肝硬化合并原发性腹膜炎111例诊断与治疗

目的提高治疗肝硬化合并原发性腹膜炎患者的疗效和改善预后。方法以肝硬化合并原发性腹膜炎患者为研究对象,详细记录患者的体温、腹部症状、体征、血象、腹水中多核细胞数和腹水培养情况。在输注血浆、白蛋白等对症治疗的基础上,根据药敏试验和临床经验使用适当的抗菌药物,观察患者的体温、腹部症状和体征的转归情况。结果近7年半收治各类肝硬化患者299例,确诊或疑诊为原发性腹膜炎患者共111例,伴有不同程度的腹胀、腹痛、腹部压痛、反跳痛和张力增高等症状和体征,感染发生率37.12%(111/299)。体温高于37.4℃75例;外周血WBC计数>10×109/L35例;中性粒细胞分类>804例;腹水中多核细胞计数>0.25×109/L33例。腹水培养结果仅1例患者细菌培养阳性。肝硬化合并原发性腹膜炎患者Child-pughB和C级人数明显多于Child-pughA级者。治愈、好转61例(55.0%),无效、恶化26例(23.4%),死亡24例(21.6%)。结论肝硬化患者合并原发性腹膜炎的症状和体征不够典型,腹水培养阳性率低。及时有效的使用合适的抗菌药物治疗,能提高疗效、改善预后。     

终末期肝病并自发性腹膜炎109例临床分析

目的分析终末期肝病患者并自发性腹膜炎的临床特征。方法以重型肝炎、肝硬化及原发性肝癌患者为研究对象,详细记录其临床症状、体征及实验室检查,根据腹水培养及药敏试验结果选择合适的抗生素,观察其疗效及转归并判断其预后。结果终末期肝病并自发性腹膜炎(SBP)109例,占所观察532例肝病患者的20.49%,其中,重型肝炎占46.53%(47/101),肝硬化占14.61%(52/356),原发性肝癌占13.33%(10/75),分别死亡27例、4例和3例;外周血白细胞>10.0×109/L者29例(26.61%),中性粒细胞分类>0.7者62例(56.88%),体温>38℃者21例,腹水培养阳性率为19.26%,其中大肠埃希菌占培养阳性者占38.10%,治疗有效率为66.06%。结论终末期肝病并SBP临床表现不典型,存在脾功能亢进,白细胞减少,腹水培养阳性率低,因此以腹水白细胞、多形核细胞及血白细胞分类作为诊断SBP的主要依据。重型肝炎并SBP发生率高于肝硬化及肝癌,同时三者的病死率均高于不并发SBP者。因此,预防SBP的发生,给予敏感药物积极有效治疗SBP对提高终末期肝病患者疗效及改善预后有积极意义。     

肝硬化并发自发性细菌性腹膜炎的临床特征及病原菌耐药分析

目的探讨肝硬化合并自发性细菌性腹膜炎(SBP)的临床特征及病原菌耐药情况。方法分析135例肝硬化合并SBP患者在抗感染治疗前后体温、腹部症状和体征、血常规、腹水白细胞及多核细胞数变化、腹水培养及药物敏感试验。结果 82.2%患者有发热,90.4%有腹部症状,88.9%有中等以上腹水7,0.4%有顽固性腹水;21.5%外周血白细胞数≥10.0×109/L,63.7%中性粒细胞0.7;45.2%腹水白细胞数0.5×109/L,57.8%多核细胞0.5;25.4%(30/118)细菌培养阳性,其中革兰氏阴性菌25例(83.3%),革兰氏阳性菌5例(16.7%),检测出的革兰氏阴性菌对大部分常用的抗菌药物耐药;治愈40例(29.63%),好转48例(35.56%),无效、恶化或自动出院47例(34.81%),其中死亡15例。结论肝硬化合并SBP的临床症状不典型,腹水培养阳性率低,以革兰阴性菌为主。除应尽早行腹水培养外,需根据临床症状、体征、血常规、腹水常规检查等综合分析,及时应用有效抗生素治疗,以提高患者的生存率。     

