Extravascular body fluids (EBF) analysis can provide useful information in the differential diagnosis of conditions that caused their accumulation. Their unique nature and particular requirements accompanying EBF analysis need to be recognized in order to minimize possible negative implications on patient safety. This recommendation was prepared by the members of the Working group for extravascular body fluid samples (WG EBFS). It is designed to address the total testing process and clinical significance of tests used in EBF analysis. The recommendation begins with a chapter addressing validation of methods used in EBF analysis, and continues with specific recommendations for serous fluids analysis. It is organized in sections referring to the preanalytical, analytical and postanalytical phase with specific recommendations presented in boxes. Its main goal is to assist in the attainment of national harmonization of serous fluid analysis and ultimately improve patient safety and healthcare outcomes. This recommendation is intended to all laboratory professionals performing EBF analysis and healthcare professionals involved in EBF collection and processing. Cytological and microbiological evaluations of EBF are beyond the scope of this document.

• ascites
• harmonization
• pericardial effusion
• pleural effusion

Spontaneous bacterial peritonitis (SBP) is a common and important clinical problem and is life-threatening in decompensated liver disease. Ascites fluid test by leukocyte esterase test strip has been recently proposed as an effective and rapid method to diagnose SBP in patients with cirrhosis.

This study aimed to evaluate sensitivity and specificity of leukocyte esterase test strip in the diagnosis of SBP.

The population of this research was all patients with cirrhosis and ascites admitted to the emergency room at Imam Reza (AS) hospital, Mashhad. A written consent was taken for inclusion in the study. 50 mL ascites sample was taken from all patients for use in a urine test strip (LER) (Urine Test Strips Convergys®Urine Matrix 11). The patient’s ascites samples were evaluated for cell counting. Positive dipstick test for LER in this study considered as grade 3 +. The values of WBC > 500 cell/mm³ or PMN > 250 cell/mm³ considered as positive result of the gold standard method for the diagnosis of SBP.

In this study, 100 patients with ascites due to cirrhosis, with an average age of 38.9 ± 6.54 years were evaluated. Twenty cases had positive results, of whom 17 cases were also detected based on the standard diagnostic criteria and other three cases were healthy individuals. Thus, sensitivity, specificity, positive and negative predictive values, and accuracy of the method were 95%, 96.3%, 85%, 97.5% and 95%, respectively.

The use of leukocyte esterase urine dipstick test can be a quick and easy method in early diagnosis of SBP to start the treatment until preparation of SBP-cell count results.

• Leukocyte Esterase Reagent Strip
• Liver Cirrhosis
• Spontaneous Bacterial Peritonitis

• Ascites/complications
• Ascites/microbiology
• Ascitic Fluid
• Bacterial Infections/microbiology
• Carboxylic Ester Hydrolases
• Cross-Sectional Studies
• Female
• Humans
• Liver Cirrhosis/complications
• Male
• Peritonitis/diagnosis
• Peritonitis/etiology
• Peritonitis/microbiology
• Reagent Strips
• Sensitivity and Specificity

• Bacterial
• diagnosis
• esterases
• leukocytes
• leukocytes esterases
• peritonitis
• reagent strips.

• pericardial effusion
• peritoneal effusion
• pleural effusion

AIM: To evaluate the diagnostic capability of calprotectin in ascitic fluid for detecting a polymorphonuclear (PMN) cell count > 250/μL ascites.

METHODS: In this prospective observational study, a total of 130 ascites samples were analysed from 71 consecutive patients referred for paracentesis. Total and differential leukocyte cell counts were determined manually with a Neubauer chamber and gentian-violet stain. Calprotectin was measured in 1 mL ascetic fluid by enzyme-linked immunosorbent assay (ELISA) and a point-of-care (POC) lateral flow assay with the Quantum Blue^® Reader (Bühlmann Laboratories). All measurements were carried out in a central laboratory by senior personnel blinded to patient history. A PMN count > 250/μL was the primary endpoint of the study. The diagnostic value of ascitic calprotectin measurement was assessed by comparing to the final diagnosis of each patient that had been adjudicated by investigators blinded to calprotectin values.

