自发性细菌性腹膜炎的诊治及预防

自发性细菌性腹膜炎 (Spontaneous BacterialPeritonitis,SBP)是指在肝病和肾病综合征腹水的基础上 ,无腹内感染灶和脏器破损 ,也无其他直接污染途径存在时发生的腹膜细菌性感染 ,是肝硬化腹水患者常见而严重的并发症 ,是导致肝功能恶化的常见诱因。临床上专指肝硬化腹水患者无外来原因的腹膜感染。SBP的发生与菌血症和腹水杀菌能力下降有关。肠源性细菌是肝硬化患者发生菌血症的主要来源。肠道内细菌可因肠通透性增加 ,经粘膜下淋巴管入血 ,也可经门脉高压侧枝循环绕过肝脏而直接进入体循环。腹水蛋白含量低者 ,调理素 (指补体等 )活性…     

Diagnosis, treatment and prevention of spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a frequent complication in cirrhotic patients with ascites. Diagnosis of SBP is established by a polymorphonuclear cell count in ascitic fluid > or =250 cells/mm(3). The organism responsible for the infection is isolated in 60-70% of the cases. The remaining cases are considered to have a variant of SBP (culture-negative SBP) and are treated in the same way as those with a positive culture. The SBP resolution rate ranges between 70 and 90%, and hospital survival between 50 and 70%. An early diagnosis and the use of a more adequate antibiotic therapy are the most probable reasons for the improvement in prognosis for SBP in recent decades. Despite the resolution of the infection, SBP may trigger severe complications such as renal impairment, gastrointestinal bleeding and accentuation of hepatic insufficiency which are responsible for the associated mortality. Patients recovering from an episode of SBP should be considered as potential candidates for liver transplantation.     

Pharmacologic treatment of portal hypertension.

Variceal formation and rupture are dreaded complications of chronic liver disease and portal hypertension. The pharmacologic treatment of portal hypertension should be able to stop as well as to prevent variceal hemorrhage. There are two principal types of vasoactive drugs in the treatment of portal hypertension: vasoconstrictors and vasodilators. Vasoconstrictors reduce the splanchnic blood flow, thereby decreasing the portal blood flow and portal pressure. Vasodilators act by different mechanisms, including by relaxation of myofibroblasts in the fibrous septa and presinusoidal areas of the liver and by direct vasodilation of the collateral circulation. In addition, paradoxically, they could decrease portal flow and pressure by inducing a baroreflex-mediated mesenteric arterial vasoconstriction. A miscellaneous group of drugs is also available. These drugs reduce the blood flow and pressure in the gastroesophageal variceal system by mechanisms other than vasoconstriction or vasodilation. The success of these pharmacologic agents is limited once the varices have ruptured. The use of beta-blockers in the prophylaxis of the first variceal bleeding has been proven of benefit in this respect. Future research should be aimed at elucidating the role that humoral and endothelial factors play in development of the hyperdynamic circulatory state that characterizes patients with portal hypertension. Once these etiologic factors have been identified and new knowledge is acquired about their role in the complications of chronic liver disease, the challenge will rest on developing novel pharmacologic therapies specifically targeting these factors.     

Rifaximin for the prevention of spontaneous bacterial peritonitis

According to a review article by Biecker et al published in a previous issue of World Journal of Gastroenterology in March 2011, intestinal decontamination with norfloxacin remains the mainstay of primary prophylaxis of spontaneous bacterial peritonitis (SBP) at the expense of development of quinolone-resistant bacteria after long-term use. In our research, the administration of a 4-wk regimen with rifaximin 1200 mg/d reduced significantly the ascitic neutrophil count in cirrhotic patients with sterile ascites in line with a significant decrease in plasma endotoxin levels. Our observations concur with recent findings, showing a significantly reduced 5-year probability of SBP in cirrhotic patients taking rifaximin.     

Relationship between the degree of portal hypertension and the onset of spontaneous bacterial peritonitis in patients with cirrhosis

BACKGROUND/AIM: Spontaneous bacterial peritonitis (SBP) is a severe complication of cirrhosis but its exact pathogenesis has not yet been elucidated and the role of portal hypertension in the development of SBP has been suggested. The aim of this study was to test the hypothesis that an association exists between the degree of portal hypertension and the occurrence of SBP. METHODS: 292 patients with cirrhosis who underwent a measurement of the hepatic venous pressure gradient (HVPG) were retrospectively studied. Following their ascites profile, patients were classified in three groups: patients with ascites who suffered from SBP, patients with sterile ascites, and patients who had no ascites. RESULTS: Among the 137 patients with ascites, 24 patients suffered from SBP (17.5%). The mean HVPG was significantly different: 20.7 +/- 6.2 mm Hg in the SBP group, 17.5 +/- 5.1 mm Hg in the sterile ascites group and 14.7 +/- 5.6 mm Hg in the group without ascites (p < 0.05). Patients with the most severe portal hypertension (HVPG > or =30 mm Hg) had the highest risk to suffer from SBP (50%). Using the multivariate analysis, only the serum albumin level (p = 0.004) and the HVPG (p = 0.02) were independently correlated with the occurrence of ascites infection. CONCLUSIONS: This study suggests that in patients with SBP the degree of portal hypertension is greater than in the non infected patients. Ascites infection is independently associated with a low serum albumin level and a high HVPG.     