肝病腹膜炎腹水检查的评价

重症肝炎及失代偿肝硬变病人合并原发性细菌性腹膜炎是临床上常见的合并症,国外报告住院肝硬变病人中发生率为3％,在肝硬变腹水病人中约占8％。肝病并发腹膜炎预后很差,其病死率可达50～90％。因此及时确诊、迅速救治具有重要意义。然而由于本病的临床症状及体征往往不典型,因而给诊断造成一定困难。Correia报告25例腹膜炎中54％无腹部体征,其中10例临床上未怀疑腹膜炎,3例未述及腹部症状。Conn报告6％的病人无     

老年严重肝病患者并发原发性腹膜炎50例临床分析

严重肝病患者并发原发性腹膜炎时,临床表现常不典型,故不能及时诊断治疗,严重影响病人的预后。为探讨老年肝病患者并发原发性腹腹炎的临床特点及治疗措施,现将我院1966～1988年间收治的住院患者50例进行分析。 一、病例选择 均为≥55岁的重型病毒性肝炎及失代偿肝硬变患者,在排除继发性腹腹炎后具备发热、腹痛、腹部压痛及反跳痛筹;腹水检查符     

血必净注射液治疗肝硬化并原发性腹膜炎45例疗效观察

原发性腹膜炎(Spontaneous Bacterial Peritonitis,SBP)是发生在肝硬化基础上的腹水感染,是严重肝病伴发腹水患者的常见和危险的并发症,病情严重易引发多脏器功能衰竭,是引起患者病情加重和死亡的主要原因.及时、有效的治疗可使SBP的治愈率明显提高.笔者从2007年3月至2008年7月以抗生素联合静脉滴注血必净注射液治疗肝硬化并原发性腹膜炎45例,并与传统常规方法治疗的40例对比观察,现报告如下.     

失代偿期肝硬化腹水并发白发性细菌性腹膜炎52例临床分析

目的探讨失代偿肝硬化腹水并发自发性细菌性腹膜炎（SBP）的临床特点及治疗方法。方法回顾性分析52例肝硬化腹水并发SBP患者的临床资料。结果52例肝硬化腹水并发SBP患者中,腹水细菌培养阳性率为3．85％,致病菌以革兰阴性杆菌为主,多数患者缺乏典型腹膜炎的症状及体征。结论及时准确的早期诊断和有效抗菌素治疗可明显提高SBP患者的治愈率。     

自发性细菌性腹膜炎诊断和治疗现状

感染是肝硬化患者的常见并发症,而自发性细菌性腹膜炎(SBP)为最常见的感染类型。总结基于腹水多核细胞数大于250/μl的SBP诊断标准形成过程、腹水细胞计数的局限性和SBP的治疗现状。提示目前SBP的诊断需要新的灵敏检测标志物,用于指导临床经验性抗菌治疗,从而优化SBP患者管理。     

肝硬化并发自发性细菌性腹膜炎临床分析

目的探讨肝硬化并发自发性腹膜炎的临床特点。方法回顾性统计分析73例失代偿期肝硬化临床资料。结果多数患者缺乏腹膜炎的症状、体征,腹水细菌培养阳性率14%。结论肝硬化并发SBP的诊断不能单纯依赖腹水中的细胞计数而PMN计数是诊断SBP的重要指标。     

