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Prevalence and risk factors for unsuspected spontaneous ascitic fluid infection in cirrhotics undergoing therapeutic paracentesis in an outpatient clinic
Abstract and Figures
Spontaneous bacterial peritonitis (SBP) has been typically described in hospitalized patients. There are little data on ascitic fluid infection in asymptomatic outpatients. The present study was aimed at determining the prevalence and risk factors for asymptomatic ascitic fluid infection among patients with liver cirrhosis attending an outpatient clinic.
Between January 2008 and December 2009, consecutive patients with cirrhosis (n = 110) undergoing therapeutic paracentesis in an outpatient setting were studied. Patients with fever, abdominal pain, hepatic encephalopathy, recent gastrointestinal bleeding, impaired renal function, previous history of SBP and on antibiotic treatment were excluded. Baseline demographic details, and etiology and severity of liver disease were recorded. Ascitic fluid cell count, culture and biochemical tests were done using standard laboratory techniques.
The causes of cirrhosis were alcohol (55.5%), hepatitis B (21.8%), hepatitis C (9.1%) and others (13.6%). A total of 278 paracenteses were done in them (average 2.5 [1.1] times per patient). Spontaneous ascitic fluid infection was found in 7 (2.5%) paracentesis, including spontaneous bacterial peritonitis in one (0.4%), monomicrobial nonneutrocytic bacterascites (MNB) in two (0.7%) and culture-negative neutrocytic ascites (CNNA) in four (1.4%). Escherichia coli, Klebsiella spp. and Staphylococcus aureus were grown. There was no difference between cirrhotic outpatients with and without infection in age, gender, alcohol consumption, etiology of cirrhosis, Child-Pugh score, serum albumin and ascitic fluid total protein. There was no death due to spontaneous ascitic fluid infection.
Asymptomatic ascitic fluid infection was very infrequent in patients with cirrhosis attending an outpatient clinic and undergoing therapeutic paracentesis.
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... It is well known that patients with cirrhosis have a good survival rate if complications do not emerge. However, once ascites occurs and SBP develops, survival time decreases dramatically [1][2][3]. ...
Due to the high risk of adverse outcome, identifying predisposing factors for spontaneous bacterial peritonitis (SBP) is of paramount importance. Serum ascites albumin gradient (SAAG) has recently been included in the recommendations for the management of ascites in patients with cirrhosis by some associations. ; Aim - to determine the value of SAAG as a predictor of SBP and to compare the average values of SAAG in patients with SBP and non-SBP.; The study was designed as a prospective-analytical-observational and was conducted at the University Clinic for Gastroenterohepatology in Skopje in one-year period. The study population included 70 patients hospitalized patients with established liver cirrhosis, regardless of etiology They were divided into two groups, 35 patients with SBP and 35 non-SBP, with similar demographic characteristics as the SBP group with sterile ascites, in which all variables were examined as in the study group. The selection of patients who were included in the study was conducted according to predetermined inclusion and exclusion criteria.; The average value of SAAG in SBP was 19.0±4.6, and in non-SBP it was higher (23.2±5.5). The difference between the mean values was statistically significant for p<0.05 (t-test = 3.46512; p=0.000992). The univariate analysis of SAAG in prediction of SBP showed that SAAG <20 g/L significantly increased the chance of SBP by five times (Exp (B) = 5.337 (CI (1.976-15.516)).; Our analysis registered a statistically significant difference between the average values of SAAG in both groups. SAAG is a good predictor, significantly associated with the occurrence of SBP. Additional and extensive studies are necessary in order to confirm our conclusion in the future.
... The ascetic fluid infection happens when there is no visceral perforation or inflammatory focus in the abdominal cavity. For SBP diagnosis, the polymorphonuclear leukocytic count (PMNLs) from the ascetic fluid obtained through paracentesis must be more than 250 cells/mm 52,54 . In addition, procalcitonin (PCT) appears to be a sensitive diagnostic indicator that can be used to predict diagnosis, monitor bacterial infections, and guide the clinical use of antibiotics. ...
