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Sánchez E, Nieto JC, Boullosa A, Vidal S, Sancho FJ, Rossi G, Sancho-Bru P, Oms R, Mirelis B, Juárez C, Guarner C, Soriano G. VSL#3 probiotic treatment decreases bacterial translocation in rats with carbon tetrachloride-induced cirrhosis. Liver Int 2015; 35:735-45. [PMID: 24750552 DOI: 10.1111/liv.12566] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/17/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Probiotics can prevent pathological bacterial translocation in cirrhosis by modulating intestinal microbiota and improving gut barrier and immune disturbances. To evaluate the effect of probiotic VSL#3 on bacterial translocation, intestinal microbiota, gut barrier and inflammatory response in rats with experimental cirrhosis. METHODS Forty-six Sprague-Dawley rats with CCl4 -induced cirrhosis were randomized into two groups: VSL#3 group (n = 22) that received VSL#3 in drinking water, and water group (n = 24) that received water only. Treatment began at week 6 of cirrhosis induction and continued until laparotomy, performed 1 week after development of ascites or at week 20. A control group included 11 healthy rats. At this study end, we evaluated bacterial translocation, intestinal flora, intestinal barrier (ileal claudin-2 and 4, β-defensin-1, occludin and malondialdehyde as index of oxidative damage) and serum cytokines. RESULTS Mortality during this study was similar in the VSL#3 group (10/22, 45%) and the water group (10/24, 42%) (P = 1). The incidence of bacterial translocation was 1/12 (8%) in the VSL#3 group, 7/14 (50%) in the water group (P = 0.03 vs. VSL#3 group) and 0/11 in the control group (P = 0.008 vs. water group). The concentration of ileal and caecal enterobacteria and enterococci was similar in the two groups of cirrhotic rats. The ileal occludin concentration was higher and ileal malondialdehyde and serum levels of TNF-α were lower in the VSL#3 group than in the water group (P < 0.05). CONCLUSIONS VSL#3 decreases bacterial translocation, the pro-inflammatory state and ileal oxidative damage and increases ileal occludin expression in rats with experimental cirrhosis.
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Affiliation(s)
- Elisabet Sánchez
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut d'Investigacions Biomèdiques (IIB) Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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Verbeke L, Farre R, Verbinnen B, Covens K, Vanuytsel T, Verhaegen J, Komuta M, Roskams T, Chatterjee S, Annaert P, Vander Elst I, Windmolders P, Trebicka J, Nevens F, Laleman W. The FXR agonist obeticholic acid prevents gut barrier dysfunction and bacterial translocation in cholestatic rats. THE AMERICAN JOURNAL OF PATHOLOGY 2015; 185:409-19. [PMID: 25592258 DOI: 10.1016/j.ajpath.2014.10.009] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/27/2014] [Accepted: 10/02/2014] [Indexed: 02/06/2023]
Abstract
Bacterial translocation (BTL) drives pathogenesis and complications of cirrhosis. Farnesoid X-activated receptor (FXR) is a key transcription regulator in hepatic and intestinal bile metabolism. We studied potential intestinal FXR dysfunction in a rat model of cholestatic liver injury and evaluated effects of obeticholic acid (INT-747), an FXR agonist, on gut permeability, inflammation, and BTL. Rats were gavaged with INT-747 or vehicle during 10 days after bile-duct ligation and then were assessed for changes in gut permeability, BTL, and tight-junction protein expression, immune cell recruitment, and cytokine expression in ileum, mesenteric lymph nodes, and spleen. Auxiliary in vitro BTL-mimicking experiments were performed with Transwell supports. Vehicle-treated bile duct-ligated rats exhibited decreased FXR pathway expression in both jejunum and ileum, in association with increased gut permeability through increased claudin-2 expression and related to local and systemic recruitment of natural killer cells resulting in increased interferon-γ expression and BTL. After INT-747 treatment, natural killer cells and interferon-γ expression markedly decreased, in association with normalized permeability selectively in ileum (up-regulated claudin-1 and occludin) and a significant reduction in BTL. In vitro, interferon-γ induced increased Escherichia coli translocation, which remained unaffected by INT-747. In experimental cholestasis, FXR agonism improved ileal barrier function by attenuating intestinal inflammation, leading to reduced BTL and thus demonstrating a crucial protective role for FXR in the gut-liver axis.
