Efficacy of vitamin D adjuvant therapy for prevention of spontaneous bacterial peritonitis in patients with decompensated cirrhosis of hepatitis B / 中华临床感染病杂志

Objective:To evaluate the efficacy of vitamin D supplementation for prevention of spontaneous bacterial peritonitis (SBP) in patients with decompensated liver cirrhosis of hepatitis B.Methods:A total of 172 patients with decompensated cirrhosis of hepatitis B admitted in Jinhua Hospital affiliated to Zhejiang University School of Medicine from January to December 2021 were randomly divided into two groups with 86 cases in each group. Patients in both groups received conventional antiviral and symptomatic treatment; while patients in the intervention group received additinal oral vitamin D drops (800 IU/d) for 6 months. After 6 months of treatment, the incidence of SBP and the serum biochemical indexes were compared between two groups. SPSS 21.0 statistical software was used for data analysis.Results:After 6 months of treatment, the incidence of SBP in the intervention group(5.81%, 5/86) was significantly lower than that in control group(30.23%, 26/86)( χ2=19.210, P<0.01). The serum 25-(OH)D level in intervention group was significantly higher than that in the control group ( t=13.425, P=0.018), while the levels of CRP, PCT and IL-6 in intervention group were significantly lower than those in control group ( t=17.312, 10.353 and 12.218, P<0.01 or <0.05). Conclusion:Vitamin D adjuvant therapy can increase serum 25-(OH)D level, decrease serum CRP, PCT and IL-6 levels, and effectively reduce the incidence of SBP in patients with decompensated cirrhosis of hepatitis B.

A Single Centre Experience of Spontaneous Bacterial Peritonitis in Ascites with Cirrhosis : A Record Based Observational Study

Spontaneous Bacterial Peritonitis (SBP) is one of the complicated infections in patients with cirrhosis and ascites which can be fatal if not diagnosed and treated. This is a record based observational study using the data of all patients admitted with established cirrhosis of liver with ascites. Aim of the study was to find out the incidence of SBP in cirrhosis patients and also to study the clinical profile of SBP. Thirty nine patients’ data were included in the study. Three patients had classic SBP, one patient had Culture Negative Neutrocytic Ascites (CNNA) and two had bacterascites. Patients were treated with injection cefotaxime (2 gm) 8hourly for 5 days and clinical and laboratory parameters were evaluated.

Insuficiência hepática crônica agudizada está independentemente associada com menor sobrevida em pacientes com peritonite bacteriana espontânea / Acute-on-chronic liver failure is independently associated with lower survival in patients with spontaneous bacterial peritonitis

ABSTRACT BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a decompensation of cirrhosis with an in-hospital mortality ranging from 20% to 40%. OBJECTIVE: The purpose of this study is to analyze if EASL-CLIF definition of acute-on-chronic liver failure (ACLF) is able to predict mortality in cirrhotic patients with SBP. METHODS: Historical cohort study conducted in a public tertiary care teaching hospital. Data from medical records from January 2009 to July 2016 were obtained by searching the hospital electronic database for samples of ascites collected in the period. Electronic and physical medical records were analyzed and patients were included if they were over 18-years old, with cirrhosis and an ascites fluid compatible with SBP: 69 patients were included. Liver-specific scores were calculated and Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis. RESULTS: All cause mortality was 44%, 56.5% and 74% for 28-, 90- and 365-day, respectively. The prevalence of ACLF was 58%. Of these, 65% grade 1, 17.5% grade 2 and 17.5% grade 3. In multivariate analysis, the use of proton-pump inhi­bitors, alanine transaminase lower than 40 U/L, hemoglobin higher than 9 g/dL, absence of ACLF and lower CLIF-SOFA and MELD scores were independently associated with higher survival for both 28- and 90-day interval. CONCLUSION: The presence of ACLF and higher CLIF-SOFA scores were independently associated with higher 28- and 90-day mortality in cirrhotic patients admitted due to SBP.