RESULTS: The PMN count was > 250/μL in 19 samples (14.6%) from 15 patients (21.1%) and varied widely among the study population (range 10-19 800/mL and 1-17 820/mL, respectively). Spontaneous bacterial peritonitis (SBP) was the final diagnosis in four patients (5.6%). All patients with PMN ≤ 250/μL had negative bacterial culture. PMN count was elevated in five patients with peritoneal carcinomatosis, three with lymphoma, one with neuroendocrine carcinoma, and two with secondary peritonitis due to abdominal perforation. PMN cell counts correlated with ascitic calprotectin values (Spearman’s rho; r = 0.457 for ELISA, r = 0.473 for POC). A considerable range of ascitic calprotectin concentrations was detected by ELISA [median 0.43 μg/mL, interquartile range (IQR) 0.23-1.23 (range 0.10-14.93)] and POC [median 0.38 μg/mL, IQR 0.38-0.56 (range 0.38-13.31)]. Ascitic calprotectin levels were higher in samples with PMN > 250/μL, by both ELISA [median (IQR) 2.48 μg/mL (1.61-3.65) vs 0.10 μg/mL (0.10-0.36), P < 0.001] and POC [2.78 μg/mL (2.05-5.37) vs 0.38 μg/mL (0.38-0.41), P < 0.001]. The area under the receiver operating characteristics curve for identifying an elevated PMN count was 0.977 (95%CI: 0.933 to 0.995) for ELISA and 0.982 (95%CI: 0.942 to 0.997) for POC (P = 0.246 vs ELISA). Using the optimal cut-off value for ELISA (0.63 μg/mL), ascitic calprotectin had 94.8% sensitivity, 89.2% specificity, positive and negative likelihood ratios of 8.76 and 0.06 respectively, positive and negative predictive values of 60.0% and 99.0% respectively, and 90.0% overall accuracy. Using the optimal cut-off value for POC (0.51 μg/mL), the respective values were 100.0%, 84.7%, 6.53, 0.00, 52.8%, 100% and 87.7%. Correlation between ELISA and POC was excellent (r = 0.873, P < 0.001). The mean ± SD of the difference was -0.11 ± 0.48 μg/mL with limits of agreement of + 0.8 μg/mL (95%CI: 0.69 to 0.98) and -1.1 μg/mL (95%CI: -1.19 to -0.91).

CONCLUSION: Ascitic calprotectin reliably predicts PMN count > 250/μL, which may prove useful in the diagnosis of SBP, especially with a readily available bedside testing device.

• Calprotectin
• Ascites
• Liver cirrhosis
• Spontaneous bacterial peritonitis
• Polymorphonuclear cells

• Adult
• Aged
• Ascitic Fluid/metabolism
• Enzyme-Linked Immunosorbent Assay
• Female
• Humans
• Leukocyte Count
• Leukocyte L1 Antigen Complex/analysis
• Male
• Middle Aged
• Neutrophils/cytology
• Peritonitis/complications
• Peritonitis/diagnosis
• Point-of-Care Systems
• Predictive Value of Tests
• Prospective Studies
• ROC Curve
• Reproducibility of Results

• AF, ascitic fluid
• LERS, leukocyte esterase reagent strips
• Multistix 10 SG® reagent strips
• NPV, negative predictive values
• PMN, polymorphonuclear leukocyte
• PPV, positive predictive values
• SAAG, serum-ascites albumin gradient
• SBP, spontaneous bacterial peritonitis
• leukocyte esterase dipstick test
• spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of cirrhosis. It occurs in 10% to 30% of patients admitted to hospital and recent studies tend to demonstrate that SBP incidence seems to be decreasing in its frequency. A bacterial overgrowth with translocation through the increased permeable small intestinal wall and impaired defense mechanisms is considered to be the main mechanism associated with its occurrence. The Gram-negative aerobic bacteria are the major responsible for SBP episodes and Gram-positive bacteria, mainly Staphylococcus aureus, are being considered an emergent agent causing SBP. The prompt diagnosis of SBP is the key factor for reduction observed in mortality rates in recent years. The clinical diagnosis of SBP is neither sensitive nor specific and the search for new practical and available tools for a rapid diagnosis of SBP is an important endpoint of current studies. Reagent strips were considered a promising and faster way of SBP diagnosis. The prompt use of empirical antibiotics, mostly cefotaxime, improves significantly the short-term prognosis of cirrhotic patients with SBP. The recurrence rate of SBP is high and antibiotic prophylaxis has been recommended in high-risk settings. Unfortunately, the long-term prognosis remains poor.

