Comment on 'Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites'.

First, I would like to congratulate the authors, Huang LL, Xia HH and Zhu SL, on the overall great work done in preparing the review article ‘Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites’.1 However, there seems to be an error in the description of diagnosis of spontaneous bacterial peritonitis (SBP). The authors state “SBP is defined by the presence of neutrophil cells greater than or equal to 250/mL or a positive bacterial culture in the ascitic fluid without evidence of an abdominal source.” The issue here is the fact that the authors make the presence of neutrophil cells greater than or equal to 250/mL for diagnoses of SBP an option (by using the conjunction term ‘or’) and not a condition, whereas it is proven by evidence in the literature that it is a prerequisite.2–4

We are very grateful to Dr. Ahmed for carefully reading our article and kindly providing comments. In response to Dr. Ahmed’s question regarding the definition of SBP, we searched and read the relevant literature again. Besides reference 81 in our article, reference 53,2 which provides clinical practice guidelines of the European Association for the Study of the Liver, states “Patients with an ascitic fluid neutrophil count ≥ 250 cells/mm3 and negative culture have culture-negative SBP”. Also, the literature listed below3–5 agree that SBP is defined by the presence of ascitic fluid with neutrophil cells greater than 250/mm3. Thus, based on the literature cited above, the presence of neutrophil cells greater than or equal to 250/mL alone can establish the diagnosis of SBP. Therefore, we agree with Dr. Ahmed that the presence of neutrophil cells greater than or equal to 250/mL is a prerequisite, not an option, and the sentence should be corrected as “SBP is defined by the presence of neutrophil cells greater than or equal to 250/mL without evidence of an abdominal source, and with or without a positive bacterial culture in the ascitic fluid”.