肝炎肝硬化并自发性腹膜炎的临床分析

目的探讨肝炎肝硬化并自发性细菌性腹膜炎的临床特点以及临床诊治方法。方法回顾性分析本院2010年1月至2013年12月间41例肝炎后肝硬化合并自发性细菌性腹膜炎患者的临床资料。结果 41例患者多临床表现不典型,腹水细胞计数和腹水细菌培养作为主要诊断依据,治愈好转35例,死亡6例(Child-Pugh分级B级全部治愈)。结论及时观察临床表现,进行必要的腹水检查,早期明确诊断、针对性的治疗有助于肝炎肝硬化并自发性腹膜炎治疗。     

自发性细菌性腹膜炎发病机制、诊治、预后进展

自发性腹膜炎是肝硬化腹水患者一种常见而严重的并发症,是肝硬化腹水患者死亡的主要原因之一。但其发病机制目前还不完全清楚,其致病菌大多数为需氧菌,症状常不典型,早期诊断是治疗的关键,自发性腹膜炎的治疗是很复杂的综合性治疗,本文从病原学、发病机制、临床表现、诊断、治疗及预防等方面对自发性腹膜炎进行综述,以期对临床医师提供一个参考。     

Bacterial DNA in the diagnosis of spontaneous bacterial peritonitis

Aliment Pharmacol Ther 2011; 33: 275–284

Summary

Background Despite inoculation into blood culture bottles, ascitic fluid culture is negative in 50% of cases of spontaneous bacterial peritonitis (SBP). Aim To determine whether 16S rDNA gene detection by real‐time polymerase chain reaction (PCR) and sequencing increases the efficacy of culture in microbiological diagnosis of spontaneous bacterial peritonitis. Methods We prospectively included 55 consecutive spontaneous bacterial peritonitis episodes in cirrhotic patients, 20 cirrhotic patients with sterile ascites and 27 patients with neoplasic ascites. Ascitic fluid was inoculated into blood culture bottles at the bedside and tested for bacterial DNA by real‐time PCR and sequencing of 16S rDNA gene. Results Bacterial DNA was detected in 23/25 (92%) culture‐positive SBP, 16/30 (53%) culture‐negative SBP (P = 0.002 with respect to culture‐positive SBP), 12/20 (60%) sterile ascites (P = 0.01 with respect to culture‐positive SBP) and 0/27 neoplasic ascites (P < 0.001 with respect to other groups). Sequencing identified to genus or species level 12 culture‐positive SBP, six culture‐negative SBP and six sterile ascites. In the remaining cases with positive PCR, sequencing did not yield a definitive bacterial identification. Conclusions Bacterial DNA was not detected in almost half the culture‐negative spontaneous bacterial peritonitis episodes. Methodology used in the present study did not always allow identification of amplified bacterial DNA.     

Usefulness of reagent strips for checking cure in spontaneous bacterial peritonitis after short-course treatment

Background  The usefulness of reagent strips to check cure of spontaneous bacterial peritonitis have not been evaluated to date.
Aim  To assess the usefulness of ascitic fluid analysis by means of reagent strips to check cure after a 5-day antibiotic course.
Methods  We prospectively included all cirrhotic patients diagnosed with spontaneous bacterial peritonitis. On day 5, conventional and reagent strip ascitic fluid analyses were performed.
Results  Fifty-three episodes of spontaneous bacterial peritonitis in 51 cirrhotic patients were included. Five patients died before the fifth day and in two patients, the control paracentesis yielded no ascitic fluid. In nine out of 46 cases (19.6%), spontaneous bacterial peritonitis had not resolved by day 5. In 32 out of 33 cases in which the ascitic fluid polymorphonuclear count was <250/μL at day five, the reagent strips was negative. The negative predictive value of the reagent strip at fifth day was 97% and the LR− 0.13.
Conclusions  Almost 20% of episodes of spontaneous bacterial peritonitis do not resolve with a short-course of antibiotic treatment. In view of the high negative predictive value and low likelihood ratio for a negative test, reagent strips analysis may be an alternative to conventional cytology if a 5-day antibiotic therapy is planned.     