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Affiliation(s)
- Len Verbeke
- Division of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium.
| | - Ricard Farre
- Translational Research Center for Gastrointestinal Disorders, KU Leuven - University of Leuven, Leuven, Belgium; Center for Biomedical Research, Network for Liver and Digestive Diseases (CIBERehd), Instituto de Salud Carlos II, Barcelona, Spain
| | - Bert Verbinnen
- Experimental Laboratory Immunology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Life Sciences, Thomas More Kempen, Geel, Belgium
| | - Kris Covens
- Department of Molecular and Vascular Biology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven - University of Leuven, Leuven, Belgium
| | - Jan Verhaegen
- Laboratory of Clinical Bacteriology and Mycology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Mina Komuta
- Departments of Morphology and Molecular Pathology, Translational Cell and Tissue Research, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Tania Roskams
- Departments of Morphology and Molecular Pathology, Translational Cell and Tissue Research, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Sagnik Chatterjee
- Department of Pharmaceutical and Pharmacological Sciences, Drug Delivery and Disposition, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, Drug Delivery and Disposition, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ingrid Vander Elst
- Division of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Petra Windmolders
- Division of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Frederik Nevens
- Division of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Wim Laleman
- Division of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
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Albillos A, Lario M, Álvarez-Mon M. Cirrhosis-associated immune dysfunction: distinctive features and clinical relevance. J Hepatol 2014; 61:1385-96. [PMID: 25135860 DOI: 10.1016/j.jhep.2014.08.010] [Citation(s) in RCA: 753] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 07/27/2014] [Accepted: 08/09/2014] [Indexed: 02/06/2023]
Abstract
The term cirrhosis-associated immune dysfunction refers to the main syndromic abnormalities of immune function, immunodeficiency and systemic inflammation that are present in cirrhosis. The course of advanced cirrhosis, regardless of its aetiology, is complicated by cirrhosis-associated immune dysfunction and this constitutes the pathophysiological hallmark of an increased susceptibility to bacterial infection, distinctive of the disease. Cirrhosis impairs the homeostatic role of the liver in the systemic immune response. Damage to the reticulo-endothelial system compromises the immune surveillance function of the organ and the reduced hepatic synthesis of proteins, involved in innate immunity and pattern recognition, hinders the bactericidal ability of phagocytic cells. Systemic inflammation, in form of activated circulating immune cells and increased serum levels of pro-inflammatory cytokines, is the result of persistent episodic activation of circulating immune cells from damage-associated molecular patterns, released from necrotic liver cells and, as cirrhosis progresses, from pathogen-associated molecular patterns, released from the leaky gut. Cirrhosis-associated immune dysfunction phenotypes switch from predominantly "pro-inflammatory" to predominantly "immunodeficient" in patients with stable ascitic cirrhosis and in patients with severely decompensated cirrhosis and extra-hepatic organ failure (e.g. acute-on-chronic liver failure), respectively. These cirrhosis-associated immune dysfunction phenotypes represent the extremes of a spectrum of reversible dynamic events that take place during the course of cirrhosis. Systemic inflammation can affect the functions of tissue somatic cells and modify the clinical manifestation of cirrhosis. The best characterized example is the contribution of systemic inflammation to the haemodynamic derangement of cirrhosis, which correlates negatively with prognosis.
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Affiliation(s)
- Agustín Albillos
- Department of Medicine, Universidad de Alcalá, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; Service of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Margaret Lario
- Department of Medicine, Universidad de Alcalá, Madrid, Spain
| | - Melchor Álvarez-Mon
- Department of Medicine, Universidad de Alcalá, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; Service of Immune Diseases and Oncology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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Giorgio V, Alisi A, Kazem HM, Monti S, Nobili V. NASH and the Cross-Talk Between the Gut and Liver. CURRENT PEDIATRICS REPORTS 2014. [DOI: 10.1007/s40124-014-0047-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wiest R, Lawson M, Geuking M. Pathological bacterial translocation in liver cirrhosis. J Hepatol 2014; 60:197-209. [PMID: 23993913 DOI: 10.1016/j.jhep.2013.07.044] [Citation(s) in RCA: 517] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 06/20/2013] [Accepted: 07/19/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Reiner Wiest
- Department Gastroenterology, Inselspital, University Hospital, Bern 3010, Switzerland.