OBJECTIVE: Spontaneous Bacterial Peritonitis (SBP) is one of the most serious liver cirrhosis with ascites complications. Vitamin D (Vit D) deficiency has been associated with a high risk of infection and mortality in cirrhotic patients. Herein, the assessment of Vit D level as a prognostic marker in SBP patients and the impact of Vit D supplementation on their treatment plan was studied as well.
PATIENTS AND METHODS: Ascetic patients with SBP and Vit D deficiency were divided randomly into treatment and control groups. The control group received standard treatment without Vit D and the treatment group received standard treatment plus Vit D. Clinical monitoring of Vit D was done over 6 months.
RESULTS: At baseline, all patients in both groups revealed an elevated serum and ascetic TLC, AST, ALT, total and direct bilirubin, in addition to elevation in INR and procalcitonin (PCT) level. Univariate regression analysis confirmed that deficiency of Vit D was an independent predictor of infection and mortality (p < 0.01; Crude Hazard Ratio: 0.951). Over 6 months, the study revealed significant improvement in serum Vit D level in the treatment group (34.6 ± 9.2 and 18.3 ± 10.0 ng/mL; p < 0.001). Moreover, a statistically significant increase in survival rate (64% vs. 42%; p < 0.05) and duration (199.5 days vs. 185.5 days; p < 0.05) were recorded as well. Univariate and multivariate regression analysis confirmed that Vit D supplementation was positively correlated to survival over 6 months (p < 0.001; Adjusted Hazard Ratio: 0.895).
CONCLUSIONS: Vit D deficiency is prevalent in SBP cirrhotic patients and is used as an independent predictor of infection and death. Therefore, Vit D supplementation revealed improvement in their response to treatment.
... There are few outpatient department for exploratory abdominal puncture, it is difficult to ensure the patients without obvious infection symptom can be identified by ascites test for the presence or absence of SBP. 2,3 At present, the main research is to find out the routine influencing factors of cirrhosis ascites complicated with SBP through convenient and accessible indicators, so as to find out whether there is SBP and intervene as early as possible, and carry out further unconventional examination and anti-infection treatment . 4 The management of patients with cirrhosis ascites can improve the detection rate of SBP through the evaluation of routine projects . ...
Objective: To investigate the characteristics and influence of type 2 diabetes in hepatocirrhosis ascites complicated with spontaneous bacterial peritonitis(SBP) to support clinical management of this condition. Methods: A retrospective study was conducted to collect patients with hepatocirrhosis ascites with hospitalization from January 1, 2016 to June 30, 2019. The patients were classified according to whether they had type 2 diabetes and SBP. Univariate and multivariate binary logistic regression analysis were performed on the data of the two groups. Results: A total of 214 patients were enrolled in the study, including 121 males and 93 females; 21 diabetics and 193 non diabetics; 119 SBP patients and 95 control subjects. There were 18 cases of SBP in hepatocirrhosis ascites complicated with diabetes, accounting for 85.7%, which was significantly higher than that in the non-diabetic group. The times of ascites, age and hospitalization days of cirrhotic ascites complicated with diabetes were 2 (1-3) times, 74 (60-76) years old and 25 (15-36) days, respectively, which were significantly higher than those in the non-diabetic group, P < 0.05. Multivariate analysis showed that diabetes , the times of hepatocirrhosis ascites, hospitalization days and total bilirubin (TBIL) increased the independent risk factors of SBP in hepatocirrhosis ascites, with OR values of 5.126 (1.358-19.345), 1.949 (1.428-2.660), 1.028 (1.010-1.047), 1.006 (1.001-1.010), respectively (P < 0.05). Conclusion: the patients with hepatocirrhosis ascites complicated with diabetes showed older age, longer hospitalization time, more SBP and more ascites; diabetes mellitus, times of ascites, hospitalization days and TBIL increased the risk of SBP in hepatocirrhosis ascites.
... 3 Mohan and Venkataraman reported a 0.4% rate of SBP, 1.4% rate of CNNA, and 0.7% rate of MNB in asymptomatic patients undergoing LVP in an outpatient clinic. 30 We had a 0.2% rate of SBP, 0.4% rate of CNNA, and 0.2% rate of MNB. Given the low rates of SBP in outpatient paracenteses clinics, we will adopt the AASLD suggestions to only send an ascites cell count and not a culture in asymptomatic patients. ...