Role of immunosuppression in the development of quinolone-resistant Escherichia coli spontaneous bacterial peritonitis and in the mortality of E. coli spontaneous bacterial peritonitis

BACKGROUND: Norfloxacin decreases the incidence of spontaneous bacterial peritonitis in cirrhotics, but promotes the appearance of quinolone-resistant Escherichia coli. AIM: : To define the characteristics of quinolone-resistant E. coli spontaneous bacterial peritonitis. METHODS: E. coli-positive ascitic fluid cultures were identified during a 6-year period. Data on quinolone-sensitive and quinolone-resistant E. coli spontaneous bacterial peritonitis were compared. RESULTS: One hundred and two E. coli-positive ascitic fluid cultures were detected. Cirrhotics accounted for 67 cases. Spontaneous bacterial peritonitis was found in 47 of the 67 (70%) cases [35 (74%) caused by quinolone-sensitive and 12 (26%) caused by quinolone-resistant E. coli]. Norfloxacin prophylaxis was higher in the quinolone-resistant group (92% vs. 6%, P < 0.001). Compared with patients with quinolone-sensitive E. coli spontaneous bacterial peritonitis, those with quinolone-resistant E. coli spontaneous bacterial peritonitis showed a higher prevalence of associated immunosuppressive factors (immunosuppressive drugs, human immunodeficiency virus infection or cancer) (92% vs. 20%, P < 0.001). Steroid therapy was independently associated with quinolone-resistant E. coli spontaneous bacterial peritonitis (odds ratio, 49; 95% confidence interval, 3.4-699; P = 0.004). The Child-Pugh score (P = 0.03), immunosuppression (P = 0.02) and renal failure (P = 0.01) were independent predictors of E. coli spontaneous bacterial peritonitis-related mortality. CONCLUSIONS: Associated immunosuppression is an important co-factor for the development of quinolone-resistant E. coli spontaneous bacterial peritonitis and for E. coli spontaneous bacterial peritonitis-related mortality.     

胸腺肽α1辅助治疗肝硬化自发性腹膜炎患者的临床观察

目的观察胸腺肽α1辅助治疗肝硬化自发性腹膜炎患者的临床疗效。方法选择38例肝硬化自发性腹膜炎患者,采用完全随机、对照的方法分成两组。胸腺肽治疗组19例,在保肝、退黄、利尿、抗感染等综合治疗基础上,同时皮下注射胸腺肽α1 1.6 mg,隔天1次,连用二周。对照组19例,仅给保肝、退黄、利尿、抗感染等综合治疗。结果胸腺肽治疗组对自发性腹膜炎的控制、稳定病情及疗效,显著优于对照组。结论胸腺肽α1辅助治疗肝硬化自发性腹膜炎患者的疗效优于常规综合治疗。     

益生菌在肝硬化自发性腹膜炎中的预防效果

目的探讨益生菌在肝硬化自发性腹膜炎中的预防效果。方法选择我院肝硬化并发自发性腹膜炎患者共56例,上述患者随机分为观察组和对照组。观察组和对照组均给予护肝类药物、利尿剂、抗生素等。自发性腹膜炎症状缓解及腹水消退后,观察组给予双歧三联活菌治疗,对照组未给予抗生素或益生菌治疗。评定两组治疗效果,观察自发性腹膜炎再发情况。结果观察组有效率为89.2%,对照组有效率为60.7%,观察组有效率高于对照组,差异有统计学意义（P〈0.06）;观察组自发性腹膜炎再发率低于对照组,差异有统计学意义（P〈0.05）。结论益生菌在肝硬化自发性腹膜炎中的预防效果显著,能降低自发性腹膜炎的再发率,值得借鉴。     