| | - Melissa Lawson
- Maurice Müller Laboratories, Universitätsklinik für Viszerale Chirurgie und Medizin (UVCM), University of Bern, Bern 3010, Switzerland
| | - Markus Geuking
- Maurice Müller Laboratories, Universitätsklinik für Viszerale Chirurgie und Medizin (UVCM), University of Bern, Bern 3010, Switzerland
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Jayakumar S, Carbonneau M, Hotte N, Befus AD, St Laurent C, Owen R, McCarthy M, Madsen K, Bailey RJ, Ma M, Bain V, Rioux K, Tandon P. VSL#3 ® probiotic therapy does not reduce portal pressures in patients with decompensated cirrhosis. Liver Int 2013; 33:1470-7. [PMID: 23968203 DOI: 10.1111/liv.12280] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/20/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS In patients with decompensated cirrhosis, bacterial translocation can contribute to splanchnic vasodilatation, decreased effective circulating volume, and portal hypertension. The primary objective of this randomized, double blind placebo controlled trial was to evaluate the effect of the probiotic VSL#3(®) on the hepatic venous pressure gradient (HVPG). METHODS Seventeen patients with decompensated cirrhosis and an HVPG of ≥ 10 mmHg were randomized to receive 2 months of VSL#3(®) or an identical placebo. HVPG, endotoxin, interleukin (IL)-6, IL-8, IL-10, renin, aldosterone, nitric oxide and stool microbiota were measured at baseline and study end. RESULTS Two of the 17 patients were taken off the trial before completion (one for alcohol abuse and the second for SBP - both in placebo arm). Data were analysed on the remaining 15 patients. The median model for end-stage liver disease score was 12, and 80% of patients had Child Pugh B disease. The treatment arm had a greater decrease in HVPG from baseline to study end than the placebo arm (median change from baseline -11.6% vs +2.8%), although this reduction was not statistically significant in either group. There was a significant reduction in the plasma aldosterone level in the VSL#3(®) group, but no significant changes in the other measured parameters, including the stool microflora analysis. CONCLUSIONS Within the limitations of our sample size, VSL#3(®) therapy does not appear to have a significant impact on portal pressure reduction in patients with decompensated cirrhosis.
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Affiliation(s)
- Saumya Jayakumar
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Oladimeji AA, Temi AP, Adekunle AE, Taiwo RH, Ayokunle DS. Prevalence of spontaneous bacterial peritonitis in liver cirrhosis with ascites. Pan Afr Med J 2013; 15:128. [PMID: 24255734 PMCID: PMC3830462 DOI: 10.11604/pamj.2013.15.128.2702] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 07/19/2013] [Indexed: 12/11/2022] Open
Abstract
Introduction Spontaneous bacterial peritonitis (SBP) is a common bacterial infection in patients with cirrhosis and ascites requiring prompt recognition and treatment. The aim of this study was to determine the prevalence, and characteristics of SBP among in-patients with cirrhosis and ascites seen at our facility. Methods Thirty one patients with liver cirrhosis and ascites who were admitted into the Medical ward of the Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, Nigeria from August 2009 to July 2010 were retrospectively studied. All the patients had abdominal paracentesis done within 48 hours of admission under aseptic condition and the data obtained were analyzed. Results The mean age of the studied population was 62±9 years (age range 43-78 years). Of the 21 that developed SPB, culture positive SBP was present in 66.7% (14/21) while CNNA was found in 33.3% (7/21). The prevalence of MNB was 26% (8/31) in this study. Of those with SBP, 93% had monomicrobial infection with aerobic Gram negative bacilli being responsible in 66.7% of the cases with E.coli (70%) being the predominant organism followed by Klebsiella species. Gram positive organisms accounted for 33.3% with Streptococcal species (60%) being the predominant organism followed by Staphylococcus aureus (40%). Patients with SBP had significantly lower platelet count when compared with those without SBP, p < 0.05. Also, international normalization ratio (INR) was significantly higher in those patients with SBP compared with those without SBP, p < 0.05. The poor prognostic indicators found in this study were; low ascitic protein, hepatic encephalopathy, coagulopathy, renal dysfunction (creatinine >2mg/dl) and leukocytosis (p < 0.05). Conclusion It is therefore imperative to do diagnostic abdominal paracentesis for cell count and culture in any patient with onset of ascites or cirrhotic patients with ascites and suggestive symptoms compatible or suggestive of SBP.