Background:
Patients needing large-volume paracenteses (LVPs) can occupy inpatient hospital beds and unnecessarily use inpatient resources.
Methods:
We describe an outpatient paracentesis clinic that was part of a quality assurance initiative at the Veterans Affairs Pittsburgh Healthcare System in Pennsylvania. A retrospective review was conducted that included patient age, sex, etiology of ascites, amount of ascites removed, time of the procedure, complications, and results of ascites cell count and cultures abstracted from the electronic health record.
Results:
Over 74 months, 506 paracenteses were performed on 82 patients. The mean volume removed was 7.9 L, and the mean time of the procedure was 33.3 minutes. There were 5 episodes of postprocedure hypotension that required admission for 3 patients. One episode of abdominal wall hematoma occurred that required admission. Two patients developed incarceration of an umbilical hernia after the paracentesis; both required surgical repair. Without the clinic, almost all the 506 outpatient LVPs we performed would have resulted in a hospital admission.
Conclusion:
An outpatient paracentesis clinic run by academic hospitalists can safely and quickly remove large volumes of ascites and minimize hospitalizations.
... The ascetic fluid infection happens when there is no visceral perforation or inflammatory focus in the abdominal cavity. For SBP diagnosis, the polymorphonuclear leukocytic count (PMNLs) from the ascetic fluid obtained through paracentesis must be more than 250 cells/mm 52,54 . In addition, procalcitonin (PCT) appears to be a sensitive diagnostic indicator that can be used to predict diagnosis, monitor bacterial infections, and guide the clinical use of antibiotics. ...
OBJECTIVE: Spontaneous Bacterial Peritonitis (SBP) is one of the most serious liver cirrhosis with ascites complications. Vitamin D (Vit D) deficiency has been associated with a high risk of infection and mortality in cirrhotic patients. Herein, the assessment of Vit D level as a prognostic marker in SBP patients and the impact of Vit D supplementation on their treatment plan was studied as well.
PATIENTS AND METHODS: Ascetic patients with SBP and Vit D deficiency were divided randomly into treatment and control groups. The control group received standard treatment without Vit D and the treatment group received standard treatment plus Vit D. Clinical monitoring of Vit D was done over 6 months.
RESULTS: At baseline, all patients in both groups revealed an elevated serum and ascetic TLC, AST, ALT, total and direct bilirubin, in addition to elevation in INR and procalcitonin (PCT) level. Univariate regression analysis confirmed that deficiency of Vit D was an independent pre-dictor of infection and mortality (p < 0.01; Crude Hazard Ratio: 0.951). Over 6 months, the study revealed significant improvement in serum Vit D level in the treatment group (34.6 ± 9.2 and 18.3 ± 10.0 ng/mL; p < 0.001). Moreover, a statistically significant increase in survival rate (64% vs. 42%; p < 0.05) and duration (199.5 days vs. 185.5 days; p < 0.05) were recorded as well. Univariate and multivariate regression analysis confirmed that Vit D supplementation was positively correlated to survival over 6 months (p < 0.001; Adjusted Hazard Ratio: 0.895).
CONCLUSIONS: Vit D deficiency is prevalent in SBP cirrhotic patients and is used as an independent predictor of infection and death. Therefore , Vit D supplementation revealed improvement in their response to treatment.
... There are few outpatient department for exploratory abdominal puncture, it is difficult to ensure the patients without obvious infection symptom can be identified by ascites test for the presence or absence of SBP. 2,3 At present, the main research is to find out the routine influencing factors of cirrhosis ascites complicated with SBP through convenient and accessible indicators, so as to find out whether there is SBP and intervene as early as possible, and carry out further unconventional examination and anti-infection treatment . 4 The management of patients with cirrhosis ascites can improve the detection rate of SBP through the evaluation of routine projects . ...
Objective
To investigate the characteristics and influence of type 2 diabetes in hepatocirrhosis ascites complicated with spontaneous bacterial peritonitis(SBP) to support clinical management of this condition.
Methods
A retrospective study was conducted to collect patients with hepatocirrhosis ascites with hospitalization from January 1, 2016 to June 30, 2019. The patients were classified according to whether they had type 2 diabetes and SBP. Univariate and multivariate binary logistic regression analysis were performed on the data of the two groups.