RESUMO CONTEXTO: A peritonite bacteriana espontânea (PBE) é uma descompensação da cirrose com uma mortalidade intra-hospitalar de 20% a 40%. OBJETIVO: O objetivo deste estudo é analisar se a definição de insuficiência hepática crônica agudizada (IHCA) como definido pelo consórcio EASL-CLIF é capaz de predizer mortalidade em pacientes cirróticos com PBE. MÉTODOS: Coorte histórica conduzida em um hospital de ensino público terciário. Foram obtidos dados de prontuários médicos de janeiro de 2009 até julho de 2016, buscando no banco de dados eletrônico do hospital por todas as amostras de ascite coletadas no período. Prontuários eletrônicos e físicos foram analisados e os pacientes com mais de 18 anos com cirrose e líquido de ascite compatível com PBE foram incluídos. Foram incluídos 69 pacientes. Escores específicos para o fígado foram calculados e a análise de sobrevida de Kaplan-Meier foi utilizada para a análise univariada, e uma abordagem progressiva para a regressão logística de Cox foi usada para a análise multivariada. RESULTADOS: A mortalidade por todas as causas foi 44%, 56,5% e 74% para 28-, 90- e 365-dias, respectivamente. A prevalência de IHCA foi de 58%. Desses, 65% grau 1, 17,5% grau 2 e 17,5% grau 3. Na análise multivariada, o uso de inibidores da bomba de prótons, alanina transaminase menor que 40 U/L, hemoglobina acima de 9 g/dL, ausência de IHCA e menores valores dos escores CLIF-SOFA e MELD foram independentemente associados com maior sobrevida para ambos intervalos de 28- e 90-dias. CONCLUSÃO: A presença de IHCA e maiores valores de CLIF-SOFA foram independentemente associados em maior mortalidade para pacientes cirróticos admitidos por PBE no intervalo de 28- e 90-dias.

Infecciones espontáneas en el paciente cirrótico: características clínicas y microbiológicas en una cohorte bi-institucional del Uruguay / Spontaneous infections in cirrhotic patients: clinical and microbiological characteristics in a bi-institutional cohort from Uruguay / Infecções espontâneas em pacientes cirróticos: características clínicas e microbiológicas em uma coorte biinstitucional do Uruguai

Resumen: Los pacientes cirróticos hospitalizados presentan una alta prevalencia de infecciones bacterianas. Entre ellas, las denominadas infecciones espontáneas del cirrótico, que incluyen la peritonitis bacteriana espontánea, la bacteriemia espontánea y el empiema bacteriano espontáneo, constituyen un grupo particular, con un elevado riesgo de complicaciones y mortalidad. El presente trabajo tiene como objetivo describir y caracterizar las infecciones espontáneas en el cirrótico, la microbiología prevalente y su perfil de resistencia antibiótica, en 2 centros asistenciales de Montevideo-Uruguay. Se realizó un estudio transversal, descriptivo y multicéntrico, que incluyó pacientes con cirrosis hepática hospitalizados, en el periodo marzo 2018-marzo 2019. Del total de pacientes ingresados con cirrosis (156), 25 (16%) desarrollaron una infección espontánea del cirrótico. En 24 de estos pacientes (96%) la cirrosis se encontraba en estadios avanzados (Child-Pugh B-C, MELD＞15). La forma de presentación más frecuente fue la peritonitis bacteriana espontánea (52%), seguida de la bacteriemia espontánea (40%) y del empiema bacteriano espontáneo (8%). El aislamiento microbiológico fue posible en 17 casos (68%). En 12 de ellos (70%) se aislaron bacilos Gram negativos, en 4 (24%) bacilos Gram positivos, y Candida en 1 solo caso. Se identificaron 3 cepas productoras de BLEE (2 K. pneumoniae y 1 E. coli), y 4 microorganismos con otros perfiles de resistencia antibiótica (2 E. faecalis, 1 K. oxytoca, 1 E. cloacae). La prevalencia de microorganismos multirresistentes fue del 41%, siendo todos los casos en el grupo de adquisición nosocomial. La realización de otros estudios en esta área podría aproximarnos al conocimiento de la epidemiología local, para la optimización de los tratamientos empíricos dirigidos a los microorganismos más prevalentes, con el objetivo de mejorar el abordaje de las infecciones en los pacientes con cirrosis.