肝硬化腹水并自发性细菌性腹膜炎诊疗体会探讨

目的探讨肝硬化腹水并自发性细菌性腹膜炎诊疗体会。方法选取2010年5月至2012年5月收治硬化腹水并自发性细菌性腹膜炎患者80例,随机分为对照组和联合治疗组,每组各40例;其中对照组患者采用左氧氟沙星静脉滴注治疗;联合治疗组患者在对照组治疗基础上,加用三联活菌口服治疗;比较两组患者临床治疗总有效率,临床症状、体征改善时间,治疗前后肝功能指标等。结果联合治疗组患者临床治疗总有效率明显高于对照组,组间比较差异显著（P〈0.05）;两组患者治疗后肝功能指标较治疗前明显改善,且联合治疗组患者改善程度明显优于对照组,组间比较差异显著（P〈0.05）。结论三联活菌联合抗生素治疗肝硬化腹水并自发性细菌性腹膜炎临床效果确切,可显著改善临床症状,提高肝脏功能,缩短病程,具有临床使用价值。     

肝病并发自发性细菌性腹膜炎临床诊断及治疗探析

目的探讨肝病并发自发性细菌性腹膜炎的临床诊治特点。方法回顾分析103例肝病并发自发性细菌性腹膜炎患者的临床资料,进行分析总结。结果 103例患者有不同程度的临床症状体征及实验室检查改变。所有患者治愈43例好转33例,死亡27例,总有效率为73.79%。死亡分为并发周围循环衰竭及并发肝衰竭。随Child-Pugh分级升高及PTA水平降低,死亡率升高(P<0.05)。结论肝病并发自发性细菌性腹膜炎表现多样,应及早综合治疗。     

血必净注射液对自发性细菌性腹膜炎患者Th1/Th2亚群的影响

目的研究血必净注射液对乙型肝炎后肝硬化合并自发性细菌性腹膜炎患者机体Th1/Th2亚群的影响。方法将60例乙型肝炎后肝硬化合并自发性细菌性腹膜炎患者随机分成2组。对照组25例,使用抗生素和保肝等治疗;血必净组35例,在对照组治疗的基础上加用血必净注射液静脉滴注。采用流式细胞仪检测血必净注射液治疗肝硬化合并自发性细菌性腹膜炎患者前后血清的Th1、Th2细胞的变化。结果两组患者Th1、Th2均于治疗第4天达到峰值(P<0.05),然后下降;治疗第8天,两组患者Th1仍高于治疗前(P<0.05),Th2水平均降低(P<0.05)。治疗第4天、第8天,血必净组的Th1均高于对照组(P<0.05),两组Th2比较差异无统计学意义(P>0.05)。两组患者治疗后Th1/Th2平衡均向Th1漂移,血必净组更加显著(P<0.01)。结论血必净可以明显促进腹膜炎患者Th1应答,改善其促炎/抗炎反应平衡,促进炎症吸收,促进病情尽早康复。     

肝硬化自发性腹膜炎采用中西药结合治疗的疗效

目的：探讨肝硬化自发性腹膜炎采用中西药结合治疗的疗效。方法肝硬化自发性腹膜炎患者82例根据治疗方法的不同分为治疗组与对照组各41例,所有患者均进行常规西医治疗,在此基础上治疗组加用自拟中药汤治疗。结果治疗组的总有效率为87.8%,对照组的总有效率为68.3%,组间对比差异有统计学意义（P＜0.05）。两组治疗前血清白介素-6（IL-6）与一氧化氮（NO）含量对比差异无统计学意义（P＞0.05）,治疗后上述值都有明显下降（P＜0.05）,同时组间对比有统计学差异（P＜0.05）。结论中西药结合治疗肝硬化自发性腹膜炎能提高治疗疗效,其可能机制是减少了血清NO及IL-6的产生,从而减轻对肝脏的损害,从而延缓肝硬化的进展。     

