Spontaneous empyema in cases with cirrhosis

ABSTRACT

Spontaneous bacterial empyema is an infection of a preexisting hydrothorax in a cirrhotic patient that cannot be attributed to chest condition. It is associated with a bad prognosis and mortality rate may reach over 20%. Infection is usually by enteric bacteria which reach pleural cavity by hematogenous spread; though transfer through bowel wall can occur. The aim of the present work is to study spontaneous bacterial empyema in cirrhotic patients with hepatic hydrothorax and its relation to ascetic fluid. The present study was performed on 40 patients with hepatic hydrothorax from Tropical Medicine Dept. Tanta University. All patients were subjected to full history taking, thorough clinical examination, routine laboratory investigations, abdominal US. Tuberculin testing and ZN examination of sputum were done to exclude TB. Examination of pleural fluid of all cases was done including Adenosine Deaminase [ADA] and LDH. Pleural fluid was examined bacteriologically for Gram stain and Ziehl Neelsen staining. Cultures were done using the conventional method and modified method. According to these data, cases were further divided into two groups group I thirteen patients [13] with cirrhosis, hepatic hydrothorax with Spontaneous bacterial empyema. Group II Twenty seven patients [27] with cirrhosis and hepatic hydrothorax. Ascitic fluid analysis macroscopically, biochemically and bacteriologically was done for all cases. There were no significant differences as regards child score, hemoglobin, white cell count, Serum bilirubin and transaminases, but there was a significant deterioration of renal function in group I compared to group II. Comparison of pleural and ascitic fluid in the two groups proved significant differences as regards total leucocytes, PMN, LDH and pH in group I compared to group II. Main bacterial pathogen in pleural fluid was E. coli followed by Pseudomonas aeroginosa. Culture was negative in 46.2% of ascitic fluid and 30.7% in pleural fluid. Spontaneous bacterial empyema is a relatively common complication of cirrhotic patients with hydrothorax. Diagnostic thoracocentesis is mandatory in cases with hepatic hydrothorax regardless the presence or absence of ascites. E. coli is the most common pathogen, and hematogenous spread may play a main role. Modified method of culture is the method of choice to increase sensitivity