肝硬化合并自发性细菌性腹膜炎患者腹水培养阳性的病原菌分析

目的探讨肝硬化合并自发性细菌性腹膜炎(SBP)的临床诊断及病原菌分布特点。方法以我院2001年1月至2003年4月诊断为肝硬化合并 SBP 腹水细菌培养结果阳性的住院患者为研究对象,详细记录患者的体温、腹部症状、体征、血常规、腹水中白细胞总数、多核细胞数(PMN)、腹水培养、耐药情况以及治疗和转归。结果发热81例(76.4%),腹痛60例(56.6%),腹部压痛或反跳痛55例(51.9%);血常规:白细胞(WBC)≥10×10~9/L 37例(34.9%),中性粒细胞≥0.7 91例(85.8%);腹水检查:白细胞总数>0.5×10~9/L 47例(44.3%),PMN≥250个/mm~3 40例(37.7%);细菌培养共分离出细菌109株25种,103例患者为单菌感染,占97.2%,革兰阴性菌89例(81.7%),分别是大肠埃希菌和肺炎克雷伯杆菌,革兰阳性菌15例(13.8%),真菌5例(4.5%);药敏试验无耐药者9例(8.3%),单类耐药者6例(5.5%),3类以上(包括3类)抗菌药物耐药细菌76例(69.7%);治愈好转52例(49.1%),自动出院8例(7.5%),死亡46例(43.3%),其中25例(53.4%)死于肝肾综合征。结论 1.对肝硬化患者判断有无合并 SBP 除应尽早进行腹水培养外,需根据临床症状、体征、血常规、腹水常规检查等综合分析。2.SBP 感染的病原菌绝大多数为肠道内正常菌群,革兰阴性菌为主,单一菌种多见。3.预后差,耐药率升高是影响预后的主要原因之一,死因主要为肝肾综合征。     

Spontaneous bacterial peritonitis]

Patients with liver cirrhosis and ascites suffer from spontaneous bacterial peritonitis (SBP) in up to 25%. The typical clinical signs are abdominal pain with tenderness and fever. 30% have no signs of peritonitis. Then clinical worsening, encephalopathy, rising serum creatinine levels, and therapy resistant ascites may be the only clinical features. SBP must be differentiated from bacterascites and culture negative neutrocytic ascites by the polymorphonuclear neutrophil (PMN) count in the ascites and the presence of positive culture results, which has prognostic implications. Gram negative rods from the colon play an important etiological role in SBP. Gastrointestinal bleeding, lack of serum complement, a low ascites protein and the extent of intrahepatic shunts predispose to SBP. Then, prophylaxis with the comparable drugs neomycin and norfloxacin is indicated. Coexisting encephalopathy has to be treated by the therefore effective neomycin. Otherwise, norfloxacin is the drug of choice because of better acceptance and lower costs. Chemical parameters of the ascites (pH value less than 7.4; LDH and lactate greater than serum levels; glucose less than 50 mg%) help to assess the severity of peritonitis. The course of ascitic PMN under therapy and the time of persisting positive cultures can discriminate SBP from secondary peritonitis. Antibiotics of choice are amoxicillin-clavulanic acid and cefotaxime. Short course therapy (5 days) is a effective as long course therapy (10 days). Today SBP is no more life-threatening because diagnosis, prophylaxis and therapy have improved. However, complication rate of patients with liver cirrhosis and ascites has not changed.     

Re-evaluation of the value of ascitic fluid pH lactate dehydrogenase and total proteins in the diagnosis of spontaneous bacterial peritonitis (SBP)

In view of high mortality, variable clinical presentation, and late results of bacterial culture, early diagnosis of SBP and treatment are based on indirect parameters of infection. Forty-two patients with ascites and liver cirrhosis were studied. Ascitic fluid (AF) was examined for total protein content, pH, lactate dehydrogenase, amylase, absolute polymorphonuclear cell count (PMN) and for presence of bacteria by examining a fresh smear of the deposit and culture of the fluid under aerobic and anaerobic conditions. AF/serum gradient of total proteins and LDH was calculated. One patient proved to have a malignant ascites and was excluded. The remaining 41 patients fell into two groups: Group I PMN less than 250 cell mm-3, culture negative, sterile ascites, 36 patients. Group II PMN greater than 250 cell mm-3. (a) Culture positive neutrophilic ascites (SBP), three patients. (b) Culture negative neutrophilic ascites (CNNA), two patients. In both CNNA and SBP:AF/serum total LDH gradient greater than 0.75 In the sterile group: AF/serum total LDH gradient less than 0.58 There was no correlation between presence of infection and ascitic fluid pH, protein content and AF/serum total protein gradient. Therefore AF PMN greater than 250 mm and AF/serum total LDH gradient greater than 0.6 should be considered reliable, indirect parameters of infection, and CNNA a variant of SBP with a small bacterial inoculum size.     