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Affiliation(s)
- Ajayi Akande Oladimeji
- Department of Medicine, Ekiti State University Teaching Hospital, P.M.B 5355, Ado Ekiti, Nigeria
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Alaish SM, Smith AD, Timmons J, Greenspon J, Eyvazzadeh D, Murphy E, Shea-Donahue T, Cirimotich S, Mongodin E, Zhao A, Fasano A, Nataro JP, Cross AS. Gut microbiota, tight junction protein expression, intestinal resistance, bacterial translocation and mortality following cholestasis depend on the genetic background of the host. Gut Microbes 2013; 4:292-305. [PMID: 23652772 PMCID: PMC3744514 DOI: 10.4161/gmic.24706] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Failure of the intestinal barrier is a characteristic feature of cholestasis. We have previously observed higher mortality in C57BL/6J compared with A/J mice following common bile duct ligation (CBDL). We hypothesized the alteration in gut barrier function following cholestasis would vary by genetic background. Following one week of CBDL, jejunal TEER was significantly reduced in each ligated mouse compared with their sham counterparts; moreover, jejunal TEER was significantly lower in both sham and ligated C57BL/6J compared with sham and ligated A/J mice, respectively. Bacterial translocation to mesenteric lymph nodes was significantly increased in C57BL/6J mice vs. A/J mice. Four of 15 C57BL/6J mice were bacteremic; whereas, none of the 17 A/J mice were. Jejunal IFN-γ mRNA expression was significantly elevated in C57BL/6J compared with A/J mice. Western blot analysis demonstrated a significant decrease in occludin protein expression in C57BL/6J compared with A/J mice following both sham operation and CBDL. Only C57BL/6J mice demonstrated a marked decrease in ZO-1 protein expression following CBDL compared with shams. Pyrosequencing of the 16S rRNA gene in fecal samples showed a dysbiosis only in C57BL/6J mice following CBDL when compared with shams. This study provides evidence of strain differences in gut microbiota, tight junction protein expression, intestinal resistance and bacterial translocation which supports the notion of a genetic predisposition to exaggerated injury following cholestasis.
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Affiliation(s)
- Samuel M. Alaish
- Department of Surgery; University of Maryland School of Medicine; Baltimore, MD USA,Correspondence to: Samuel M. Alaish,
| | - Alexis D. Smith
- Department of Surgery; University of Maryland School of Medicine; Baltimore, MD USA
| | - Jennifer Timmons
- Department of Surgery; University of Maryland School of Medicine; Baltimore, MD USA
| | - Jose Greenspon
- Department of Surgery; University of Maryland School of Medicine; Baltimore, MD USA
| | - Daniel Eyvazzadeh
- Department of Surgery; University of Maryland School of Medicine; Baltimore, MD USA
| | - Ebony Murphy
- Department of Surgery; University of Maryland School of Medicine; Baltimore, MD USA
| | - Terez Shea-Donahue
- Department of Medicine; University of Maryland School of Medicine; Baltimore, MD USA
| | - Shana Cirimotich
- Institute for Genome Sciences; University of Maryland School of Medicine; Baltimore, MD USA
| | - Emmanuel Mongodin
- Institute for Genome Sciences; University of Maryland School of Medicine; Baltimore, MD USA
| | - Aiping Zhao
- Department of Medicine; University of Maryland School of Medicine; Baltimore, MD USA
| | - Alessio Fasano
- Department of Medicine; University of Maryland School of Medicine; Baltimore, MD USA,Department of Pediatrics; University of Maryland School of Medicine; Baltimore, MD USA
| | - James P. Nataro
- Department of Pediatrics; University of Virginia School of Medicine; Charlottesville, VA USA
| | - Alan S Cross
- Department of Medicine; University of Maryland School of Medicine; Baltimore, MD USA
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Moore CM, Van Thiel DH. Cirrhotic ascites review: Pathophysiology, diagnosis and management. World J Hepatol 2013; 5:251-263. [PMID: 23717736 PMCID: PMC3664283 DOI: 10.4254/wjh.v5.i5.251] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 04/19/2013] [Indexed: 02/06/2023] Open
Abstract
Ascites is a pathologic accumulation of peritoneal fluidcommonly observed in decompensated cirrhotic states.Its causes are multi-factorial, but principally involve significant volume and hormonal dysregulation in the setting of portal hypertension. The diagnosis of ascites is considered in cirrhotic patients given a constellation of clinical and laboratory findings, and ultimately confirmed, with insight into etiology, by imaging and paracentesis procedures. Treatment for ascites is multi-modal including dietary sodium restriction, pharmacologic therapies, diagnostic and therapeutic paracentesis, and in certain cases transjugular intra-hepatic portosystemic shunt. Ascites is associated with numerous complications including spontaneous bacterial peritonitis, hepato-hydrothorax and hepatorenal syndrome. Given the complex nature of ascites and associatedcomplications, it is not surprising that it heralds increased morbidity and mortality in cirrhotic patients and increased cost-utilization upon the health-care system. This review will detail the pathophysiology of cirrhotic ascites, common complications derived from it, and pertinent treatment modalities.
