Patients with spontaneous bacterial peritonitis, and malignant and cirrhotic ascites

BACKGROUND: Cytokines play a key role in the regulation of cells of the immune system and also have been implicated in the pathogenesis of malignant diseases. METHOD AND PATIENTS: We studied tumor necrosis factor-alpha, tumor necrosis factor receptor and C-reactive protein levels in both ascitic fluid and serum in patients with spontaneous bacterial peritonitis (SBP) (n = 22), and in the malignant (n = 38) and cirrhotic (n = 32) ascites. RESULTS: C-reactive protein, tumor necrosis factor-alpha and tumor necrosis factor receptor levels in the ascitic fluid were found to be elevated in the SBP (p < 0.001) and malignant groups (p < 0.005) when compared with the sterile cirrhotic group. C-reactive protein levels in the serum were found to be elevated in the SBP group when compared with the sterile cirrhotic (p < 0.001) and malignant group (p < 0.005). Tumor necrosis factor-alpha in the serum was significantly elevated in the SBP when compared with the cirrhotic (p < 0.005) and malignant ascites (p < 0.001). Sensitivity and specificity of ascitic fluid CRP in discriminating malignant 84% and 67% and SBP from sterile ascites were 90% and 76%, respectively. Sensitivity and specificity of ascitic fluid TNF-alpha in discriminating malignant 77% and 60% and SBP from sterile ascites were 82% and 66%, respectively. Sensitivity and specificity of TNF-r p60 in discriminating malignant 74% and 70% and SBP from sterile ascites were 80% and 76%, respectively. CONCLUSION: The sensitivity and specificity of ascitic fluid CRP, TNF-alpha and TNF-r values were found to be similar. Ascitic fluid Creactive protein to differentiate SBP and malignant ascitic from cirrhotic ascites are cheap, practical and safe tests used in the differential diagnosis of ascites.     

Spontaneous bacterial peritonitis in patients with decompensated liver cirrhosis and "tense" ascites

In the study 52 patients with decompensated liver cirrhosis and "tense" ascites were included. According to the clinical picture, ascites cultures and the number of polymorphonuclears in cmm of the ascitic fluid, all patients were selected in one of the following groups: 1. group of patients with sterile ascites (28), 2. group of patients with spontaneous peritonitis (16), and 3. group of patients with bacterascites (8). The results have shown that the incidence of spontaneous peritonitis is much higher in the group of "tense" ascites patients than in the group of all patients with ascites, the ratio being 30.7% compared to 6% in all cirrhotic patients with ascites. Spontaneous bacterial peritonitis correlates with increased polymorphonuclears in the ascitic fluid (p less than 0.05), decreased pH values (p less than 0.0), and increased amounts of total proteins in the ascitic fluid (p less than 0.05). The lethality rate in the group of spontaneous peritonitis and sterile ascites was 43.7% and 7.1% respectively. Early diagnosis and, of course, adequate therapy are the main points in spontaneous bacterial peritonitis.     

Improved method for bacteriological diagnosis of spontaneous bacterial peritonitis.

The definitive diagnosis of spontaneous bacterial peritonitis is made by a positive ascitic fluid culture. Causative organisms cannot be isolated in up to 65% of patients with well-defined spontaneous bacterial peritonitis, probably due to inadequate ascites culture techniques. We prospectively compared two ascites culture methods: conventional (on chocolate agar and thioglycolate broth) and modified (inoculation of 10 ml of ascites in a tryptic soy broth blood culture bottle at the patient's bedside). In a 10-month period, 31 cirrhotic patients met our diagnostic criteria for spontaneous bacterial peritonitis; both culture methods were performed on their ascitic fluid. The conventional method grew bacteria in only 16 of the 31 episodes (52%), whereas the modified method grew bacteria in 25 (81%), a significantly higher sensitivity (P less than 0.05). The modified method also shortened significantly the time for detection of bacterial growth. We conclude that ascites inoculation into a blood culture bottle at the patient's bedside should be the routine method for ascites culture.     