左氧沙星和头孢曲松治疗自发性腹膜炎临床分析

目的 :评价左氧沙星与头孢曲松治疗自发性腹膜炎的临床疗效和安全性。方法 :6 0例患者随机分为左氧沙星组 (LVLX)2 9例 ,2 0 0mg静脉滴注 ,1日 2次 ;头孢曲松组 (CRO) 31例 ,2g静脉滴注 ,1日 1次 ,疗程均为 7d～ 14d。评价其临床疗效及安全性。结果 :左氧沙星组与头孢曲松组的临床总有效率和不良反应分别为 89 7%、6 9%和 87 1%、6 4 % ,两组差别无显著性 (P >0 0 5 )。结论 :左氧沙星与头孢曲松在治疗自发性腹膜炎上具有相同的疗效及安全性。     

谷氨酰胺对肝硬化患者肠屏障作用的干预效果及机制

目的探讨谷氨酰胺对肝硬化患者肠屏障作用的影响。方法选择本院2011年6月～2012年6月收治的肝硬化患者40例,按患者入院时间随机分为研究组和对照组,各20例。对照组患者给予保肝、营养支持、并发症处理等常规治疗,研究组患者在对照组治疗的基础上给予L-谷氨酰胺呱仑酸钠治疗,持续用药8周。观察两组患者治疗前后小肠黏膜通透性改变及自发性腹膜炎的发病率。结果治疗后研究组患者小肠黏膜通透性（L/M）明显低于治疗前,差异有统计学意义（P〈0．05）,且L／M低于对照组（P〈0．05）;研究组自发性腹膜炎发病率显著低于对照组（P〈0．05）。结论谷氨酰胺可以增强肝硬化患者的肠道屏障作用,减少肠道内的细菌移位,减少腹腔感染及自发性腹膜炎的发生。     

Switch therapy with ciprofloxacin vs. intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis in patients with cirrhosis: similar efficacy at lower cost

BACKGROUND: Intravenous administration of a third-generation cephalosporin is optimal antibiotic treatment for spontaneous bacterial peritonitis. AIMS: To compare an intravenous-oral step-down schedule with ciprofloxacin (switch therapy) to intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis, and to evaluate the impact of terlipressin and albumin in the treatment of type 1 hepatorenal syndrome on mortality. METHODS: A total of 116 cirrhotic patients with spontaneous bacterial peritonitis, were randomly given switch therapy with ciprofloxacin (61 patients) or intravenous ceftazidime (55 patients). All patients who developed type 1 hepatorenal syndrome were treated with terlipressin (2-12 mg/day) and albumin (20-40 g/day). RESULTS: Resolution of infection was achieved in 46/55 patients treated with ceftazidime (84%) and in 49/61 patients treated with ciprofloxacin (80%, P = N.S.). An intravenous-oral step-down schedule was possible in 50/61 patients (82%) who received ciprofloxacin; 45/61 patients (74%) were discharged before the end of antibiotic treatment and completed it at home. The mean saving per patient due to the reduction of hospital stay in the ciprofloxacin group was 1150 . Type 1 hepatorenal syndrome was treated successfully in 12/19 patients (63%). As a consequence, the in-hospital mortality rate due to infection was 10%. CONCLUSIONS: Switch therapy with cephalosporin is more cost-effective than intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis in cirrhotic patients who are not on prophylaxis with quinolones.     

临床药师对1例肝硬化伴自发性腹膜炎患者的抗感染诊疗分析

目的:探讨肝硬化自发性腹膜炎的诊疗要点,为肝硬化患者自发性腹膜炎抗菌药物的合理使用提供药学服务和支持。方法:临床药师参与1例肝硬化伴自发性腹膜炎患者抗菌药物使用的药学干预。鉴于检出的克雷伯杆菌和大肠埃希菌,临床药师建议医师将最初的第1代头孢菌素改为第3代头孢菌素,使用氨曲南腹腔灌注有助于渗出性肝硬化腹水治疗,阐明抗菌药物在肝硬化伴肾功不全患者中的合理应用。结果:患者经抗生素腹腔热灌注后腹水未再培养出细菌,腹水细胞数明显下降,血培养阴性。结论:临床药师与临床医务人员的密切配合可以提高肝硬化伴自发性腹膜炎患者用药安全性和有效性。     