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Kawaratani H, Tsujimoto T, Kubo T, Aihara Y, Takaya T, Uejima M, Moriya K, Noguchi R, Yoshiji H, Fukui H. Liver abscesses after peritoneal venous shunt. Case Rep Gastroenterol 2013; 7:245-50. [PMID: 23874262 PMCID: PMC3712811 DOI: 10.1159/000351833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 70-year-old man was referred to our hospital for high-grade fever with chills. He has visited our hospital for alcoholic liver cirrhosis and diabetes mellitus for over 20 years. Nine months earlier, he had received a peritoneal venous shunt (Denver shunt®) because of refractory ascites. Laboratory examinations revealed elevated C-reactive protein and liver dysfunction. Ultrasonography and abdominal enhanced computed tomography showed multiple small abscesses in the right lobe of the liver. Blood culture test did not detect the pathogenic bacteria of liver abscesses. The patient was treated with antibiotics for more than 2 months and cured from the infection, but 3 months later, he developed high-grade fever again. He had a recurrence of multiple small liver abscesses involving both lobes of the liver. He was treated with antibiotics, and the abscesses disappeared within a month. After the antibiotic treatment, he had selective intestinal decontamination with kanamycin. He has had no recurrence of liver abscess for over a year. To our knowledge, this is the first report of liver abscess in a cirrhotic patient with Denver shunt. Clinicians should bear liver abscess in mind when treating patients with high-grade fever and liver dysfunction following Denver shunt implantation.
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Affiliation(s)
- Hideto Kawaratani
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
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Vlachogiannakos J, Viazis N, Vasianopoulou P, Vafiadis I, Karamanolis DG, Ladas SD. Long-term administration of rifaximin improves the prognosis of patients with decompensated alcoholic cirrhosis. J Gastroenterol Hepatol 2013; 28:450-5. [PMID: 23216382 DOI: 10.1111/jgh.12070] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Cirrhotic patients are predisposed to intestinal bacterial overgrowth with translocation of bacterial products which may deteriorate liver hemodynamics. Having shown that short-term administration of rifaximin improves liver hemodynamics in decompensated cirrhosis, we conducted this study to investigate the effect of intestinal decontamination with rifaximin on the long-term prognosis of patients with alcohol-related decompensated cirrhosis (Child-Pugh > 7) and ascites. METHODS Patients who had received rifaximin and showed improved liver hemodynamics were enrolled in the current study and continued to receive rifaximin (1200 mg/day). Each patient was matched by age, sex, and Child-Pugh grade to two controls and followed up for up to 5 years, death or liver transplantation. Survival and risk of developing portal hypertension-related complications were compared between rifaximin group and controls. RESULTS Twenty three patients fulfilled the inclusion criteria and matched with 46 controls. Patients who received rifaximin had a significant lower risk of developing variceal bleeding (35% vs. 59.5%, P = 0.011), hepatic encephalopathy (31.5% vs. 47%, P = 0.034), spontaneous bacterial peritonitis (4.5% vs. 46%, P = 0.027), and hepatorenal syndrome (4.5% vs. 51%, P = 0.037) than controls. Five-year cumulative probability of survival was significantly higher in patients receiving rifaximin than in controls (61% vs. 13.5%, P = 0.012). In the multivariate analysis, rifaximin administration was independently associated with lower risk of developing variceal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, and higher survival. CONCLUSIONS In patients with alcohol-related decompensated cirrhosis, long-term rifaximin administration is associated with reduced risk of developing complications of portal hypertension and improved survival.
