自发性细菌性腹膜炎的诊断进展

自发性细菌性腹膜炎(spontaneous bacterial peritonitis,SBP)是终末期肝病患者的严重并发症。其临床表现大相径庭,可从完全无症状到典型腹膜炎。因此,诊断本病的关键是对之存有戒心,给所有肝硬化或重症肝病腹水患者在入院和/或出现提示SBP的症状或体征时,及时诊断性腹腔穿刺,常规检测腹水细胞数,并作腹水细菌培养。排除继发性腹膜炎后,腹水细菌培养阳性是确诊SBP的依据。但腹水细菌培养阳性率低,即使采用床边抽取腹水10ml,立即注入血培养瓶中送检的方法,培养阳性率也仅提高至40%左右,不尽如人意。而且,细菌培养耗时,难以立即获得结果,…     

Spontaneous Bacterial Peritonitis Associated with Cardiac Ascites

A patient who developed fatal spontaneous bacterial peritonitis associated with cardiac ascites is reported. Spontaneous bacterial peritonitis most frequently occurs in patients with decompensated cirrhosis of alcoholic or nonalcoholic type. Although there are reports of spontaneous bacterial peritonitis occurring in patients with nephrotic syndrome, or with acute or chronic hepatitis, there appear to be no reports of spontaneous bacterial infection developing in cardiac ascites.     

自发性细菌性腹膜炎的研究进展

自发性细菌性腹膜炎(Spontaneoua bacterial peritonitis,SBP)是在腹水形成的基础上,无腹腔感染灶和脏器损伤,也无其它污染途径直接存在时发生的腹膜细菌感染,多见于晚期肝硬化和其它一些重症肝病患者及肾病综合症的患者,是终末期肝病患者的重要死亡原因之一,其发病率估计在8%～27%之间,病死率高达48%～57%[1].近年来,关于SBP的病原学、发病机制、诊断、治疗及预防方面取得了很大的进展.     

Chylous Ascites and Encapsulating Peritonitis: Unusual Complications of Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis was diagnosed in a 36-yr-old woman 3 wk after she had delivered. The patient had no past history of abdominal or pelvic disease. Ampicillin therapy was started and determined complete resolution of infectious manifestations. Ten days later, chylous ascites and chyluria were evidenced. Thereafter an ascitic effusion persisted for 2 months, when an occlusive syndrome developed, requiring emergency surgery. An encapsulating peritonitis was recognized, encasing small bowel loops, stomach and partially, pelvic organs. In this case, encapsulating peritonitis was most likely a consequence of simultaneous bacterial infection and transient lymphatic blockade. Both mechanisms should be considered in the development of this rare and usually unexplained disease.     

小肠细菌过度生长与肝硬化并发自发性腹膜炎

目的探讨小肠细菌过度生长(SIBO)与肝硬化并发自发性腹膜炎(SBP)之间的关系,方法对80例肝硬化患者的SIDO和并发SBP情况进行分析,并与健康对照组进行比较。结果 80例肝硬化患者中27例SIBO阳性,阳性率33.75%(27/80),按Child-Pugh分级分组,分为A级、B级、C级三组,其SIBO阳性率分别为14.8%(4/27)、29.6%(8/27)、57.7%(15/26),各组间比较差异有显著性(P<0.01)。健康对照组25例SIBO全为阴性,与肝硬化组比较差异有显著性(P<0.01)。58例肝硬化并发SBP患者中有25例SIBO阳性,阳性率为43.1%;22例未并发SBP患者2例存在SIBO阳性,阳性率为9.1%,两组比较有统计学差异(P<0.01)。肝硬化并发SBP且SIBO阳性的25例患者,经2周治疗后有20例SIBO转阴,其中并发SBP的有2例,而在治疗后SIBO仍然阳性的5例患者中,并发SBP者有4例。结论肝硬化患者SIBO发生率高,并且随着肝功能损害程度的加重,SIBO发生率也随之增加,肝硬化伴SBP者SIBO发生率增加尤为显著。治疗SIBO能显著减少SBP的发生率。     

Constrictive Pericarditis with Cardiac Ascites Caused Spontaneous Bacterial Peritonitis

Patients with constrictive pericarditis (CP) typically present with symptoms related to right-sided heart failure, such as cardiac ascites. Spontaneous bacterial peritonitis (SBP) usually arises in association with ascites secondary to hepatic cirrhosis. We herein report a rare case of CP in which SBP developed due to cardiac ascites, even in the absence of cirrhosis. In this case, pericardiectomy improved both the hemodynamics and the ascites, while therapy with diuretics alone was insufficient. It is important to consider SBP in the differential diagnosis when any abdominal symptoms or an inflammatory response is found in patients with heart failure and cardiac ascites.     

Does Spontaneous Bacterial Peritonitis Occur in Malignant Ascites?

