Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax

Abstract

Background and study aims: Spontaneous bacterial empyema (SBEM) is an underestimated condition in patients with ascites and hepatic hydrothorax with a high mortality. This study aimed to find whether spontaneous bacterial peritonitis (SBP) is a prerequisite for SBEM.

Patients and methods: 3000 HCV-related cirrhotic patients with ascites and hydrothorax were screened for the presence of SBP (ascitic fluid neutrophils >250/mm³) and SBEM (positive pleural fluid culture and neutrophils >250/mm³ or negative pleural fluid culture and neutrophils >500/mm³ with no evidence of pneumonia/parapneumonic effusion on chest radiograph or CT).

Results: The prevalence of SBEM in cirrhotic patients was 1.2% (36/3000) unlike SBP (1.6%; 48/3000). SBEM was detected in 51.4% of the patients with hepatic hydrothorax (36/70). A total of 70 patients had concomitant ascites and hydrothorax, namely SBP (n=17), SBEM (n=5), and dual SBP and SBEM (n=31), whereas 17 patients had sterile concomitant ascites and hydrothorax. Age, sex, liver function, kidney function tests, complete blood count, INR, MELD, MELD-Na, blood chemistry, and culture/sensitivity for ascitic and pleural fluid were statistically not different (p>0.05) between SBP and dual SBP and SBEM patients. Escherichia coli and Klebsiella pneumoniae were detected in the culture. From univariate analysis, no predictors of dual SBP and SBEM were detected.

Conclusion: SBEM is a part of SBP in cirrhotic patients with ascites and hydrothorax.

Keywords: Ascites; Cirrhosis; Hydrothorax; Spontaneous bacterial empyema; Spontaneous bacterial peritonitis.