Diagnosis of spontaneous and secondary bacterial peritonitis in patients with hepatic cirrhosis and ascites.

Spontaneous bacterial peritonitis (SBP) is an infection that is not caused by intra-abdominal source requiring surgery. Nowadays SBP is the main cause of death in patients with cirrhosis. Treatment is carried out with third generation cephalosporins and albumin infusions. The aim of the study is to identify patients with SBP and to be distinguished from the cases with secondary bacterial peritonitis (SecBP) in patients with cirrhosis and ascites. We studied 167 patients with cirrhosis and ascites and SBP was observed in 25 of them, while SecBP--in 22. The diagnosis of SBP is set in neutrophilic leukocytes in ascites > or = 250 cells/mm3 as bacterial cultures are positive in only 16% of them. Completely asymptomatic course had 16% of patients with SBP. Diagnosis of SecBP (according to Runyon's criteria) is based on increased total protein in ascitic fluid > 10 g/l (in 63.7% of patients > 30 g/l), elevated lactate dehydrogenase in ascites (LDH is > 240 U/l in all patients) and glucose < 2,7 mmol/l (only 4.5% of cases with secondary bacterial peritonitis). In support of SecBP are the polymicrobial flora, the isolation of anaerobes, enterococci, fungi, and the very high number of neutrophilic leukocytes in the peritoneal effusion and the refractoriness from conservative treatment. The examination of ascites with Multistix is more informative in secondary than in spontaneous bacterial peritonitis. In suspected secondary bacterial peritonitis CT is indicated.

Intraperitoneal perfusion chemotherapy with hyperthermia in some malignant ascites.

Intraperitoneal administration of chemotherapeutic drugs with hyperthermia (HIPEC) increases their local effect on malignant peritoneal diseases and reduces systemic cytotoxicity. The most commonly used are cisplatin, doxorubicin, and mitomycin C. A major disadvantage of intraperitoneal chemotherapy is limited penetration of the drug in the tumor lesion depth (1-3 mm). Extended exposure and increased pressure in the abdominal cavity solution increases penetration of the agent into the tumor and hyperthermia has synergy with cytostatic agent on the permeability of cell membranes and metabolism of the drug. Real clinical hyperthermia is achieved at 41 degrees C. Of greatest importance is the concentration of the drug, but crucial for the prognosis is complete cytoreductive surgery. A major disadvantage of the closed technique is the uneven distribution of the perfusion solution in the peritoneal cavity, and the main advantage is better control of the perfusion, keeping of constant hyperthermia of the solution and regular repetition of manipulation, like intravenous chemotherapy. Laparoscopy determines the stage of the tumor process, refines the indications and preoperative selection for HIPEC, monitors the effects of treatment and determines locations for introducing catheters. In the review the results of the inraperitoneal chemotherapy with hyperthermia in gastric, colorectal, ovarian and other cancers are discussed as well as in diffuse malignant peritoneal mesothelioma and others.

A study of Helicobacter pylori infection in patients with pernicious anemia.

INTRODUCTION: Chronic atrophic gastritis presents with atrophy of the gastric mucosa, hypochlorhydria or achlorhydria and unstable gastrin level. Type A chronic atrophic gastritis associated with hypergastrinemia is regarded as the principle causative factor for pernicious anemia. AIM: The study aimed at evaluation of the incidence of H. pylori infection in patients with pernicious anemia and analyze its relation to the severity of gastritis. MATERIAL AND METHODS: Forty patients with pernicious anemia (group 1) were examined for presence of H. pylori infection. Sex- and age-matched patients with gastric ulcer (group 2) and chronic superficial gastritis (group 3) were used as controls. Three antral forceps biopsies were obtained from all patients during videogastroscopy. The presence of H. pylori was verified by urease test, histological and microbiological examination. RESULTS: All patients with pernicious anemia had chronic atrophic gastritis and several times lower incidence of H. pylori infection than the patients with gastric ulcer. Chronic atrophic gastritis was not diagnosed in group 3 patients. Statistically significant difference in Helicobacter pylori infection was found between groups 1 and 2 (P < 0.001) but not between groups 1 and 3 (P > 0.05). CONCLUSIONS: Atrophic gastritis was diagnosed in all patients with pernicious anemia. These patients showed significantly lower incidence of H. pylori infection than the gastric ulcer patients. The patients with pernicious anemia had lower gastritis index and quantitatively less expressed infection than the other two groups.

Diagnostic strategies for evaluation and prognosticating the outcome of jaundice among patients with cholestasis caused by neoplastic diseases of the hepatobiliary system and the pancreas.

The purpose of the present study was to assess the diagnostic approach and the outcome of neoplastic diseases of the hepatobiliary system and the pancreas that develop cholestasis. 84 patients over 40 years of age treated in our Department between January 1994 and January 1998 were included. The etiological cause of jaundice was established by ultrasonography, computed tomography, thin needle biopsy with cytological and histological examination of the obtained material or ERCP. 11 of the 84 patients died, 9 underwent surgery and 64 were referred to the Oncologic Center for further treatment.

A rare case of fibrosarcoma of the inferior vena cava expanding into the right atrium.

The authors report in detail a case of fibrosarcoma of the inferior vena cava. A 53-year-old female presented with echographic and computed tomographic evidence of a solid formation in the porta hepatis that fused with the inferior vena cava. Because of appearance and rapid development of symptoms of right cardiac failure, the patient was transferred to the Clinic of Cardiac Surgery and underwent an emergency operation. A solid formation arising from the inferior vena cava and expanding into the right atrium was found during the operation. The operation performed was not a radical one. Fibrosarcoma of the inferior vena cava was proved on histological examination. A single therapeutic course with vincristine and farmorubicin was administered. The patient died from recurrence of the malignancy 26 months after the operation. The epidemiologic, diagnostic, and therapeutic aspects of the case are discussed in relation with the literature data.