Spontaneous bacterial peritonitis is a well-described entity estimated to occur in 8% of patients with cirrhotic ascites. Characteristic clinical findings may often be absent and the only manifestation may be decompensation of liver function. Ascites at Memorial Hospital is most commonly related to malignancy. We reviewed the records of 101 patients with ascitic fluid cytology positive for malignancy during the calendar year 1979. The most common malignant cytological diagnosis was adenocarcinoma, seen in 76 patients. Of the 101 patients with positive ascitic fluid cytology, 65 fluid specimens had microbiological studies performed which included aerobic, anerobic, fungal, and acid fast bacterial cultures. Only three patients had positive ascitic fluid cultures. We believe that these three patients had other reasons for peritonitis and do not represent true spontaneous bacterial peritonitis. Ascites alone, without liver disease, as often seen when malignant ascites is present, does not seem to predispose to spontaneous bacterial peritonitis. Perhaps, the presence of liver disease with less than normally effective hepatic reticuloendothelial function and portasystemic shunting is needed for the development of spontaneous bacterial peritonitis.     

Granulocyte Elastase in Cirrhotic Patients with Spontaneous Bacterial Peritonitis

Granulocyte elastase (GE) is a powerfulproteolytic enzyme that is released by PMNs whendegranulated in infectious processes. The aim of thisstudy was to measure GE in ascites and plasma ofcirrhotic patients with spontaneous bacterial peritonitis(SBP). We studied 29 cirrhotic patients, 17 of themhaving SBP (group A). Twelve patients with noninfectedascites formed the control group (group B). At the time of diagnosis of SBP, GE levels inascites (183.17 ± 86.11 g/liter) and plasma(114.6 ± 35.99 g/liter) were higher in groupA than in group B (27.41 ± 11.54 g/liter, P< 0.00001 and 82.54 ± 20.52 g/liter, P = 0.01,respectively). Levels of GE in ascites had a high valuefor discriminating between patients with and withoutSBP. In the patients who responded to the initialantibiotic treatment, these values significantly decreasedin ascites (67.69 ± 54.22 g/liter, P = 0.003)and plasma (67 ± 22.39 g/liter, P = 0.01) 48hr after therapy was started, in parallel with thedecrease of PMN in ascites. In patients who did notrespond, the production of GE remained elevated.Patients who developed renal insufficiency following SBPhad more marked elevation of GE in plasma (144.8± 33.43 g/liter) than those with normal renalfunction (99.5 ± 27.53 g/liter, P = 0.02).These results suggest that the measurement of GE may behelpful for the diagnosis of SBP in patients withcirrhosis and for assessing the efficacy of therapy. Inaddition, the release of GE into plasma may contributeto the impairment of renal function that follows SBP insome patients.     

Small Intestinal Bacterial Overgrowth versus Antimicrobial Capacity in Patients with Spontaneous Bacterial Peritonitis

Background: Spontaneous bacterial peritonitis (SBP) is a serious infection in cirrhotic patients with ascites. Both defects in the host defense mechanisms and the enhancement of the offensive factor (small intestinal bacterial overgrowth (SIBO)) may contribute to the development of SBP. Therefore, the aim of this study was to evaluate the role of SIBO versus various antimicrobial capacities in the pathogenesis of SBP in cirrhotic patients. Methods: Forty-five cirrhotic patients were enrolled in this study. Bacterial overgrowth was evaluated by breath hydrogen test (BH₂T). The hepatic reticuloendothelial system phagocytic index (HRESPI) was measured by intravenously injected colloid suspensions. Results:     

Risk of Spontaneous Bacterial Peritonitis Associated With Gastric Acid Suppression

The primary objective of this study was to determine the association between the use of gastric acid suppressants (GAS) and the risk of developing spontaneous bacterial peritonitis (SBP) in patients with advanced liver cirrhosis (LC).A case–control study nested within a cohort of 480,000 representatives of Taiwan National Health Insurance beneficiaries was carried out. A case was matched with 100 controls on age, gender, and index date of SBP diagnosis. GAS use was identified from the 1-year period before the index date. Conditional logistic regression analysis was used to adjust for various unbalanced covariates between users and nonusers of GAS.A total of 947 cases of SBP were identified among the 86,418 patients with advanced LC. A significant increased risk of developing SBP was found to be associated with current (within 30 days), and recent (within 30–90 day) use of 2 different classes of GAS: proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs). The confounder adjusted rate ratio (aRR) for the current use of PPIs was 2.77 (95%CI: 1.90–4.04) and H2RAs was 2.62 (95%CI: 2.00–3.42). The risk of SBP attenuated for the recent use of PPIs (aRR: 2.20, 95%CI: 1.60–3.02) or H2RAs (aRR: 1.72, 95%CI: 1.25–2.37).In addition, sensitivity analysis using hospitalized SBP as the primary outcome showed a similar risk for the current use of PPIs (aRR, 3.24; 95%CI: 2.08–5.05) and H2RAs (aRR 2.43; 95%CI 1.71–3.46). Furthermore, higher cumulative days of gastric acid suppression were associated with a higher risk of SBP (trend P < 0.0001).To conclude, exposure to GAS was associated with an increased risk of SBP in patients with advanced LC. The association was more pronounced in current PPI users compared with nonusers.     

