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