Abstract: Hospitalized cirrhotic patients present with a high prevalence of bacterial infections. Among them, spontaneous cirrhotic infections include spontaneous bacterial peritonitis, spontaneous bacteremia and spontaneous bacterial empyema, which constitute a particular group, with a high risk of complications and mortality. The work above aims to describe and characterize the spontaneous infections in the cirrhotic, the prevalent microbiology and its resistance profile, in 2 healthcare centers in Montevideo-Uruguay. A multicenter, descriptive, cross-sectional study was held, including hospitalized patients with liver cirrhosis, between March 2018 - March 2019. 25 (16%) of the 156 patients admitted with cirrhosis developed a spontaneous cirrhotic infection. 24 (96%) of these patients were in an advanced stage of their disease, (Child-Pugh B-C, MELD＞15). The most frequent presentation was the spontaneous bacterial peritonitis (52%), followed by the spontaneous bacteremia (40%) and the spontaneous bacterial empyema (8%). Microbiological isolation was possible in 17 cases (68%), of which 12 (70%) developed gram negative bacilli, 4 (24%) gram positive bacilli and 1 case Candida. 3 ESBL producing strains were identified, (2 K. pneumoniae and 1 E. coli), and other 4 microorganisms with different antibiotic resistance profile (2 E. faecalis, 1 K. oxytoca, 1 E. cloacae). The prevalence of multiresistant microorganisms was 41%, all of nosocomial acquisition. Research on this topic may provide more knowledge about the local epidemiology, improving the empiric treatments, targeting the most prevalent microorganisms, in order to better approach the infections in cirrhotic patients.

Resumo: Pacientes cirróticos hospitalizados presentam alta prevalência de infecções bacterianas. Dentre elas, as chamadas infecções cirróticas espontâneas, que incluem a peritonite bacteriana espontânea, a bacteremia espontânea e o empiema bacteriano espontâneo, constituem um grupo particular, com alto risco de complicações e mortalidade. O presente trabalho tem como objetivo descrever e caracterizar as infecções espontâneas em pacientes cirróticos, a microbiologia prevalente e seu perfil de resistência aos antibióticos, em 2 centros de saúde em Montevidéu-Uruguai. Foi realizado um estudo transversal, descritivo e multicêntrico, que incluiu pacientes hospitalizados com cirrose hepática, no período de março de 2018 a março de 2019. Do total de pacientes internados com cirrose (156), 25 (16%) desenvolveram infecção cirrótica espontânea. A cirrose estava em estágios avançados, em 24 desses pacientes (96%) (Child-Pugh B-C, MELD ＞ 15). A forma de apresentação mais frequente foi peritonite bacteriana espontânea (52%), seguida de bacteremia espontânea (40%) e empiema bacteriano espontâneo (8%). O isolamento microbiológico foi possível em 17 casos (68%). Em 12 deles (70%) foram isolados bacilos Gram negativos, em 4 (24%) bacilos Gram positivos e Candida em apenas 1 caso. Foram identificadas 3 cepas produtoras de ESBL (2 K. pneumoniae e 1 E. coli) e 4 microrganismos com outros perfis de resistência a antibióticos (2 E. faecalis, 1 K. oxytoca, 1 E. cloacae). A prevalência de microrganismos multirresistentes foi de 41%, todos no grupo de aquisição nosocomial. A realização de outros estudos nesta área poderá nos aproximar do conhecimento da epidemiologia local, para a otimização de tratamentos empíricos direcionados aos microrganismos mais prevalentes, com o objetivo de melhorar o manejo de infecções em pacientes com cirrose.

A rare and unusual cause of Vibrio cholerae non-O1, non-O139 causing spontaneous peritonitis in a patient with cirrhosis

@#Spontaneous bacterial peritonitis caused by Vibrio cholerae non-O1/ non-O139 is a rare phenomenon. V. cholerae is known as a common aetiology of epidemic diarrheal disease and rarely causes extra-gastrointestinal infections. In this report, a 52-year-old man presented to our hospital with a clinical scenario for chronic liver cirrhosis with low grade fever and loose stools. V. cholerae was isolated from peritoneal fluid culture, which was further confirmed as non-O1/ non-O139 strain by multiplex polymerase chain reaction. The patient was successfully treated with antimicrobial therapy and peritoneal drainage. This case represents the first isolation of V. cholerae non-O1/ non-O139 strain from peritoneal fluid.