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Affiliation(s)
- Jiannis Vlachogiannakos
- Hepatogastroenterology Unit, 1st Department of Medicine-Propaedeutic, Medical School, Athens University, Laiko General Hospital, Athens, Greece.
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Abstract
Liver cirrhosis has a high morbidity and poses a large threat to human health worldwide. In China, viral hepatitis, especially hepatitis B, is the main pathogenic factor of liver cirrhosis. Ascites formation in cirrhosis is the result of combined action of portal hypertension and liver function impairment, and it is the most prominent clinical manifestation of decompensated cirrhosis. The understanding of pathophysiology of ascites formation can help provide more accurate treatment of this condition so as to alleviate patients' mental and economic burdens.
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Bellot P, Francés R, Such J. Pathological bacterial translocation in cirrhosis: pathophysiology, diagnosis and clinical implications. Liver Int 2013; 33:31-9. [PMID: 23121656 DOI: 10.1111/liv.12021] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 08/27/2012] [Indexed: 02/13/2023]
Abstract
Bacterial translocation (BT) is defined by the passage of viable indigenous bacteria from the intestinal lumen to mesenteric lymph nodes (MLNs) and other territories, and its diagnostic criteria rely on the isolation of viable bacteria in MLNs. Small intestinal overgrowth, increased intestinal permeability and immunological alterations are the main factors involved in its pathogenesis. BT is obviously difficult to identify in patients with cirrhosis, and alternative methods have been proposed instead. Bacterial DNA detection and species identification in serum or ascitic fluid has been proposed as a reliable marker of BT. Bacterial products, such as endotoxin, or bacterial DNA can translocate to extra-intestinal sites and promote an immunological response similar to that produced by viable bacteria. Therefore, pathological BT plays an important role in the pathogenesis of the complications of cirrhosis, not only in infections, but by exerting a profound inflammatory state and exacerbating the haemodynamic derangement. This may promote in turn the development of hepatorenal syndrome, hepatic encephalopathy and other portal hypertension-related complications. Therapeutic approaches for the prevention of BT in experimental and human cirrhosis are summarized. Finally, new investigations are needed to better understand the pathogenesis and consequences of translocation by viable bacteria (able to grow in culture), or non-viable BT (detection of bacterial fragments with negative culture) and open new therapeutic avenues in patients with cirrhosis.
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Affiliation(s)
- Pablo Bellot
- Liver Unit, Hospital General Universitario de Alicante and Miguel Hernández University, Elche, Alicante, Spain
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Seo YS, Shah VH. The role of gut-liver axis in the pathogenesis of liver cirrhosis and portal hypertension. Clin Mol Hepatol 2012; 18:337-46. [PMID: 23323248 PMCID: PMC3540369 DOI: 10.3350/cmh.2012.18.4.337] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 10/03/2012] [Accepted: 10/17/2012] [Indexed: 12/12/2022] Open
Abstract
Because of the anatomical position and its unique vascular system, the liver is susceptible to the exposure to the microbial products from the gut. Although large amount of microbes colonize in the gut, translocation of the microbes or microbial products into the liver and systemic circulation is prevented by gut epithelial barrier function and cleansing and detoxifying functions of the liver in healthy subjects. However, when the intestinal barrier function is disrupted, large amount of bacterial products can enter into the liver and systemic circulation and induce inflammation through their receptors. Nowadays, there have been various reports suggesting the role of gut flora and bacterial translocation in the pathogenesis of chronic liver disease and portal hypertension. This review summarizes the current knowledge about bacterial translocation and its contribution to the pathogenesis of chronic liver diseases and portal hypertension.