Clinical features and outcome of spontaneous bacterial peritonitis in HIV-infected cirrhotic patients: a case-control study

The aim of this study was to evaluate the clinical characteristics and outcome of spontaneous bacterial peritonitis, a serious complication in patients with cirrhosis and ascites, in an HIV-infected cirrhotic population. Thirty-five HIV-infected cirrhotic patients who developed spontaneous bacterial peritonitis during a 12-year period were compared with 70 non-HIV-infected cirrhotic subjects. Patients were matched according to the date of the first episode of spontaneous bacterial peritonitis. A bacteriological diagnosis was made in 37 of 47 (79%) and in 50 of 97 (52%) episodes in the HIV group and in the non-HIV group, respectively (p=0.003), and Streptococcus pneumoniae was isolated more frequently in the HIV group (22 vs. 8%, p=0.02). Median survival after the initial diagnosis of spontaneous bacterial peritonitis was 2.9 and 14.0 months in the HIV group and non-HIV group, respectively. Age (hazard ratio [HR] 1.04; 95%CI 1.01–1.07), male sex (HR 2.55; 95%CI 1.34–4.83), Child–Pugh score at first spontaneous bacterial peritonitis episode (HR 1.29; 95%CI 1.10–1.54), renal impairment at first spontaneous bacterial peritonitis episode (HR 2.61; 95%CI 1.49–4.62), and HIV infection (HR 9.81; 95%CI 4.03–23.84) were independently associated with higher long-term mortality after the first diagnosis of spontaneous bacterial peritonitis. In conclusion, HIV-infected cirrhotic patients with spontaneous bacterial peritonitis have a higher rate of bacteriological diagnosis and a more frequent pneumococcal etiology than non-HIV-infected subjects. Life expectancy in these patients, once spontaneous bacterial peritonitis has developed, is poor. These data are particularly relevant for determining the optimal time for liver transplantation in this population.     

The lactate dehydrogenase activity and isoenzyme pattern of normal and hypokinetic human tendons

Summary The LDH specific activity and the LDH isoenzyme pattern of eleven pairs of different normal tendons were compared with hypokinetic tendons. The LDH specific activity of hypokinetic tendons was 13–66% of the specific activity of normal tendons. The isoenzyme pattern of hypokinetic tendons altered in such a way that — with one exception — the ratio of LDH-5 and LDH-4 decreased and the ratio of LDH-1, LDH-2, and LDH-3 increased and, as a consequence, the amount of the M subunit decreased.     

The efficiency of lactate dehydrogenase isoenzyme determination for the diagnosis of acute myocardial infarction

Values for total lactate dehydrogenase (LDH; EC 1.1.1.27) activity and LDH isoenzymes 1 and 2 were determined in 80 patients with acute myocardial infarction (AMI) and in 40 without AMI every 24 hours up to 15 days after admission, when total serum LDH level returned to normal. The sensitivity, specificity, and efficiency of three LDH isoenzyme factors (LDH-1, greater than 90 U/L; LDH-1 greater than LDH-2; LDH-1/LDH ratio, greater than 0.4) for diagnosing AMI were assessed in three groups of patients according to total serum LDH values--group A, LDH level over 600 U/L; group B, 400 to 599 U/L; group C, 225 to 399 U/L--and in five groups of patients according to the time after admission--(1) first 48 hours; (2) three to five days; (3) six to eight days; (4) nine to 11 days; (5) 12 to 15 days. All three factors were found to be highly efficient for diagnosing AMI (91.5% to 97.5%) in groups A and B, but the most efficient factor in each group was LDH-1 value above 90 U/L. In group C, the only efficient factor was the LDH-1 value over 90 U/L (96%). The most efficient factor for diagnosing AMI in relation to time after admission up to 15 days after AMI was the LDH-1 value over 90 U/L (96% to 97.5%). The factors LDH-1 greater than LDH-2 and LDH-1/LDH above 0.4 were more efficient in patients up to five days after AMI (91.5% to 97.5%) than in patients six to 15 days after admission. We conclude that the most efficient LDH value for diagnosing AMI is the absolute value of LDH-1 above 90 U/L. Its superiority over other LDH isoenzyme values is best documented in a group of patients six to 15 days after admission and with only slight to moderate elevation of total serum LDH values (225 to 399 U/L).     