自发性细菌性腹膜炎的诊治

肝硬化腹水患者发生的腹水感染称为自发性或原发性细菌性腹膜炎（spontaneous bacterial pefitonitis,SBP）,它是指无明显腹腔内感染源伴无菌腹水的继发感染。在肝硬化腹水患者中发病率高达10％～32％,是肝硬化腹水患者中最常见的严重并发症之一。现将近年来有关SBP的诊治概况作一介绍。     

Pharmacologic therapy of portal hypertension

Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. During the last few decades, significant clinical advances in the prevention of initial variceal hemorrhage, the management of acute variceal hemorrhage, and the prevention of recurrent variceal hemorrhage have reduced the morbidity and mortality of this lethal complication of cirrhosis. This article discusses the pharmacologic treatment of portal hypertension, including preprimary prophylaxis, prevention of a first variceal hemorrhage, treatment of acute variceal hemorrhage, and secondary prophylaxis of a variceal hemorrhage.     

Pharmacologic therapy for portal hypertension

Pharmacologic therapy for portal hypertension is effective in the treatment and prevention of hemorrhage from esophagogastric varices. Acute hemorrhage from varices can be treated with intravenous agents such as somatostatin or terlipressin, either alone or in combination with endoscopic sclerotherapy or band ligation. Intravenous octreotide has not shown effectiveness as monotherapy, but it appears to be beneficial when combined with endoscopic treatment. The prevention of rebleeding after initial hemorrhage is best accomplished with non-selective beta blockers, endoscopic band ligation of varices, or a combination of endoscopic and pharmacologic therapies. The addition of oral nitrates may further decrease rebleeding rates, but more data from randomized trials are needed. Beta blockers are currently the only agents recommended for the primary prevention of variceal hemorrhage.     

Spontaneous bacterial peritonitis in isolated splenic vein thrombosis with portal hypertension.

Spontaneous bacterial peritonitis (SBP) is a known complication of ascites due to cirrhosis; it has also been reported in some non-cirrhotic conditions with ascites. We report a 50-year-old lady with isolated splenic vein thrombosis who developed SBP due to E. coli .     

肝硬化并发自发性细菌性腹膜炎的诊断与治疗

自发性细菌性腹膜炎(spontaneous bacterial peritonitis, SBP)是指腹腔内无原发感染病灶和脏器损伤而出现的急性或亚急性细菌性腹膜炎.它是肝硬化的严重并发症之一,也是肝硬化肝功能失代偿的重要标志.     

自发性细菌性腹膜炎诊断与治疗的研究进展

自发性细菌性腹膜炎是肝硬化腹水常见的一种并发症。其发病率高,病情进展快,病死率高。目前国内外有关自发性细菌性腹膜炎的临床诊断标准尚不统一,且有些患者的临床症状不典型,因此不少患者容易出现漏诊,延误病情。综述了国内外有关自发性细菌性腹膜炎的诊断、发病机制及治疗的相关进展,以期为临床医师提供参考,提高自发性细菌性腹膜炎的诊断率,降低临床病死率,改善患者的预后。     

自发性细菌性腹膜炎的诊断及防治

自发性细菌性腹膜炎(SBP)是指在腹腔及邻近组织无感染源(如腹腔脓肿、急性胰腺炎、胆囊炎、肠穿孔等)情况下发生的腹水感染，常见于肝硬化患者。有关该病最早的病例报告见于1907年，但美国学者Conn于1964年最先使用“自发性细菌性腹膜炎”这一术语。     

Early events in spontaneous bacterial peritonitis

Insight into the very early events in the pathogenesis of spontaneous bacterial peritonitis.     

Norfloxacin and trimethoprim-sulfamethoxazole therapy have similar efficacy in prevention of spontaneous bacterial peritonitis

Background and Aim: Although norfloxacin (N) is widely accepted as the drug of choice for spontaneous bacterial peritonitis (SBP) prophylaxis, there is data to suggest that trimethoprim–sulfamethoxazole (TS) may be similarly effective. However, no studies have compared the efficacy and safety of N and TS in SBP prophylaxis. The aim of this retrospective analysis was to compare outcomes in patients who received either N or TS for the prevention of SBP. Methods: Records of all cirrhotic patients prescribed either N or TS for SBP prevention between April 2001 and May 2004 were reviewed. Data collected included age, sex, Child–Pugh score, ascitic protein concentration, etiology of liver disease, infections (SBP, bacteremia, and extraperitoneal infections), side‐effects, and survival. Results: Sixty‐nine patients (18 female, 51 male), mean age 53.9 ± 10.6 years, were prescribed N (n = 37) or TS (n = 32). The Child–Pugh score, model for end‐stage liver disease score, and the prevalence of a low ascitic protein (<15 g/L) were similar between the groups (12.0 vs 12.4, 19.7 vs 18.2, and 78% vs 84%, respectively, P > 0.05). Fourteen (38%) infections occurred in the N group and 16 (50%) in the TS group (P > 0.05). Eight patients (21.6%) in the N group and nine (28%) in the TS group developed SBP (P > 0.05). The rates of liver transplantation (10 vs 13), adverse events (two in each group) and death (13 vs 14) were similar in the two treatment groups. Conclusions: Our findings suggest N and TS have similar efficacy in preventing SBP. This has significant implications for both the cost of SBP prophylaxis and the prevalence of fluoroquinolone resistance in patients with cirrhosis.