Results
A total of 214 patients were enrolled in the study, including 121 males and 93 females; 21 diabetics and 193 non diabetics; 119 SBP patients and 95 control subjects. There were 18 cases of SBP in hepatocirrhosis ascites complicated with diabetes, accounting for 85.7%, which was significantly higher than that in the non-diabetic group. The times of ascites, age and hospitalization days of cirrhotic ascites complicated with diabetes were 2 (1-3) times, 74 (60-76) years old and 25 (15-36) days, respectively, which were significantly higher than those in the non-diabetic group, P < 0.05. Multivariate analysis showed that diabetes, the times of hepatocirrhosis ascites, hospitalization days and total bilirubin (TBIL) increased the independent risk factors of SBP in hepatocirrhosis ascites, with OR values of 5.126 (1.358-19.345), 1.949 (1.428-2.660), 1.028 (1.010-1.047), 1.006 (1.001-1.010), respectively (P < 0.05).
Conclusion
the patients with hepatocirrhosis ascites complicated with diabetes showed older age, longer hospitalization time, more SBP and more ascites; diabetes mellitus, times of ascites, hospitalization days and TBIL increased the risk of SBP in hepatocirrhosis ascites.
Droplet digital PCR (ddPCR) is increasingly used in diagnosing clinical pathogens, but its effectiveness in cirrhosis patients with suspected ascites infection remains uncertain.
The diagnostic performance of ddPCR was assessed in 305 ascites samples, utilizing culture and clinical composite standards. The quantitative value and potential clinical impact of ddPCR were further analyzed in patients with spontaneous bacterial peritonitis.
With culture standards, ddPCR demonstrated a sensitivity of 86.5% and specificity of 83.2% for bacterial or fungal detection. After adjustment of clinical composite criteria, specificity increased to 96.4%. Better diagnostic performance for all types of targeted pathogens, particularly fungi, was observed with ddPCR compared to culture, and more polymicrobial infections were detected (30.4% versus 5.7%, p < 0.001). Pathogen loads detected by ddPCR correlated with white blood cell count in ascites and blood, as well as polymorphonuclear cell (PMN) count in ascites, reflecting infection status rapidly. A positive clinical impact of 55.8% (43/77) was observed for ddPCR, which was more significant among patients with PMN count ≤ 250/mm3 in terms of medication adjustment and new diagnosis. ddPCR results for fungal detection were confirmed by clinical symptoms and other microbiological tests, which could guide antifungal therapy and reduce the risk of short-term mortality.
ddPCR, with appropriate panel design, has advantages in pathogen detection and clinical management of ascites infection, especially for patients with fungal and polymicrobial infections. Patients with atypical spontaneous bacterial peritonitis benefited more from ddPCR.
Background: HbA1c (glycated hemoglobin) is often used to monitor blood sugar levels as it is stable and reflects the average sugar level over the previous 3 months. Many studies have proven the correlation between HbA1c and the risk of micro and macrovascular complications. This study aims to assess the possible correlations of HbA1c with the severity of coronary artery disease (CAD) among patients with type 2 diabetes mellitus (T2DM).
Methods: The study included 30 consecutive patients with type T2DM underwent coronary angiography for the evaluation of suspected coronary disease. The participants were divided into two groups according to the level of HbA1c: HbA1c ≤ 7% group I and HbA1c > 7% group II.
The CAD severity was quantified by the SYNTAX score algorithm to tertiles: Tertile I, Tertile II and Tertile III (SYNTAX score ≤ 8, >8 – ≥16 and > 16, respectively).
Results: The mean of SYNTAX score value was higher in HbA1c >7% group in comparison with HbA1c ≤ 7% group (19.56 ± 5.876 and 13.71 ±7.356), (p=0.044). There were no statistically significant differences between two groups of HbA1c and mean values of total cholesterol (TC), triglycerides (TR), LDL cholesterol (LDL) and HDL cholesterol (HDL), (p=0.12, 0.44, 0.19 and 0.78 respectively). Also there were no statistically significant differences between two groups of HbA1c in relation to gender, smoking, and hypertension. Whereas there were significant positive corelation between HbA1c groups and Syntax score tertiles (p=0.035)
Conclusion: This study showed that the level of HbA1c in patients with T2DM is significantly associated with the extent and severity of coronary lesions quantified by SYNTAX score.