• ascites
• cirrhosis
• diagnosis
• peritonitis
• treatment

Ascites remain the commonest complication of decompensated cirrhosis. Spontaneous bacterial peritonitis (SBP) is defined as the infection of ascitic fluid (AF) in the absence of a contiguous source of infection and/or an intra-abdominal inflammatory focus. An AF polymorphonuclear (PMN) leucocyte count ≥ 250/mm³ -irrespective of the AF culture result- is universally accepted nowadays as the best surrogate marker for diagnosing SBP. Frequently the results of the manual or automated PMN count do not reach the hands of the responsible medical personnel in a timely manner. However, this is a crucial step in SBP management. Since 2000, 26 studies (most of them published as full papers) have checked the validity of using leukocyte esterase reagent strips (LERS) in SBP diagnosis. LERS appear to have low sensitivity for SBP, some LERS types more than others. On the other hand, though, LERS have consistently given a high negative predictive value (> 95% in the majority of the studies) and this supports the use of LERS as a preliminary screening tool for SBP diagnosis. Finally, an AF-tailored dipstick has been developed. Within the proper setting, it is set to become the mainstream process for handling AF samples.

• Peritonitis
• Leukocytes
• Esterases
• Diagnosis
• Reagent strips
• Bacterial

• Ascitic Fluid/enzymology
• Bacterial Infections/diagnosis
• Bacterial Infections/enzymology
• Bacterial Infections/etiology
• Carboxylic Ester Hydrolases/analysis
• False Positive Reactions
• Female
• Humans
• Hypertension, Portal/complications
• Liver Cirrhosis/complications
• Male
• Middle Aged
• Neutrophils/enzymology
• Peritonitis/diagnosis
• Peritonitis/enzymology
• Peritonitis/etiology
• Point-of-Care Systems/statistics & numerical data
• Reagent Strips
• Sensitivity and Specificity

• Aged
• Automation, Laboratory
• Colony Count, Microbial
• False Negative Reactions
• Female
• Humans
• Male
• Middle Aged
• Paracentesis
• Peritonitis/diagnosis
• Peritonitis/microbiology
• Predictive Value of Tests
• Prospective Studies
• Reagent Strips
• Reproducibility of Results
• Sensitivity and Specificity
• Thailand

• Ascites/etiology
• Esophageal and Gastric Varices/etiology
• Gastrointestinal Hemorrhage/etiology
• Hepatic Encephalopathy/etiology
• Hepatorenal Syndrome/etiology
• Humans
• Hypertension, Portal/etiology
• Korea/epidemiology
• Liver Cirrhosis/complications
• Liver Cirrhosis/epidemiology
• Liver Cirrhosis/therapy
• Peritonitis/etiology
• Prognosis
• Risk Factors

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.

• Ascites
• Ascitic fluid lactoferrin
• Automated blood cell counter
• Paracentesis
• Polymorphonuclear cell count
• Urinary reagent strips

AIM: To evaluate the accuracy of automated blood cell counters for ascitic polymorphonuclear (PMN) determination for: (1) diagnosis, (2) efficacy of the ongoing antibiotic therapy, and (3) resolution of spontaneous bacterial peritonitis (SBP).

METHODS: One hundred and twelve ascitic fluid samples were collected from 52 consecutive cirrhotic patients, 16 of them with SBP. The agreement between the manual and the automated method for PMN count was assessed. The sensitivity/specificity and the positive/negative predictive value of the automated blood cell counter were also calculated by considering the manual method as the “gold standard”.