Serum lactate dehydrogenase isoenzymes in breast tumours

Total serum LDH and its isoenzymes were estimated in 10 female controls and 30 cases of breast lump (22 malignant, 6 benign and 2 breast abscess). In breast malignancy, there was a significant elevation of total LDH and LDH-3, LDH-4 and LDH-5 isoenzymes with a significant fall in LDH-1 and LDH-2 percentage value. Following therapy, there was a significant elevation in LDH-1 and LDH-2 towards normal with a significant fall in total serum LDH and LDH-4 and LDH-5 isoenzymes. The estimation was found to be helpful in assessing the response of patient to the therapy given.     

Influence of maternal nicotine exposure during gestation and lactation on lactate dehydrogenase isoenzyme profile and transcript levels in developing neonatal rat lung

In this study we investigated the effect of (a) aging on rat lung lactate dehydrogenase (LDH) mRNA expression and isoenzyme profile and, (b) the effect of maternal nicotine exposure during gestation and lactation on LDH isoenzyme profile and mRNA expression in the lungs of the offspring. Pregnant rats were injected subcutaneously (1 mg nicotine/kg body weight/day) from day 1 after mating. Lung tissue to determine LDH isoenzyme profile and mRNA expression was obtained from the offspring. LDH mRNA expression and isoenzyme profile was determined on postnatal days 1, 7, 14, 21 and 49. Generally the %Densities of all the isoenzymes decreased between postnatal days 1 and 49. Between postnatal days 7 and 14, a period associated with rapid alveolar formation, all isoenzymes except LDH-1, decreased (P < 0.01). During this period all the isoforms in nicotine-exposed lung increased (P < 0.05). In both control and nicotine-exposed lung LDH-1 is the dominant isoenzyme. The LDH-M and LDH-H isoenzyme levels are higher (P < 0.001) in the lungs of the nicotine exposed rats. Maternal nicotine exposure during gestation and lactation changed the metabolic status of the nicotine-exposed lungs to become more glycolytic compared to that of the control lung. These changes in LDH isoenzyme profiles and mRNA expression are irreversible.     

Enhancement of normal polymorphonuclear cells respiratory burst in ascitic fluid by fibronectin. Comparison between cirrhotic and malignant ascitic fluids.

The chemiluminescence (CL) response of normal peripheral blood polymorphonuclear cells (PMN) in ascitic fluids (cirrhotic = 32; malignant = 17) was studied independently of the ascitic fluid complement activity. CL response and fibronectin levels were higher in malignant ascitic fluid than in cirrhotic ascitic fluid (p less than 0.001). Addition of pure fibronectin or malignant ascitic fluids to cirrhotic ascitic fluids increased the CL response of normal PMN. These findings suggest that the susceptibility of cirrhotic patients to spontaneous bacterial peritonitis (SBP) is a multifactorial defect involving factors distinct from low C3 levels. Fibronectin is an important factor in the promotion of the respiratory burst of normal PMN stimulated by opsonized zymosan or PMA in ascitic fluid. Our results suggest that low levels of ascitic fluid fibronectin could partly explain the high susceptibility of cirrhotic patients to spontaneous bacterial peritonitis.     

胸腹水细胞端粒酶活性定性和定量检测

目的探讨端粒酶活性定量检测在诊断良恶性胸腹水中的应用价值。方法采用TRAP-银染定性方法和rrRAP-PicoGreen定量方法,对102例已确诊患者的胸腹水细胞进行端粒酶活性分析。结果恶性胸腹水细胞端粒酶活性明显高于良性胸腹水细胞,其定性检测诊断率明显高于细胞病理学。乳腺癌患者胸腹水细胞的端粒酶活性明显高于卵巢癌、肝癌患者胸腹水细胞的端粒酶活性;肺癌患者胸腹水细胞端粒酶活性明显高于肝癌。在良性胸腹水中,感染性胸腹水细胞端粒酶活性高于非感染性胸腹水。结论恶性胸腹水细胞端粒酶活性明显升高。端粒酶活性定量检测较定性检测更敏感、简便,对良恶性胸腹水的诊断和鉴别诊断有一定应用价值。     