Study of liver function tests and spontaneous bacterial peritonitis in a patients of liver cirrhosis

Background: Liver cirrhosis patients are highly susceptible to bacterial infections specially Spontaneous bacterial peritonitis (SBP) which is commonest infection. this study undertaken to understand liver function tests and Spontaneous bacterial peritonitis in patients of liver cirrhosis admitted to tertiary care hospital.Methods: A descriptive cross-sectional study conducted among Liver cirrhosis patients in tertiary care center. Total 100 liver cirrhotic patients were included in present study. All the patients were subjected for biochemical evaluation of Serum albumin and globulin level, Serum bilirubin, SGOT (Serum glutamic oxaloacetic transaminase), SGPT (Serum glutamic pyruvate transaminase) and Ascitic fluid polymorph nuclear neutrophil (PMN) count to diagnose SBP.Results: Spontaneous bacterial peritonitis was present in 12% patients. Relation of Serum bilirubin level and SBP was statistically significant. Relation of serum SGOT, SGPT level and serum globulin between SBP and non-SBP group was statistically non-significant.Conclusions: Liver cirrhosis patients are susceptible for bacterial infections because of defects in various host defense mechanism and hence patients of liver cirrhosis must be screened for spontaneous bacterial peritonitis along with liver function tests.

Short- and long-term predictors of spontaneous bacterial peritonitis in Singapore

INTRODUCTION@#Spontaneous bacterial peritonitis (SBP) is the commonest complication of liver cirrhosis. Timely and appropriate treatment of SBP is crucial, particularly with the rising worldwide prevalence of multidrug-resistant organisms (MDROs). We aimed to investigate the clinical outcomes of SBP in Singapore.@*METHODS@#All cirrhotic patients with SBP diagnosed between January 2014 and December 2017 were included. Nosocomial SBP (N-SBP) was defined as SBP diagnosed more than 48 hours after hospitalisation. Clinical outcomes were analysed as categorical outcomes using univariate and multivariate analysis.@*RESULTS@#There were 33 patients with 39 episodes of SBP. Their mean age was 64.5 years and 69.7% were male. The commonest aetiology of cirrhosis was hepatitis B (27.3%). The Median Model for End-stage Liver Disease (MELD) score was 17; 33.3% had acute-on-chronic liver failure and 60.6% had septic shock at presentation. N-SBP occurred in 25.6% of SBP cases. N-SBP was more commonly associated with MDROs, previous antibiotic use in the past three months (p = 0.014) and longer length of stay (p = 0.011). The 30-day and 90-day mortality among SBP patients was 30.8% and 51.3%, respectively. MELD score > 20 was a predictor for 30-day mortality. N-SBP and MELD score > 20 were predictors for 90-day mortality.@*CONCLUSION@#N-SBP was significantly associated with recent antibiotic use, longer hospitalisation, more resistant organisms and poorer survival among patients with SBP. N-SBP and MELD score predict higher mortality in SBP. Judicious use of antibiotics may reduce N-SBP and improve survival among cirrhotic patients.

Clinico-bacteriological profile of spontaneous bacterial peritonitis in cirrhosis of liver with ascites

Background: A good and an effective empirical treatment of SBP is not possible unless bacteriological spectrum and their antibiogram is clear. This becomes more important in country like India due to high antibiotic resistance.  Authors aim was to assess the prevalence of SBP, clinical and microbiological profile of its variants, in patients with cirrhosis seeking care at a tertiary care teaching hospital.Methods: Patients of liver cirrhosis with ascites seeking care at study subject during January- December 2018 formed the study population. Diagnosis was based on clinical examination, biochemical investigation and ultrasonography. Diagnostic abdominal paracentesis was performed on subjects within 24 hours of admission. Ascitic fluid was aspirated. It was sent for microbiological examination.Results: Prevalence of SBP was 16.12%. Out of total ten subjects with Spontaneous Bacterial Peritonitis (SBP), six subjects were of Culture Negative Neutrocytic Ascites (CNNA). Thus most common (60%), variant of Spontaneous Bacterial Peritonitis (SBP) was Culture Negative Neutrocytic Ascites (CNNA). Prevalence of Mono-microbial Non-neutrocytic Bacterascites (MNBA) and Classic-Spontaneous Bacterial Peritonitis (C-SBP) was 20%.  Two subjects found positive for MNBA, Staphylococcus aureus and Acinitobacter spp. was detected in each patient. Klebseila pneumonia, Escherichia coli and Coagulase negative Staphylococcus were found in ascitic fluid culture of C-SBP. In clinical variants of SBP, 80% subject’s complaint about abdominal pain. Hepatic-encephalopathy and fever was seen in 7(70%) patients. Rebound tenderness was seen among 60%.Conclusions: Diagnostic paracentesis should be advised to all cirrhotic patients with ascites. Ascitic fluid analysis should be sent for better selection of antibiotics thus better outcome of cirrhotic patients.