Keywords: HbA1c, SYNTAX score, CAD.
Introduction:
Spontaneous bacterial peritonitis (SBP) is a common complication of decompensated cirrhosis with high morbidity and mortality rate. There is a paucity of evidence regarding the incidence of SBP in asymptomatic liver cirrhosis patients undergoing routine out-patient large-volume paracentesis (LVP). The aim of this study was to perform a systematic review and meta-analysis to determine the incidence of SBP among asymptomatic decompensated cirrhosis patients undergoing routine outpatient LVP.
Methods:
A systematic search of Ovid Medline, Embase, Web of Science and CENTRAL electronic databases was performed in January 2021, along with a manual search of reference lists of retrieved articles. Data were extracted to determine the incidence of SBP [polymorphonuclear cells (PMNs) greater than 250 PMNs/mm3 with or without positive culture] and the incidence of all positive paracentesis (SBP or bacterascites-positive ascitic culture but no elevation in PMNs).
Results:
A total of 504 studies were retrieved with 16 studies being included in the review. A total of 1532 patients were included with a total of 4016 paracentesis performed. The incidence of a positive paracentesis (SBP and/or bacterascitis) was 4% [95% confidence interval (CI), 3-6%]. However, the incidence of definite SBP was 2% (95% CI, 1-3%).
Conclusion:
The incidence of SBP in asymptomatic outpatients with decompensated cirrhosis requiring LVP is low. The benefit of routine analysis of all paracentesis samples in this population is questionable. Further studies are required to determine the cost-effectiveness of routine analysis and to determine if certain subgroups are at higher risk of SBP that require routine analysis.
To assess the risk of development of spontaneous bacterial peritonitis in relation to the ascitic fluid total protein concentration, routine admission abdominal paracentesis was performed on a group of 107 patients during 125 hospitalizations. The paracentesis was repeated if evidence of peritonitis developed during hospitalization. Twenty-one episodes of spontaneous peritonitis (or its culture-negative variant) were documented in 17 patients. The ascitic fluid protein concentration in the spontaneous peritonitis group (0.72 ± 0.53 g/dl) was significantly lower (p < 0.001) than that in the group of patients with sterile portal hypertension-related ascites (1.36 ± 0.89 g/dl) and was significantly lower than that of patients with ascites due to miscellaneous causes. Of the patients whose initial sterile ascitic fluid protein concentration was ≤1.0 g/dl, 7 of 47 (15%) developed spontaneous peritonitis during their hospitalization; whereas only 1 of 65 (1.5%) patients who had an initial sterile ascitic fluid protein concentration >1.0 g/dl developed spontaneous peritonitis. This difference in risk of development of peritonitis in relation to initial ascitic fluid protein concentration was also significant (p < 0.01). Low-protein-concentration ascitic fluid predisposes to spontaneous bacterial peritonitis.
A review of the medical records of patients diagnosed as having "spontaneous bacterial perito-nitis" (SBP) revealed 18 episodes of culture-negative neutrocytic ascites (CNNA) in 17 patients. The following criteria were all required in order to qualify for this diagnosis: (i) an ascitic fluid neutrophil count greater than 500 cells per mm3; (ii) negative ascitic fluid culture (5); (iii) absence of an intraabdominal source of infection; (iv) no antibiotic treatment within 30 days, and (v) no evidence of pancreatitis. Five patients had positive blood cultures. Two patients with CNNA had SBP in the past, and two other patients, who survived the episode of CNNA, subsequently developed SBP. Clinical signs and symptoms of patients with CNNA were not different from those of 32 patients with 33 episodes of culture-positive SBP. The mortality of CNNA (50%) was not different from that of SBP (70%). Because of the high mortality and because of the similarity of CNNA to SBP, it is presumed that many patients with CNNA have bacterial infection of their ascitic fluid,
Abstract To determine the potential role of orthotopic liver transplantation (OLT) in cirrhotic patients surviving a first episode of spontaneous bacterial peritonitis (SBP), medical records of 79 patients presenting with a first episode of SBP were reviewed. Of these patients, 37 were selected as potential candidates for OLT using the following criteria: absence of hepatocellular carcinoma; no severe organ failure other than the liver; age ≤ 66 years; and survival after SBP > 60 days. Survival time was calculated from the day of SBP diagnosis. Prognostic value of clinical, biological and bacteriological data recorded at the time of SBP was determined using univariate and multivariate analysis (Cox's regression model).