CT引导下腹膜活检对不明原因腹水的诊断价值

目的：探讨CT引导下经皮腹膜穿刺活检对原因不明腹水的诊断价值 方法：在CT引导下对不明原因腹水患者增厚的腹膜穿刺活检并行病理组织学检查。6例患者共行7次穿刺，每次取2-3块腹膜壁层组织。结果：6例中经活检明确腹水原因，其中经病理证实结核性腹膜炎3例，转移性腺癌2例；另1例无明确意义（大致正常腹膜组织）。结论：经皮腹膜穿刺活检对不明原因腹水的诊断，特别是对结核性腹膜炎和腹膜肿瘤的鉴别诊断具有重要的价值。     

A characterization of human B and T lymphocytes by their lactate dehydrogenase isoenzyme pattern

Human lymphocytes have been separated by two different techniques: the rosette sedimentation technique and the nylon wool column filtration method. The unseparated lymphocytes and each B and T fraction obtained, were examined according to their capacity to form E and erythrocyte antibody-complement complex (EAC) rosettes. The lactate dehydrogenase (LDH) isoenzyme pattern was studied on each cell population after agar gel electrophoresis. The T lymphocytes showed a significantly higher activity in the LDH-1 band compared to the B lymphocytes. Previous contradictory reports on the LDH isoenzyme pattern of unseparated lymphocytes and the characterstic decrease of the LDH-1 band observed in chronic lymphocytic leukemia cells are discussed. A possible application of the isoenzyme distribution in B and T cells, i.e. a criterion for characterization of human B and T lymphocytes, is proposed.     

The Role of Serum Procalcitonin Levels in Predicting Ascitic Fluid Infection in Hospitalized Cirrhotic and Non-cirrhotic Patients

Objective: To determine the role of serum procalcitonin levels in predicting ascites infection in hospitalized cirrhotic and non-cirrhotic patients.Methods: A total of 101 patients (mean age: 63.4±1.3, 66.3% were males) hospitalized due to cirrhosis (n=88) or malignancy related (n=13) ascites were included in this study. Spontaneous bacterial peritonitis (SBP, 19.8%), culture-negative SBP (38.6%), bacterascites (4.9%), sterile ascites (23.8%) and malign ascites (12.9%) groups were compared in terms of procalcitonin levels in predicting ascites infection. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of procalcitonin levels and predicting outcome of procalcitonin levels was compared with C-reactive protein (CRP).Results: Culture positivity was determined in 26.7% of overall population. Serum procalcitonin levels were determined to be significantly higher in patients with positive bacterial culture in ascitic fluid compared to patients without culture positivity (median (min-max): 4.1 (0.2-36.4) vs. 0.4 (0.04-15.8), p<0.001). Using ROC analysis, a serum procalcitonin level of <0.61 ng/mL in SBP (area under curve (AUC): 0.981, CI 95%: 0.000-1.000, p<0.001), <0.225 ng/mL in culture-negative SBP (AUC: 0.743, CI 95%: 0.619-0.867, p<0.001), <0.42 ng/mL in SBP and culture-negative SBP patients (AUC: 0.824, CI 95%: 0.732-0.916, p<0.001), and <1.12 ng/mL in bacterascites (AUC: 0.837, CI 95%: 0.000-1.000, p=0.019) were determined to accurately rule out the diagnosis of bacterial peritonitis. Predictive power of serum procalcitonin levels in SBP + culture-negative SBP group (AUCs: 0.824 vs 0.622, p=0.004, Fig 4), culture-positive SBP (AUCs: 0.981 vs 0.777, p=0.006, Fig 5) and (although less powerfull) in culture-negative SBP (AUCs: 0.743 vs 0.543, p=0.02, Fig 6) were found significantly higher than CRP.Conclusion: According to our findings determination of serum procalcitonin levels seems to provide satisfactory diagnostic accuracy in differentiating bacterial infections in hospitalized patients with liver cirrhosis related ascites.     