Association between Proton Pump Inhibitor Use and Spontaneous Bacterial Peritonitis

Proton pump inhibitors (PPIs) increase enteric bacterial colonization, overgrowth, and translocation, all effects which might predispose to spontaneous bacterial peritonitis. We investigated whether PPI usage is associated with spontaneous bacterial peritonitis. Our retrospective case-control study included 116 consecutive cirrhotic patients with ascites who underwent diagnostic paracentesis upon hospital admission (2002–2005). Spontaneous bacterial peritonitis was defined as paracentesis yielding ≥250 polymorphonuclear leukocytes/ml. We performed logistic regression to determine the risk of spontaneous bacterial peritonitis by PPI usage. Of the 116 subjects, 32 had spontaneous bacterial peritonitis. Patient characteristics were similar between groups with and without infection, with the exception of the Model for End-Stage Liver Disease score (median: 23 and 18, respectively; P = 0.002). Crude and adjusted odds ratios for the development of spontaneous bacterial peritonitis by exposure to PPIs were 1.22 (95% confidence interval: 0.52–2.87) and 1.05 (0.43–2.57), respectively. In conclusion, we did not find a positive association between PPI use and spontaneous bacterial peritonitis. Mical S. Campbell and Keith Obstein contributed equally to this work. The study was not funded. Dr. Y.-X. Yang has served as a consultant to AstraZeneca.     

Clostridium cadaveris: An Unusual Cause of Spontaneous Bacterial Peritonitis

Bacterial peritonitis has been known to complicate severe liver disease. Aerobic organisms are responsible for the vast majority of cases, whereas anaerobic bacteria are responsible for less than 5% of all cases reported in the literature. We now report a case of Clostridium cadaveris anaerobic bacterial peritonitis in a 58-yr-old female, an organism that to our knowledge has not been previously implicated as an infectious agent in this entity.     

Factors Associated with Delayed Paracentesis in Patients with Spontaneous Bacterial Peritonitis

Background and Aim

In patients with spontaneous bacterial peritonitis (SBP), studies show that delayed paracentesis (DP) is associated with worse outcomes and mortality. We aimed to assess the rate of DP in the community setting and associated factors with early versus delayed paracentesis.

Methods

Patients hospitalized with SBP were retrospectively studied between 12/2013 and 12/2018. DP was defined as paracentesis performed?>?12 h from initial encounter. Data collected included: patient factors (i.e., age, race, symptoms, history of SBP, MELD) and physician factors (i.e., admission service, shift times, providers ordering and performing paracentesis). Logistic regression analysis was performed to assess for factors associated with DP.

Results

DP occurred 82% of the time (n?=?97). The most significant factors in predicting timing of paracentesis were ordering physician [emergency department (ED) physician was associated with early paracentesis (57% vs 8%, p?<?0.001) and specialty of physician performing paracentesis (interventional radiology was associated with DP (88% vs 48%, p?<?0.001)]. Younger patients were more likely to receive early paracentesis. In regression analysis, the factor most associated with early paracentesis was when the order was made by the ED provider (OR 0.07, 95% CI 0.02–0.22). No differences were observed in patients with prior history of SBP, abdominal pain, encephalopathy, or creatinine level.

Conclusions

Studies have suggested that DP is associated with increased mortality in patients with SBP. Despite this, DP is common in the community setting and is influenced by ordering physician and specialty of physician performing paracentesis. Future efforts should assess interventions to improve this important quality indicator.

     

自发性细菌性腹膜炎的细菌谱及发病机制的研究进展

随着社会经济的发展、新型抗菌药物的应用,自发性细菌性腹膜炎(spontaneous bacterial peritonitis,SBP)的细菌谱已有所变化。且随着研究方法的进步及交叉学科的发展,自发性细菌性腹膜炎发病机制的研究也有了长足的进展。自发性细菌性腹膜炎的细菌谱90%以上的SBP为单一的细菌,少数病例为两种,甚至是两种以上的细菌感染。直至上世纪末,多数SBP的报道都是以革兰阴性菌为主,约占有60%~80%。2005年,Cholongitas等[1]总结雅典大学和Hippokration总院SBP的细菌谱,发现上世纪末,该院革兰阴性菌SBP为75%,而新千年后的3年为40%,革兰阳性菌SBP…