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; (3) no antibiotics have been given; and (4) there is no other ex- planation for the elevated PMNL count (e.g., hemorrhage into ascites, peritoneal carcinomatosis, tuberculosis, or pan- creatitis) (2). Cultures are negative in »30-50 % of cirrhotic patients with an elevated ascites PMNL count (3). Because CNNA is diagnosed partly by exclusion, appropriate tests should be performed, such as an ascitic fluid amylase test or a determination of adenosine deaminase (ADA) activ- ity—neither of which were mentioned by Cone and Leung in their report. ADA determination has been shown to be a highly sensitive and specific test in countries with a high incidence of tuberculosis and in high-risk patients (4) such as Cone and Leung's. Although poor sensitivity has been reported in the United States (5), especially in cirrhotic pa- tients, it has been shown to have good accuracy and spec- ificity elsewhere; therefore, an abnormal result strongly sug-

Peritoneal Biopsy Is Not Needed to Diagnose Culture-Negative Spontaneous Bacterial Peritonitis