应用白细胞酯酶试纸诊断自发性细菌性腹膜炎

自发性细菌性腹膜炎是肝硬化失代偿期的严重并发症之一,早期诊治对改善患者的预后尤为重要,但是现有的检验方法难以满足这一需要。近年来,国内外文献对白细胞酯酶试纸诊断自发性细菌性腹膜炎进行了研究。该文综述了白细胞酯酶试纸应用于腹水检验中的尚存问题及可能的解决方法。     

Review article: albumin for circulatory support in patients with cirrhosis

Renal function abnormalities and ascites in cirrhosis are the final consequence of a circulatory dysfunction characterized by marked splanchnic arterial vasodilation. This causes a reduction in effective arterial blood volume and the homoeostatic activation of vasoconstrictor and sodium-retaining systems. Albumin is very effective in preventing renal failure associated with large-volume paracentesis and spontaneous bacterial peritonitis, conditions that are known to cause an impairment of circulatory function in patients with cirrhosis and ascites. Moreover, albumin administration improves survival in patients with spontaneous bacterial peritonitis. In patients with hepatorenal syndrome the administration of vasoconstrictor drugs in combination with albumin improves circulatory and renal function markedly and survival slightly. By contrast, the administration of albumin without vasoconstrictors has marginal or no effects on renal function in this setting.     

208例肝炎肝硬化并自发性细菌性腹膜炎回顾分析

目的探讨自发性细菌性腹膜炎（spontaneous bacterial peritonitis,SBP）的临床特征,及时诊断、治疗和预防。方法对208例肝炎肝硬化合并SBP患者的临床资料进行回顾性分析。结果 SBP临床表现不典型且变化多样,诊断依据主要是腹水细胞计数和腹水细菌培养,但腹水细菌培养率极低。结论及时观察临床表现,进行必要的腹水检查,早期诊断有助于SBP的治疗和预防。     

慢性重型肝炎50例临床特征分析

目的 了解慢性重型肝炎的临床特征,为其防治提供参考资料.方法 对50例慢性重型肝炎和92慢性乙型肝炎的临床资料进行了调查分析.结果 白蛋白、前白蛋白、TB、PTA在两组患者之间差异有显著性(P＜0.01);慢性重型肝炎和慢性乙型肝炎组合并感染的发生率分别为40%、12.0%(P＜0.01),以自发性腹膜炎最为常见;慢性重型肝炎和慢性乙型肝炎组的治疗好转率分别为40%(20/50)、96.7%(89/92).结论 慢性重型肝炎肝功能损伤严重、并发感染率高、预后差.自发性腹膜炎的早期诊断和治疗是防止慢性重型肝炎患者病情进一步加重和提高生存率的关键措施之一.     

肝硬化并发自发性腹膜炎腹水培养的病原菌及耐药性分析

目的探讨肝硬化并发自发性腹膜炎腹水培养的病原菌及耐药性并进行分析。方法本院2005年1月至2009年1月住院的肝硬化并发自发性细菌性腹膜炎242例患者腹水病原菌培养及药敏试验观察结果。结果42例腹水培养的阳性病原菌120株,阳性率为49.58%。G-杆菌占73.7%,G＋球菌占15.9%。进行药敏试验,未出现耐药菌株7株（5.83%）,产生耐药菌株113株（94.17%）。结论自发性腹膜炎早期诊断,及时足量地使用有效的抗生素治疗是改善晚期肝病患者预后的主要因素。用药应遵循早期、足量、联合、广谱、避免肝肾毒性的原则,正确合理和科学地使用抗菌药物,延缓细菌耐药性的产生。