Study on Ascitic Fluid Culture and Antimicrobial Sensitivity Profile in Cirrhotic Patients admitted in a Medical College Hospital

Background: Spontaneous bacterial peritonitis is a fatal complication of liver cirrhosis. Ascitic fluid culture is positive in half of the cases. Materials and methods: The present cross-sectional study was conducted upon the patients admitted in Medicine ward of VIMS, Pawapuri. Bacterial examination of ascitic fluid, culture and antibiotic sensitivity was done. Results: 47.2% of SBP cases were culture positive. E. coli (46.2%), Klebsiella (26.9%), Acinetobacter (7.7%) and Pseudomonas aeruginosa (3.8%) were the common organisms isolated. Conclusion: As half of SBP cases have positive culture, ascitic fluid culture and antibiotic sensitivity testing is essential in such cases.

Prevalence of acute on chronic liver failure, underlying etiology and precipitating factors

Background: Acute on chronic liver failure (ACLF) was first described in 1995 as a clinical syndrome distinct to classic acute decompensation. Characterized by complications of decompensation, ACLF occurs on a background of chronic liver disease and is associated with high rates of organ failure and significant short-term mortality estimated between 45% and 90%. Despite the clinical relevance of the condition, it still remains largely undefined with continued disagreement regarding its precise etiological factors, clinical course, prognostic criteria, and management pathways. It is concerning that, despite our relative lack of understanding of the condition, the burden of ACLF among cirrhotic patients remains significant with an estimated prevalence of 30.9%. Aim of the study: The present study was aimed at estimating the prevalence of acute on chronic liver failure in our institute, etiology of underlying chronic liver disease, precipitating acute event and mortality rate. Materials and methods: 150 patients admitted and treated with the diagnosis of ACLF in the Institute of Hepatobiliary Sciences, Rajiv Gandhi Government General Hospital during the period from December 2016 to November 2018 were included in the study. Their data regarding etiology of chronic liver disease, precipitating acute events and mortality were collected and analyzed. Results: Out of 386 patients, 150 patients were admitted with acute on chronic liver failure with a prevalence of 39%. In 41% of patients, infection was the precipitating factor for ACLF either in the form of Sepsis, spontaneous bacterial peritonitis, Lower respiratory tract infection or skin, and soft tissue infections. Alcohol was the second most precipitating factor (32%), followed by upper gastrointestinal hemorrhage (12%) and drugs (2%). No precipitating cause could be identified in Premkumar K, Krishnasamy Narayanasamy. Prevalence of acute on chronic liver failure, underlying etiology and precipitating factors. IAIM, 2019; 6(4): 49-54. Page 50 12.7% of patients. Mortality rate was high in ACLF grade 3 (95%), followed by ACLF grade 2 (62%) and ACLF grade 1 (15%). Conclusion: ACLF is a dynamic syndrome presenting with single, two or more organ failure in a patient with chronic liver disease following a triggering event and associated with high short term mortality. In our hospital, the prevalence of ACLF was 39% and the overall mortality rate was 83%. Infection and alcohol were found to be important precipitating factors. A multi-centre study involving a larger number of patients are needed to know the clinical characteristics, other precipitating factors and to form a standard treatment protocol for this dynamic syndrome

Effect of trimethoprim-sulfamethoxazole vs. norfloxacin on fecal E. coli resistance pattern and efficacy in patients receiving prophylaxis for spontaneous bacterial peritonitis