RESULTS: The mean ± SD of the difference between manual and automated measurements was 7.8 ± 58 cells/mm³, while the limits of agreement were +124 cells/mm³ [95% confidence interval (CI): +145 to +103] and -108 cells/mm³ (95% CI: -87 to -129). The automated cell counter had a sensitivity of 100% and a specificity of 97.7% in diagnosing SBP, and a sensitivity of 91% and a specificity of 100% for the efficacy of the ongoing antibiotic therapy. The two methods showed a complete agreement for the resolution of infection.

CONCLUSION: Automated cell counters not only have a good diagnostic accuracy, but are also very effective in monitoring the antibiotic treatment in patients with SBP. Because of their quicker performance, they should replace the manual counting for PMN determination in the ascitic fluid of patients with SBP.

• Spontaneous bacterial peritonitis
• Ascites
• Polymorphonuclear cell count
• Automated cell counter
• Paracentesis
• Cirrhosis

• Albumins/therapeutic use
• Anti-Bacterial Agents/therapeutic use
• Bacterial Infections/diagnosis
• Bacterial Infections/etiology
• Bacterial Infections/therapy
• Humans
• Peritonitis/diagnosis
• Peritonitis/etiology
• Peritonitis/microbiology
• Peritonitis/therapy

• Aged
• Ascites/etiology
• Ascites/microbiology
• Ascitic Fluid/chemistry
• Bacterial Infections/complications
• Bacterial Infections/diagnosis
• Carboxylic Ester Hydrolases/analysis
• Clinical Enzyme Tests/methods
• Female
• Humans
• Leukocyte Count
• Liver Cirrhosis/complications
• Liver Cirrhosis/microbiology
• Male
• Middle Aged
• Neutrophils
• Paracentesis
• Peritonitis/complications
• Peritonitis/diagnosis
• Pilot Projects
• Point-of-Care Systems/statistics & numerical data
• Prospective Studies
• Reagent Kits, Diagnostic
• Sensitivity and Specificity
• Spectrophotometry/instrumentation
• Spectrophotometry/methods

• Anti-Bacterial Agents/therapeutic use
• Bacterial Infections/complications
• Bacterial Infections/prevention & control
• Bacterial Infections/therapy
• Humans
• Liver Cirrhosis/complications
• Peritonitis/diagnosis
• Peritonitis/microbiology
• Peritonitis/therapy
• Quinolones/therapeutic use

AIM: To evaluate the efficacy of dipstick test in diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients who underwent abdominal paracentesis based on the locally available dipstick test.

METHODS: There were 200 consecutive samples from cirrhotic patients who underwent abdominal paracentesis. Urine dipstick (Combur¹⁰ Test^®M, Roche, Mannheim, Germany) was used as a screening test. A manual cell count with differential study was done in all samples by experienced technicians. The polymorphonuclear (PMN) cell count more than 250 cells/mm³ was used as a diagnostic cut off level. One to three plus dipstick results were used as cut off levels for a positive result. The dipstick test results had to be agreed by three experienced readers. The sensitivity, specificity, positive and negative predictive values and accuracy of two different colorimetric cut off scales (1+ and 2+) were calculated and compared.

RESULTS: The prevalence of SBP diagnosed by manual cell count was 21.0%. There were 128 specimens that had a true negative result by dipstick. The sensitivity, specificity, positive and negative predictive values and accuracy of 1+ and 2+ cut off scale to diagnose SBP were 88%, 81%, 55%, 96% and 83% respectively, and 63%, 96%, 82%, 81% and 89% respectively.

CONCLUSION: Dipstick test can be used as a rapid test for screening of SBP. The higher cut off colorimetric scale has a better specificity and positive predictive value but a lower sensitivity.

• Spontaneous bacterial peritonitis
• Diagnosis
• Dipstick
• Screening

• Adult
• Aged
• Bacterial Infections/diagnosis
• Carboxylic Ester Hydrolases/urine
• Clinical Enzyme Tests
• Female
• Humans
• Liver Cirrhosis/complications
• Male
• Middle Aged
• Paracentesis
• Peritonitis/diagnosis
• Reagent Strips