Survival rate of the potential candidates for OLT at 3 months, 1 year and 2 years was 94, 46 and 30%, respectively. Serum creatinine value (P= 0.001) and Pugh score (P= 0.005) were independently correlated with death. The 1 year survival rate was 80% for the 11 patients with a Pugh score < 10, and 26% for the 26 patients with a Pugh score ≥ 10.
Our results suggest that after SBP, OLT should be considered in patients with severe liver disease. Survival of patients with a moderate liver disease (i.e. Pugh score < 10) might be relatively high.
Preamble This guideline has been approved by the AASLD and represents the position of the Association. These recom-mendations provide a data-supported approach. They are based on the following: (1) formal review and analysis of the recently-published world literature on the topic (Medline search); (2) American College of Physicians Manual for Assessing Health Practices and Designing Practice Guidelines 1 ; (3) guideline policies, including the AASLD Policy on the Development and Use of Practice Guidelines and the American Gastroenterological Associ-ation Policy Statement on Guidelines 2 ; and (4) the au-thor's decades of experience caring for patients with cirrhosis and ascites. Intended for use by physicians, these recommenda-tions suggest preferred approaches to the diagnostic, ther-apeutic, and preventive aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published infor-mation. To more fully characterize the quality of evidence supporting recommendations, the Practice Guidelines Committee of the AASLD requires a Class (reflecting benefit versus risk) and Level (assessing strength or cer-tainty) of Evidence to be assigned and reported with each recommendation (Table 1, adapted from the American College of Cardiology and the American Heart Associa-tion Practice Guidelines 3). 4 These guidelines were developed for the care of adult patients with clinically detectable ascites. Although the general approach may be applicable to children, the pedi-atric database is much smaller and there may be unantic-ipated differences between adults and children. Patients with ascites detected only by imaging modalities but not yet clinically evident are excluded because of the lack of published information regarding the natural history of this entity. A Medline search from 1966 through 2007 was per-formed; search terms included ascites, hepatorenal syn-drome, diet therapy, drug therapy, radiotherapy, surgery, and therapy. The search involved only articles published in English and involving humans. A manual search of the author's files and recent abstracts was also performed. The search yielded 2115 articles including 153 published since a similar search was performed in 2002 in preparation for writing the previous guideline on ascites.
Spontaneous bacterial peritonitis is diagnosed when (a) the ascitic fluid culture is positive, (b) the ascitic fluid neutrophil count is ≥ 250 cells/mm3 and (c) there is no evident intraabdominal surgically treatable source for infection. Few details are available regarding the variant of ascitic fluid infection in which the culture grows bacteria (pure growth of a single type of organism), but the neutrophil count is <250 cells/mm3. In this prospective study of 138 episodes of culture-positive spontaneously infected ascites detected in 105 patients, 44 (31.9%) were episodes of “monomicrobial nonneutrocytic bacterascites” compared with 94 (68.1%) episodes of spontaneous bacterial peritonitis. Seventeen patients had both types of infection. The infection-related mortality and hospitalization mortality were similar between the two groups. Patients with bacterascites appeared to have less severe liver disease. In 62% of bacterascites episodes in which a second paracentesis was performed before any treatment the fluid spontaneously became sterile without development of ascitic fluid neutrocytosis. Thirty-eight percent of patients with bacterascites (who underwent a second paracentesis before treatment was started) progressed to spontaneous bacterial peritonitis—sometimes within a few hours. The concentration of the chemoattractant C5a was not decreased in the ascitic fluid of the bacterascites patients; this excludes ascitic fluid C5a deficiency as the explanation of the lack of neutrocytosis.