Background: Spontaneous Bacterial Peritonitis (SBP) is an infection of ascitic fluid. It is highly mortal and recurrent condition, so prophylaxis with Norfloxacin (NOR) or Trimethoprim-sulfamethoxazole (TMP-SMX) seems to play an important role in the prevention of further episodes of SBP. Aims of the study were to assess the effect of TMP-SMX/NOR on the sensitivity pattern of fecal E. coli after long term prophylaxis in Spontaneous Bacterial Peritonitis (SBP) and to compare the efficacy of TMP-SMX and NOR in prophylaxis of SBP.Methods: An interventional, prospective, open label, single center study conducted in Maulana Azad medical college, New Delhi, India. 52 patients of SBP or with high risk of SBP were screened and finally 39 patients were recruited. Stool sensitivity testing of fecal E. coli was done and they were divided into TMP-SMX group(n=18) and NOR group(n=21) according to sensitivity. After 45±3 days (7 weeks) their stool sample was re-examined for change sensitivity pattern of E. coli. Efficacy variables like any episode of SBP, fever (FEV) resolution of ascites (ASC), bacteremia (BACT), extraperitoneal infection (EPI), liver transplantation (LT) or death (D) were noted throughout the period of 24 weeks.Results: Resistance developed in 60% vs. 48% in TMP-SMX vs. NOR group(p=0.46) after 45 days of prophylaxis. By the end of 24 weeks, Incidence of SBP (29%vs. 25%, p>0.99), episodes of FEV(P=0.60), EPI(p>0.99), ASC(p>0.99) and death (14% vs. 16%, p>0.99) were almost similar in both the groups (TMP-SMX vs. NOR) respectively.Conclusions: Both TMP-SMX and NOR showed same degree of resistance and found equi-efficacious when administered as long-term prophylactic therapy in SBP. TMP-SMX can be a suitable as well as cost effective alternative to NOR for the prophylaxis of SBP.

Spontaneous Bacterial Peritonitis / 대한소화기학회지

Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any significant intraperitoneal infection, accounting for approximately 10–30% of bacterial infections in hospitalized patients. SBP develops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm³ in ascites after paracentesis. If SBP is diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review describes the pathophysiology, diagnosis, treatment, and prevention of SBP.

Procalcitonin combined with coagulation factors in prognosis of cirrhotic patients complicated with spontaneous bacterial peritonitis / 中华临床感染病杂志

Objective To examine the short-term prognostic value of procalcitonin ( PCT ) combined with coagulation factors for cirrhotic patients complicated with spontaneous bacterial peritonitis (SBP).Methods Clinical data of 128 cirrhotic patients complicated with SBP admitted in Jinhua Central Hospital from June 2014 to October 2017 were retrospectively analyzed .In 3 months after admission , 83 patients survived ( survival group ) and 45 patients died ( fatal group ) .The factors related to prognosis were analyzed with Logistic regression and the prediction model was constructed with the weights derived from regression coefficients.The ROC curve and the area under the curve (AUC) of combination of PCT with coagulation factors were used to predict the survival of patients .Results Univariate analysis indicated that the level of PCT , total bilirubin ( TBil ) , serum creatinine ( Scr ) , prothrombin time ( PT ) , prothrombin activity ( PTA ) , blood coagulation factor Ⅱ, Ⅴ, Ⅶ, Ⅸ, Ⅹ, Ⅺ and Ⅻ were factors affecting the prognosis of cirrhotic patients complicated with SBP (P<0.01).Multivariate analysis showed that PCT , blood coagulation factors Ⅴ and Ⅸ were independent factors of short-term prognosis of cirrhotic patients complicated with SBP.The constructed predictive model was Logit (P) =1.200+0.099 ×PCT-0.026 × clotting factor Ⅴ-0.038 ×clotting factor Ⅸ.The sensitivity and specificity of the model were 0.822 and 0.675, respectively, and the AUC was 0.829.Compared with the classic MELD score , the difference was not statistically significant (P>0.05).Conclusions The predictive model based on PCT and coagulation factors Ⅴand Ⅸcan effectively predict the short-term survival of cirrhotic patients complicated with SBP . The overall prognostic ability is not different from MELD score , but the model is more simple and easier to apply.