Reabsorption of ascites and the factors that affect this process in cirrhosis

Ascites is one of the main features of liver decompensation in cirrhosis, and it is considered to be a dynamic process. In this study, we aimed to (1) measure the reabsorption rate of ascites; (2) evaluate whether these findings were related to features of ascites, hemodynamics, and serum measurements; and (3) examine morphologic changes in the diaphragm of cirrhotic patients. In all, 42 cirrhotic patients with ascites were enrolled in the study to comprise our study group. Using the dextran 70 test, patient ascites volumes and reabsorption rates were measured. Biopsies from the peritoneal side of the diaphragm were also processed for scanning electron microscopy and lymphatic immunohistochemical studies from the cirrhotic patients and control cadavers. The mean ascites reabsorption rate was 4.5 +/- 4.5 (0.18-14.6) mL/min, which correlated significantly with the calculated ascites volume (r = 0.75, P < 0.001). The mean ascites viscosity was 1.07 +/- 0.07 (0.99-1.17) centipoise, which demonstrated a high degree of negative correlation with the ascites reabsorption rate (r = -0.77, P < 0.001). Patients with a history of spontaneous bacterial peritonitis had significantly lesser ascites reabsorption rates than patients without this particular history. The size of lymphatic stomata in scanning electron microscopy depictions was increased, and lymphatic lacunae were dilated in immunohistochemical studies in the cirrhotic patients with ascites. However, these findings were not uniform in every cirrhotic patient with ascites. The volume and viscosity of ascites seem to influence its reabsorption rate. Additionally, previous episodes of spontaneous bacterial peritonitis may be responsible for the decreased ascites reabsorption rates observed in certain patient populations.     

Klebsiella pneumoniae septic arthritis in a cirrhotic patient with hepatocellular carcinoma

Despite septic arthritis is increasingly being reported in elderly patients with diabetes or alcoholism, reported cases of spontaneous bacterial arthritis in cirrhotic patients are extremely rare. We present the first reported case of K. pneumoniae septic arthritis and spontaneous bacterial peritonitis in a cirrhotic patient with hepatocellular carcinoma. K. pneumoniae, one of the most common causative organisms of spontaneous bacterial peritonitis in cirrhotic patients, was isolated from both the blood and the joint fluid, which suggests that the route of infection was hematogenous. After the treatment with cefotaxime and closed tube drainage, the condition of the patient was improved, and subsequently, the joint fluid became sterile and the blood cultures were proved negative. Therefore, this case provides further evidence for the mode of infection being bacteremia in cirrhotic patients and suggests that the enteric bacteremia in cirrhotics may cause infection in different organ systems.     

Diagnostic accuracy of adenosine deaminase for tuberculous peritonitis: a meta-analysis

Introduction

Tuberculous peritonitis remains a diagnostic challenge for clinicians. Many studies have investigated the usefulness of adenosine deaminase (ADA) in ascites for the diagnosis of tuberculous peritonitis; however, the overall diagnostic accuracy of ADA for tuberculous peritonitis remains unclear. The aim of the present meta-analysis was to determine the overall accuracy of ADA measurements in the diagnosis of tuberculous peritonitis.

Material and methods

We performed a systematic search in PubMed and Embase to identify published studies that evaluated the diagnostic role of ADA for tuberculous peritonitis. Quality was assessed according to standardized Quality Assessment of Diagnostic Accuracy Studies criteria. Sensitivity, specificity and other measures of accuracy of ADA assay in order to diagnose tuberculous peritonitis were pooled using random effects models. Summary receiver operating characteristic curve (SROC) was used to summarize overall test performance.

Results

Sixteen studies met inclusion criteria for the present meta-analysis. The pooled sensitivity and specificity for diagnosing tuberculous peritonitis were 0.93 (95% CI: 0.89–0.95) and 0.96 (95% CI: 0.94–0.97), respectively. The positive likelihood ratio was 15.80 (95% CI: 10.87–22.95), negative likelihood ratio was 0.09 (95% CI: 0.05–0.16) and diagnostic odds ratio was 249.28 (95% CI: 113.11–549.39). The area under the SROC was 0.98.

Conclusions

Ascitic ADA determination is a relatively sensitive and specific test for the diagnosis of tuberculous peritonitis. Measurement of ADA in ascites is thus likely to be a useful diagnostic method for tuberculous peritonitis.     