Identification of bacterial DNA in neutrocytic and non‐neutrocytic cirrhotic ascites by means of a multiplex polymerase chain reaction

Background: Even though bacterial cultures of ascitic fluid are negative in up to 65% of the cases of spontaneous bacterial peritonitis (SBP); bacterial DNA (bactDNA) has been frequently detected in episodes of SBP as well as in culture‐negative non‐neutrocytic ascites. Aims: To evaluate multiplex polymerase chain reaction (PCR) for pathogen identification in SBP and to determine the prevalence of ascitic bactDNA and its prognostic relevance in hospitalized patients with liver cirrhosis. Methods: Ascitic fluid from 68 consecutive patients who underwent diagnostic paracentesis was analysed for polymorphonuclear leucocyte (PMN) count, bacterial culture and bactDNA. BactDNA was identified by gel analysis after multiplex PCR of selectively enriched prokaryotic nucleic acids. Correlations of bactDNA status with PMN count, bacterial culture result and 3‐month mortality were determined for neutrocytic and for non‐neutrocytic ascites. Results: 11/68 patients presented with an elevated ascitic PMN count. BactDNA was detected in 5/5 culture‐positive neutrocytic samples, in 1/6 culture‐negative neutrocytic samples and in 8/56 culture‐negative non‐neutrocytic samples. Three‐month mortality did not differ with respect to ascitic bactDNA status (7/14 vs. 14/47, P=0.162). 3‐month mortality was increased in the presence of ascitic bactDNA for patients older than 65 years (4/5 vs. 4/14, P=0.046) and for patients with a model for end‐stage liver disease score >15 (7/10 vs. 9/30, P=0.025). Conclusions: Identification of ascitic bactDNA is an appropriate alternative to bacterial ascite culture for pathogen identification in patients at risk for SBP. Its prognostic relevance as a proposed marker of bacterial translocation for certain risk groups has to be further evaluated.     

Prevalence of Peritonitis and the Ascitic Fluid Protein Concentration among Chronic Liver Disease Patients

The prevalence of spontaneous bacterial peritonitis (SBP) or its variants, bacterascites (BA), and culture-negative neutrocytic ascites (CNNA), may vary depending on the underlying liver disease and protein content of ascites. In this study, we compared the frequency of peritonitis (SBP, BA, CNNA) upon admission in alcoholic (ALD), cholestatic (CLD), and hepatocellular liver disease (HLD); determined the relationship between Child's class and prevalence of peritonitis; and assessed ascitic total protein as a risk factor for peritonitis. Between January 1989 and April 1991, 113 consecutive patients were admitted with chronic liver disease and ascites (49, ALD; 22, CLD; and 42, HLD). All had admission paracentesis. SBP was defined as polymorphonuclear cell count (PMN) ≥250 mm³ with a positive culture, BA as PMN <250/mm³ and positive culture, and CNNA as PMN 250/mm³ with negative culture. No patients with obvious intraabdominal source for infection ( i.e. , secondary peritonitis) were included in the analysis. The prevalence of peritonitis was 8/113 (7%); four patients had SBP, one BA, and three CNNA. The occurrence of peritonitis was independent of the type of liver disease (ALD, 8%; CLD, 9%; HDL, 5%). Neither ascitic fluid total protein nor the severity of liver disease (Child's class) predicted the occurrence of peritonitis. We conclude that the occurrence of peritonitis is unrelated to the type of liver disease, and severity of liver disease did not predict the presence of peritonitis. Also, ascitic fluid total protein <1.0 g/dl may not be a sensitive predictor of risk of peritonitis.     