Management of Cirrhotic Ascites / 胃肠病学

Ascites formation represents a hallmark of decompensation of liver cirrhosis and predicts a poor prognosis. Patients with cirrhotic ascites are at high risk of some complications,such as hyponatremia,hepatorenal syndrome and spontaneous bacterial peritonitis(SBP). Currently,there are consensuses on treatment with sodium intake restriction, diuresis,paracentesis,albumin supplement,anti-infection and etc. In recent years,some advancements have been achieved,such as aquaretics,vasoactive drugs,prevention of SBP with rifaximin,alfapump?,stem cell transplantation and etc.,and yet there are still many issues deserved to be researched. This article focused on the management of cirrhotic ascites and related controversies with reference to current international and local guidelines and latest evidences.

Follow-up Creatinine Level Is an Important Predictive Factor of In-hospital Mortality in Cirrhotic Patients with Spontaneous Bacterial Peritonitis

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is one of the severe complications of liver cirrhosis. Early detection of high-risk patients is essential for prognostic improvement. The aim of this study is to investigate the predictive factors related to in-hospital mortality in patients with SBP. METHODS: This was a retrospective study of 233 SBP patients (181 males, 52 females) who were admitted to four tertiary referral hospitals between August 2002 and February 2013. The patients' laboratory and radiologic data were obtained from medical records. The Child-Turcotte-Pugh (CTP) score and model for end-stage liver disease sodium model (MELD-Na) scores were calculated using the laboratory data recorded at the time of the SBP episode. RESULTS: The causes of liver cirrhosis were hepatitis B (44.6%), alcohol (43.8%), hepatitis C (6.0%), and cryptogenic cirrhosis (5.6%). The mean MELD-Na and CTP scores were 27.1 and 10.7, respectively. Thirty-one of the patients (13.3%) died from SBP in hospital. Multivariate analysis revealed that maximum creatinine level during treatment was a statistically significant factor for in-hospital mortality (P = 0.005). The prognostic accuracy of the maximum creatinine level during treatment was 78.0% (P < 0.001). The optimal cutoff point for the maximum serum creatinine was 2 mg/dL (P < 0.001). CONCLUSION: The follow-up creatinine level during treatment is an important predictive factor of in-hospital mortality in cirrhotic patients with SBP. Patients with SBP and a serum creatinine level during treatment of ≥ 2.0 mg/dL might have a high risk of in-hospital mortality.

Peritonitis bacteriana espontánea por Listeria monocytogenes en un paciente con cirrosis hepática: reporte de un caso / Spontaneous bacterial peritonitis due to Listeria monocytogenes in a patient with cirrhosis: case report

Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients. Listeria monocytogenes is a rare cause of SBP, which should be suspected in individuals with impaired immunity such as advanced liver disease and inadequate response to standard antibiotic therapy. We report a case of a 72 year-old patient with liver cirrhosis secondary to alcohol consumption, asymptomatic carrier of Hepatitis B virus, diabetes Type II and coronary artery disease; who is admitted with a diagnosis of hepatic encephalopathy and suspicion of spontaneous bacterial peritonitis receiving empiric antibiotic treatment with ceftriaxona. Initially he showed clinical response but a few days later he got worse. Ascitic culture confirmed infection by Listeria monocytogenes. Antibiotic treatment was adjusted but patient continued deteriorating progressively, and finally died due to renal dysfunction.

La peritonitis bacteriana espontánea (PBE) es una complicación frecuente y grave en los pacientes cirróticos. Listeria monocytogenes es una causa poco frecuente de PBE, que debe sospecharse en individuos con inmunidad alterada como es la enfermedad hepática avanzada y con respuesta inadecuada a terapia antibiótica habitual. Presentamos el caso de un paciente de 72 años con antecedentes de cirrosis hepática secundaria a consumo de alcohol, portador asintomático del virus de la Hepatitis B (VHB), diabético tipo II y cardiópata coronario. Se hospitaliza por encefalopatía hepática secundaria a PBE, recibe tratamiento antibiótico empírico con ceftriaxona con respuesta clínica inicial y deterioro posterior. Cultivo de líquido ascítico confirma infección por Listeria monocytogenes. Pese a ajuste de tratamiento antibiótico, continúa empeorando y finalmente fallece por disfunción renal.