ADA、ACE、LDH、CEA的联合检测在结核性和恶性胸腔积液中的鉴别诊断价值

目的测定血清和胸水中腺苷脱氨酶（ADA）、血管紧张素转化酶（ACE）、乳酸脱氢酶（LDH）与癌胚抗原（CEA）的水平,探讨其指标联合检测对结核性和恶性胸水的鉴别诊断意义。方法对临床已确诊的72例胸腔积液患者（结核性40例,恶性32例）的胸水和血清分别采用酶免疫法和化学发光法进行ADA、ACE、LDH和CEA含量测定。结果结核性胸水中ADA的含量为（60.2±20.10）U/L,ACE的含量为（35±9.6）U/L,LDH的含量为（338±41）U/L,CEA的含量为（12.8±5.82）μg/L;在恶性胸水中,ADA为（11.02±5.23）U/L,ACE为（16±11.0）U/L,LDH为（379±69.0）U/L,CEA为（39.9±19.7）μg/L。结核性胸水ADA和ACE含量较恶性胸水组明显增高（P〈0.01）,CEA在恶性胸水中含量较结核性胸水组明显增高（P〈0.01）。胸水中ADA和ACE的检测对结性性胸膜积液诊断的敏感性分别为84.3%、87.5%,特异性分别为87.5%、80.0%;而胸水中LDH和CEA的检测对恶性胸膜积液诊断的敏感分别为84.3%、75.0%,特异性分别为80.0%、93.0%。四项指标联合检测敏感性性为78.1%,特异性为97.5%,较单一指标的特异性高。结论胸水中ADA、ACE、LDH和CEA的联合检测对结核性和恶性胸水的鉴别诊断具有一定价值,有助于临床胸水性质的诊断。     

Tuberculous peritonitis during etanercept therapy for rheumatoid arthritis

In August 2010, a 73-year-old woman with rheumatoid arthritis receiving etanercept (ETN) therapy for two years, developed high-fever and abdominal fullness. Though she had not been exposed to tuberculosis, isoniazid prophylaxis was administrated. Antibiotics were not effective. CT images revealed the massive ascites and peritonitis, and Ga scintigraphy demonstrated notable uptake in the peritoneum. Ascites analysis showed an elevated adenosine deaminase activity value (104.9 IU/l) without malignant cells. Moreover, PCR and culture for Mycobacterium tuberculosis were positive. Finally, a diagnosis of tuberculous peritonitis was established. After initiating a standard anti-tuberculosis regimen with four drugs, her clinical condition ameliorated and ascites promptly regressed. Although the tuberculous peritonitis during ETN therapy is rare, this report emphasized the importance of initial suspicion of tuberculosis in these patients with tumor necrosis factor inhibitors such as ETN.     

Lactate Dehydrogenase Isoenzyme Pattern: Marker for Differentiation of Lymphocytes

The lactate dehydrogenase isoenzyme pattern has been determined in different murine thymocyte cell populations. Enrichment of thymocytes with more mature cells through total irradiation results in a smaller percentage of LDH-1, LDH-2, LDH-3 and a greater percentage of LDH-4 and LDH-5. Fractionation of normal thymocytes by velocity sedimentation at unit gravity yields a fraction of cells with a high sedimentation rate. LDH-1 and LDH-2 formed a smaller percentage of the total enzyme activity in these cells. These findings indicate that the LDH isoenzyme distribution is a marker for differentiation of thymocytes.     

Changes in nature and antibiotic resistance of bacteria causing peritonitis in cirrhotic patients over a 20 year period.

AIM: To assess all clinically and bacteriologically documented episodes of spontaneous bacterial peritonitis diagnosed in a single unit over a 20 year period, to identify changes in the nature and antibiotic resistance of the causative bacteria. SETTING: A specialist liver disease unit in a tertiary care centre. MATERIAL: Cultured ascitic fluid obtained in the course of 240 consecutive episodes of clinically and bacteriologically proven spontaneous bacterial peritonitis. Patient recruitment remained stable during the 20 year period in terms of the number of cirrhotic patients admitted and the severity of their condition. RESULTS: 78.7% of isolates were Enterobacteriaceae (Escherichia coli in 51%) and 19% were Gram positive cocci. Until 1979 all the Enterobacteriaceae had the wild phenotype, compared with only 50% at the end of the study period. Since 1993, 22% of Enterobacteriaceae have been resistant to third generation cephalosporins. Methicillin resistant staphylococci were only isolated after 1989. CONCLUSIONS: Changes in the epidemiology and antibiotic resistance of bacteria causing spontaneous bacterial peritonitis must be monitored for optimal treatment.