Spontaneous bacterial peritonitis.

SBP is an infection of ascites that occurs in the absence of a local infectious source. It is mainly a complication of cirrhotic ascites, with a prevalence of 15% to 19% (when culture-negative cases are included). Gram-negative enteric bacteria are the causative agents in more than 70% of cases. SBP is probably the consequence of bacteremia due to defects in the hepatic reticuloendothelial system and in the peripheral destruction of bacteria by neutrophils, with secondary seeding of an ascitic fluid deficient in antibacterial activity. Patients with advanced liver disease and low ascitic fluid protein concentrations seem to have an increased susceptibility to SBP. A diagnostic paracentesis should be performed in any cirrhotic patient who suddenly deteriorates or presents with any compatible symptom of SBP, most frequently fever or abdominal pain, or both. A PMN count greater than 500/mm3 is indicative of SBP, and treatment with intravenous broad-spectrum antibiotics should be initiated immediately. Although the mortality of an acute episode of SBP decreases with early therapy, it is still high (approximately 50%), and patients who survive an episode of SBP have a high frequency of recurrence. Mortality seems to be related to the severity of the underlying liver disease, because only a third of patients die from sepsis and prophylactic antibiotics decrease the frequency of SBP but do not seem to improve long-term survival.     

肝硬化合并自发性细菌性腹膜炎预后影响因素分析

目的探讨肝硬化合并自发性细菌性腹膜炎（SBP）预后的影响因素。方法回顾性分析135例肝硬化合并SBP患者的临床资料,根据其预后分为存活组（88例）与死亡组（47例）,比较两组病例年龄、性别、既往SBP史、症状与体征、Child-Pugh分值、外周血和腹水中白细胞数、并发症、重要生化指标等因素。结果两组病例在年龄、既往SBP史、腹部多数症状及其它（呃逆、黄疸加深、休克）、Child-Pugh评分、外周血中性粒细胞比例、腹水白细胞数及多核粒细胞（PMN）比例、多数并发症及发生并发症个数、重要生化指标间差异均有统计学意义（P〈0.05,P〈0.01）。结论年龄、既往SBP史、多数症状与体征、Child-Pugh评分、外周血中性粒细胞比例、腹水白细胞数及多核粒细胞（PMN）比例、重要生化指标及并发症等因素均影响肝硬化并SBP患者转归,可作为评价此病预后的重要指标。     

肝功能衰竭合并自发性腹膜炎的特点分析及治疗体会

目的分析肝衰竭合并自发性腹膜炎患者的临床特点及治疗疗效。方法回顾性研究201例肝硬化合并自发性腹膜炎患者,将其分为两组,分别为肝衰竭组及对照组,研究两组患者血常规、腹水细胞计数和腹水培养情况,进行t检验或χ2检验。对肝衰竭合并自发性腹膜炎患者中经验使用抗菌药物（三代头孢、莫西沙星、亚胺培南）的临床疗效进行分析。结果肝衰竭合并腹膜炎组患者血中中性粒细胞比例、PCT〈2的比例、腹水细胞总数分别为（81.50±9.25）%、12.5%、（3.43±0.44）log/ml高于对照组（P〈0.05）。两组腹水培养阳性率均较低,分别为22.7%及15.9%,两组间差异无统计学意义（P〉0.05）。肝衰竭组腹水培养结果大肠杆菌所占比例为35.0%,对三代头孢普遍敏感率为25.0%,均低于对照组（分别为72.2%,66.7%）,差异有统计学意义（P〈0.05）。在肝衰竭合并腹膜炎组中应用亚安培南及莫西沙星治疗的有效率分别为84.0%、74.0%,高于三代头孢（52.6%）,平均治疗时间分别为（7.10±1.64）d、（8.50±2.57）d短于三代头孢组（12.20±4.11）d,差异有统计学意义（P〈0.05）。结论肝衰竭合并自发性腹膜炎的感染重,腹水培养阳性率低,对三代头孢的敏感率低,亚安培南及莫西沙星治疗疗效优于三代头孢。     