Advances in basic and clinical research on liver cirrhosis in 2016 / 中华肝脏病杂志

Esophageal and gastric varices are common complications of liver cirrhosis and are seen in 50% of patients with liver cirrhosis. The annual incidence rate of esophagogastric variceal bleeding is 5%-15%, and even if the recommended treatment is used, the 6-week mortality rate is still as high as 15%-20%. Spontaneous bacterial peritonitis (SBP) is a common complication of end-stage liver disease and has an incidence rate of 10%-30% in patients with severe liver damage. SBP refers to the bacterial infection of the peritoneum and/or ascites that occurs in the absence of any inflammation in adjacent tissues (e.g., intestinal perforation and intestinal abscess). Hepatic encephalopathy (HE) is the clinical syndrome manifesting as cognitive impairment in patients with chronic liver disease, and its pathogenesis has not yet been fully elucidated and may be associated with ammonia poisoning theory, γ-aminobutyric acid and endogenous benzodiazepine complex receptor theory, and inflammatory pathway theory. This article introduces the advances in the treatment of upper gastrointestinal bleeding in patients with liver cirrhosis, SBP, and HE in 2016.

Risk of Bacterial Infection from Proton Pump Inhibitor Use

Currently, proton pump inhibitors are used in a wide range of patients with gastroesophageal reflux disease, peptic ulcer, and upper gastrointestinal symptoms such as dyspepsia. In addition, the application of proton pump inhibitors for prevention of gastrointestinal complications induced by non-steroidal anti-inflammatory drugs is expected to increase their use in the future. The use of proton pump inhibitors promotes bacterial growth by reducing gastric acid concentration. If the acidity (pH) of the stomach fluid is lower than 4, most pathogens can be sterilized. However, patients who need to use a proton pump inhibitor should maintain a gastric acidity of at least 5 or 6, and can be at risk of infections such as pneumonia and Clostridium difficile infection. Several infectious diseases associated with the use of proton pump inhibitors were reviewed.

Infecção por Pasteurella multocida em paciente cirrótico: relato de caso / Pasteurella multocida infection in a cirrhotic patient: a case report

Pasteurella multocida é uma bactéria que coloniza todo o trato gastrointestinal de cães e gatos. A infecção em humanos ocorre quando há arranhadura ou mordida por esses animais. Um subgrupo de pacientes com estado imunológico comprometido, como os cirróticos, possui certa propensão a desenvolver infecções sistêmicas por este germe. Neste relato descrevemos o caso de uma paciente com doença hepática alcoólica descompensada a partir de uma celulite em membro inferior direito (MID), peritonite bacteriana espontânea (PBE) e sepse, com culturas positivas para P. multocida. A despeito da antibioticoterapia e tratamento clínico adequado, o desfecho foi desfavorável. A paciente não apresentava história de mordida ou arranhadura por cães ou gatos.

Pasteurella multocida is a bacterium that colonises the entire gastrointestinal tract of cats and dogs. Infection in humans occurs when there is scratch or bite by these animals. A subgroup of patients with compromised immune status, such as cirrhosis, has a certain propensity to develop systemic infections by this germ. We describe a case of a patient with uncompensated alcoholic liver disease from a cellulitis in the lower limb, spontaneous bacterial peritonitis and sepsis, with positive cultures for P. multocida. Despite antibiotic therapy and appropriate clinical treatment outcome was unfavorable. The patient had no history of a bite or scratch by dogs or cats.

Peritonitis bacteriana espontánea en un paciente con cirrosis hepática / Spontaneous bacterial peritonitis in a patient with liver cirrhosis

Se presenta el caso clínico de un paciente de 65 años de edad, mestizo, de ocupación campesino con antecedentes de cirrosis hepática por etilismo crónico hace 6 años, quien fue remitido al Servicio de Gastroenterología del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso" de Santiago de Cuba por presentar dolor abdominal moderado y aumento de volumen del abdomen. Se le realizó paracentesis diagnóstica, la cual indicó una peritonitis bacteriana espontánea; por tanto, recibió tratamiento con cefepime y evolucionó satisfactoriamente.

The case report of a 65 years mixed race patient, is presented who worked as a peasant with a history of liver cirrhosis due to chronic alcoholism since 6 years ago, who was referred to the Gastroenterology Service of "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital in Santiago de Cuba due to moderate abdominal pain and abdomen increase volume. The diagnostic peritoneal tap was carried out, which indicated a spontaneous bacterial peritonitis; therefore, he received treatment with cephepime and had a satisfactory clinical course.