients with secondary peritonitis showed a significantly more severe local inflammatory response than patients with SBP. Considering diagnosis of secondary peritonitis, the sensitivity of Runyon’s criteria was 66.6% and specificity 89.7%, Runyon’s criteria and/or polymicrobial ascitic fluid culture were present in 95.6%, and abdominal computed tomography was diagnostic in 85% of patients in whom diagnosis was confirmed by surgery or autopsy. Mortality during hospitalization was higher in patients with secondary peritonitis than in those with SBP (16/24, 66.6% vs. 28/106, 26.4%) (p < 0.001). There was a trend to lower mortality in secondary peritonitis patients who underwent surgery (7/13, 53.8%) than in those who received medical treatment only (9/11, 81.8%) (p = 0.21). Considering surgically treated patients, the time between diagnostic paracentesis and surgery was shorter in survivors than in non-survivors (3.2 ± 2.4 vs. 7.2 ± 6.1 days, p = 0.31).

Conclusions

Secondary peritonitis is an infrequent complication in cirrhotic patients but mortality is high. A low threshold of suspicion on the basis of Runyon’s criteria and microbiological data, together with an aggressive approach that includes prompt abdominal computed tomography and early surgical evaluation, could improve prognosis in these patients.

Introduction

Spontaneous bacterial peritonitis (SBP) is a frequent complication in cirrhotic patients with ascites and morbidity and mortality remain significantly high even though advances in the management of this complication have improved survival in recent years [1], [2], [3], [4], [5], [6], [7].

In contrast with SBP, secondary bacterial peritonitis consists of ascitic fluid bacterial infection due to an intraabdominal infectious source such as gastrointestinal tract perforation or abscess [8], [9], [10], [11], [12], [13]. In cirrhotic patients, secondary peritonitis is much less frequent than SBP and therefore much less reported [5], [8], [9], [10], [11], [12], [13], [14]. There are two main concerns in secondary peritonitis. The first is the differential diagnosis with SBP [8], [9], [10], [12], [13] as surgical treatment should be considered in secondary peritonitis but never in SBP [2], [9], [15], [16] and furthermore, an unnecessary laparotomy carries a high risk of mortality in cirrhotic patients [17]. Consequently, highly sensitive and specific diagnostic criteria are needed [9], [10], [16]. The second major concern is the high mortality rate, reported to range from 50% [9] to 80% [8], [13].

It should also be pointed out that most articles on secondary peritonitis were published two decades ago [8], [9], [10], [11], [12], [13]. In recent years, besides the improvement in the general management of cirrhotic patients, abdominal computed tomography (CT) [15] with the possibility of percutaneous drainage of abscesses [18] has become common practice, and more effective antibiotics are available [19]. It is therefore of interest to examine the mortality of cirrhotic patients with secondary peritonitis in recent years, and determine which patients could benefit from surgery.

The objectives of the present study were to: (1) analyze the frequency of secondary peritonitis among cirrhotic patients with peritonitis, (2) describe the clinical and analytical characteristics, treatment and prognosis of cirrhotic patients with secondary peritonitis in comparison with patients with SBP, (3) evaluate the accuracy of ascitic fluid analysis and abdominal CT in the diagnosis of secondary peritonitis, and (4) analyze which patients could benefit from surgery.

Section snippets

Patients and methods

We retrospectively analyzed all cirrhotic patients with ascites who presented secondary bacterial peritonitis between January 2000 and December 2007 at two university hospitals in Barcelona, Spain: Hospital Universitari de Bellvitge and Hospital de la Santa Creu i Sant Pau. Secondary bacterial peritonitis was diagnosed when patients fulfilled the three following criteria: ascitic fluid neutrophil count was ⩾250/mm3, a positive ascitic fluid culture, and evidence of an intraabdominal source of

Results

Between January 2000 and December 2007, 24 cirrhotic patients fulfilled the diagnostic criteria for secondary bacterial peritonitis in the two hospitals: 14 were diagnosed at Hospital de Bellvitge and 10 at Hospital de la Santa Creu i Sant Pau. In addition, a total of 124 episodes of SBP were diagnosed in 108 cirrhotic patients between January 2001 and December 2004 in the Hospital de la Santa Creu i Sant Pau. From these 124 SBP episodes, 18 were excluded because: (1) parameters to calculate

Discussion

The true incidence of secondary peritonitis in cirrhotic patients is not well known, although it has been suggested to represent approximately 10% of all peritonitis in this setting [5], [8], [14]. The present study included 24 patients, the largest series of cirrhotic patients with secondary bacterial peritonitis reported until now, and we confirm the rarity of this complication as it represented 4.5% of all peritonitis in cirrhotic patients with ascites. We could have underestimated the

Acknowledgements

The authors who have taken part in this study declared that they do not have anything to disclose regarding funding from industries or conflict of interest with respect to this manuscript.

We thank Carolyn Newey for English language revision and Ignasi Gich from Clinical Epidemiology Department of Hospital de la Santa Creu i Sant Pau for assistance with statistical analysis.

References (29)

  • J. Ortiz et al.

    Early microbiologic diagnosis of spontaneous bacterial peritonitis with BacT/ALERT

    J Hepatol

    (1997)
  • P. Tandon et al.

    Bacterial infections, sepsis, and multiorgan failure in cirrhosis

    Semin Liver Dis

    (2008)
  • C. Guarner et al.

    Spontaneous bacterial peritonitis

    Semin Liver Dis

    (1997)
  • F. Wong et al.

    Sepsis in cirrhosis: report on the 7th meeting of the International Ascites Club

    Gut

    (2005)
  • Cited by (80)

    • Infections in Cirrhosis: A Guide for the Clinician

      2021, American Journal of Medicine
    • Outcomes of pancreatoduodenectomy in the cirrhotic patient: risk stratification and meta-analysis

      2019, HPB
      Citation Excerpt :

      Contemporary practice has seen major advances in perioperative care and an improved understanding of liver disease. Nevertheless, contemporary series of patients with cirrhosis undergoing general surgical procedures reveal persistently poor outcomes even in patients undergoing relatively simple operations such as inguinal or ventral hernia repair.4–12 Despite improvements in mortality associated with, the morbidity of pancreatoduodenectomy remains high, in the order of 50–60%.

    View all citing articles on Scopus
    View full text