Bacterial peritonitis in hepatic inferior vena cava disease: a hypothesis to explain the cause of infection in high protein ascites.

Hepatic IVC disease (HVD), a disease caused by complete obstruction or stenosis of inferior vena cava (IVC) near cava-atrial junction is endemic in Nepal. It is a chronic disease characterized by upper abdominal pain, hepatomegaly, splenomegaly and dilated superficial veins in the body trunk. Ascites commonly, with high protein content is a feature of acute and subacute stages and during acute exacerbation of the chronic disease. We assessed the occurrence of bacterial peritonitis among patients of HVD with ascites. One hundred and sixty seven consecutive patients with ascites, which included 91 patients with HVD were examined for the presence of bacterial peritonitis. The ascitic fluids were examined for total and differential WBC count. The fluid and the blood were cultured for aerobic microorganisms by bedside inoculation in blood culture bottles. HVD is a common cause of non-cirrhotic high protein content ascites in Nepal. It was uniquely associated with high incidence of bacteremia (61%) and high incidence of mono-bacterial peritonitis (67%) from Gram-negative enteric bacteria (58.5%) and Staphylococcus aureus (42.5%). Ascites and bacterial peritonitis generally occurred almost simultaneously in these patients. It is postulated that when bacteremia occurred the defective portion of IVC near the cava-atrial junction become infected resulting in hepatic venous outflow obstruction and formation of ascites with high protein content. And spread of infection from the infected IVC to the peritoneum resulted in bacterial peritonitis.