Total ascitic fluid leukocyte count for reliable exclusion of spontaneous bacterial peritonitis in patients with ascites

BACKGROUND AND AIMS: The diagnosis of spontaneous bacterial peritonitis (SBP) in patients with ascites is established by definition with a polymorphonuclear (PMN) cell count in the ascitic fluid greater than 0.250 g/l determined via cytological (microscopic) examination. In this study, we correlated the automatically assessed total ascitic nucleated cell count with PMN and determined its predictive value for diagnosis of SBP. METHODS: Six hundred and eleven consecutive paracenteses of 179 patients with ascites of various aetiologies (liver cirrhosis, hepatocellular carcinoma, peritoneal carcinomatosis, and ascites of other aetiology) were studied retrospectively. RESULTS: The most reliable diagnostic cut-off level was determined for differentiation between SBP and non-SBP via receiver operating characteristics analysis. A total ascitic nucleated cell count less than 1.0 g/l is unlikely to represent SBP (negative predictive value, 95.5%). CONCLUSIONS: If ascitic fluid samples with machine-made total ascitic nucleated cell count below 1.0 g/l are not followed by additional laboratory tests, the risk of missing the diagnosis of SBP is low. Applying these criteria we would have classified 51 samples of 611 samples (20 of 179 patients) wrongly using the cut-off value of 1 g/l. On the other hand we would have spared cytologic evaluation in about 63% of paracentesis performed in our hospital. Nevertheless, to insure patient safety, standard laboratory analysis is recommended in circumstances of clinical uncertainty. Thus, patients with first manifestation of ascites should always receive cytologic examination and full diagnostic investigation to exclude other causes of ascites.     

血清降钙素原和C-反应蛋白水平预测肝硬化患者发生自发性细菌性腹膜炎的价值分析

目的 评估血清C-反应蛋白(CRP)和降钙素原(PCT)预测失代偿期肝硬化患者发生自发性细菌性腹膜炎(SBP)的临床价值。 方法 2014年12月～2018年6月我院住院的失代偿期肝硬化患者148例,检测血清CRP和PCT及腹水多形核细胞(PMN)计数,采用二分类Logistic回归分析和受试者工作特性曲线(ROC)下面积(AUC)分析指标诊断SBP的效能。 结果 在148例失代偿期肝硬化患者中,诊断SBP 90例,非感染性腹水患者58例;SBP患者Child-Pugh评分为(11.5±1.4),显著高于肝硬化患者,腹水PMN计数为 280.0(61.5,582.0)×10⁶/L,显著高于肝硬化患者,外周血WBC计数为(7.5±3.2)×10⁹/L,显著高于肝硬化患者,血清PCT为[3.91(1.32,9.61)ng/ml,显著高于肝硬化患者, 血清CRP为(32.0±21.7)mg/L,显著高于肝硬化患者; Logistic回归分析结果显示腹水PMN计数、血清PCT和CRP水平是失代偿期肝硬化患者发生SBP的独立危险因素(P均<0.05);腹水PMN计数、血清PCT和CRP诊断SBP敏感性分别为75.6%、73.3%和72.2%,特异性分别为68.9%、75.6%和88.9%,而以血清PCT=0.45ng/ml和CRP=12.68 mg/L为同时必须达到的标准,结果联合检测诊断SBP的敏感性为66.7%,特异性为90.0%。结论 检测腹水PMN计数及血清PCT和CRP水平有助于早期诊断失代偿期肝硬化患者并发SBP,对早期治疗有很大的益处。