Monomicrobial nonneutrocytic bacterascites is a common variant of ascitic fluid infection that may resolve without treatment or may progress to spontaneous bacterial peritonitis. (HEPATOLOGY 1990;12:710–715).
Among 342 consecutive patients admitted to the hospital with cirrhosis of the liver 68 (17%) had ascites and had a diagnostic paracentesis performed. Fourteen episodes of peritonitis were diagnosed in 13 patients, which is an overall incidence of peritonitis of 19%. The incidence of peritonitis was 36% in patients with hepatic encephalopathy and 10% in patients without hepatic encephalopathy (P less than 0.01). In all except one case the infecting organism was most likely of enteric origin--that is, gram-negative or anaerobic species. The infected patients had lower mean ascites pH and higher mean ascites leukocyte and polymorphonuclear cell counts than non-infected patients. However, there was a considerable overlap between the two groups, and the diagnostic sensitivity did not exceed 65% for any of these three features. The survival of infected patients without encephalopathy was 33%, which was significantly lower (P less than 0.05) than that the 89% for non-infected patients. In patients with encephalopathy the survival was identical for infected and non-infected patients.
To investigate the natural history of compensated cirrhosis, 293 consecutive patients without previous major complications (ascites, jaundice, encephalopathy or gastrointestinal hemorrhage) were studied in terms of morbidity (probability of developing decompensated cirrhosis during follow-up) and survival. Patients were diagnosed by liver histology between 1968 and 1980. Median follow-up was 63 months. Decompensation of cirrhosis was considered when a patient first developed one of the major complications of the disease. Ten years after diagnosis, the probability of developing decompensated cirrhosis and the survival probability rate were 58 and 47%, respectively. A multivariate survival analysis (Cox's regression model) using clinical, biochemical and histological data obtained at diagnosis disclosed seven factors that predicted prognosis: serum bilirubin; serum gamma-globulin concentration; hepatic stigmata; prothrombin time; sex; age, and alkaline phosphatase. According to the contribution of each one of these factors to the final model, a prognostic index was constructed that allows calculation of the estimated survival probability. The predicting value of this index was validated by a split sample testing technique.
Spontaneous bacterial peritonitis is an infection of the ascitic fluid of patients who, in general, have severe chronic liver disease. Several variants of this disease exist including bacterascites, culture-negative neutrocytic ascites, and secondary bacterial peritonitis. Spontaneous bacterial peritonitis is frequently manifested by signs and symptoms of peritonitis although the findings may be subtle; however, occasionally it may be completely without clinical manifestation. The clinician must have a high index of suspicion in order to make this diagnosis at a relatively earlier stage of infection. An abdominal paracentesis is required to make the diagnosis of spontaneous bacterial peritonitis. This paracentesis should be performed on all patients who are admitted to the hospital for ascites and should be repeated if there is any manifestation of bacterial infection during the hospitalization. Patients with severe intrahepatic shunting--as manifested by marked redistribution of activity from the liver to the spleen and to the bone marrow on liver-spleen scan as well as patients with an ascitic fluid total protein concentration of less than 1 g/dl--appear to be particularly susceptible to bacterial infection of their ascites. In order to optimize the yield of ascitic fluid culture, it is probably appropriate to inject blood culture bottles with ascites at the bedside immediately after the abdominal paracentesis. The mortality of spontaneous bacterial peritonitis continues to be very high. Perhaps routine admission paracentesis and prompt empiric antibiotic therapy with a third-generation cephalosporin will decrease the mortality of this infection if the Gram stain of the ascitic fluid demonstrates bacteria or the ascitic fluid neutrophil count is greater than 250 cells/cu mm. Repeating the paracentesis after 48 hours of treatment to reculture the fluid and reassess the ascitic fluid neutrophil count appears to be the best way to assess efficacy of treatment. After 48 hours of treatment the ascitic fluid neutrophil count should be less than 50% of the original value if the antimicrobial therapy is appropriate. The optimal duration of antibiotic treatment is unknown; however, until controlled trials provide data regarding duration of treatment it is appropriate to treat with parenteral antibiotics for 10 to 14 days. Research is also needed to determine if there are measures which can be taken to prevent the development of spontaneous peritonitis.