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Affiliation(s)
- Yeon Seok Seo
- Gastroenterology Research Unit, Mayo Clinic, Rochester, MN 55905, USA
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Fritz JS, Fallon MB, Kawut SM. Pulmonary vascular complications of liver disease. Am J Respir Crit Care Med 2012; 187:133-43. [PMID: 23155142 DOI: 10.1164/rccm.201209-1583ci] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hepatopulmonary syndrome and portopulmonary hypertension are two pulmonary vascular complications of liver disease. The pathophysiology underlying each disorder is distinct, but patients with either condition may be limited by dyspnea. A careful evaluation of concomitant symptoms, the physical examination, pulmonary function testing and arterial blood gas analysis, and echocardiographic, imaging, and hemodynamic studies is crucial to establishing (and distinguishing) these diagnoses. Our understanding of the pathobiology, natural history, and treatment of these disorders has advanced considerably over the past decade; however, the presence of either still increases the risk of morbidity and mortality in patients with underlying liver disease. There is no effective medical treatment for hepatopulmonary syndrome. Although liver transplantation can resolve hepatopulmonary syndrome, there appears to be worse survival even with transplantation. Liver transplantation poses a very high risk of death in those with significant portopulmonary hypertension, where targeted medical therapies may improve functional status and allow successful transplantation in a small number of select patients.
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Affiliation(s)
- Jason S Fritz
- Department of Medicine, M.S., Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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66
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Hartmann P, Chen WC, Schnabl B. The intestinal microbiome and the leaky gut as therapeutic targets in alcoholic liver disease. Front Physiol 2012; 3:402. [PMID: 23087650 PMCID: PMC3468817 DOI: 10.3389/fphys.2012.00402] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 09/24/2012] [Indexed: 01/18/2023] Open
Abstract
Alcoholic liver disease (ALD) encompasses hepatic steatosis, which may progress to alcoholic hepatitis, fibrosis, and cirrhosis. It remains a leading cause of morbidity and mortality in the US and worldwide. The severity of liver disease correlates with plasma levels of bacterial products in patients, and experimental ALD depends on the level of gut derived bacterial products in rodents. Since intestinal decontamination and deficiency of bacterial product receptors or their downstream signaling molecules protect from alcohol-induced liver disease, bacterial translocation (BT), qualitative, and quantitative changes of the enteric microbiome are considered as being of fundamental importance in the pathogenesis of ALD. Recent enhancements in diagnostic technologies provide a better insight into these shifts. This review highlights vital events in ALD such as BT, the importance of Toll-like receptor (TLR) signaling, intestinal bacterial overgrowth (IBO), and changes in the intestinal microbiome. Furthermore, a treatment trial section of patients reviews possible future options of therapy for ALD modifying the enteric microbiome.
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Affiliation(s)
- Phillipp Hartmann
- Department of Medicine, University of California San DiegoLa Jolla, CA, USA
| | - Wei-Chung Chen
- Department of Medicine, The Methodist Hospital, Weill Cornell CollegeHouston, TX, USA
| | - Bernd Schnabl
- Department of Medicine, University of California San DiegoLa Jolla, CA, USA
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67
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Microbial translocation in chronic liver diseases. Int J Microbiol 2012; 2012:694629. [PMID: 22848224 PMCID: PMC3405644 DOI: 10.1155/2012/694629] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 06/18/2012] [Indexed: 02/08/2023] Open
Abstract
The intestinal microflora is not only involved in the digestion of nutrients, but also in local immunity, forming a barrier against pathogenic microorganisms. The derangement of the gut microflora may lead to microbial translocation, defined as the passage of viable microorganisms or bacterial products (i.e., LPS, lipopeptides) from the intestinal lumen to the mesenteric lymph nodes and other extraintestinal sites. The most recent evidence suggests that microbial translocation (MT) may occur not only in cirrhosis, but also in the early stage of several liver diseases, including alcoholic hepatopathy and nonalcoholic fatty liver disease. Different mechanisms, such as small intestinal bacterial overgrowth, increased permeability of intestinal mucosa, and impaired immunity, may favor MT. Furthermore, MT has been implicated in the pathogenesis of the complications of cirrhosis, which are a significant cause of morbidity and mortality in cirrhotic subjects. Therapeutic strategies aiming at modulating the gut microflora and reducing MT have focused on antibiotic-based options, such as selective intestinal decontamination, and nonantibiotic-based options, such as prokinetics and probiotics. In particular, probiotics may represent an attractive strategy, even though the promising results of experimental models and limited clinical studies need to be confirmed in larger randomized trials.
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68
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Thiele M, Krag A, Rohde U, Gluud LL. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther 2012; 35:1155-65. [PMID: 22449261 DOI: 10.1111/j.1365-2036.2012.05074.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 01/24/2012] [Accepted: 03/05/2012] [Indexed: 01/30/2023]
Abstract
BACKGROUND In patients with oesophageal varices, the combination of endoscopic variceal ligation (EVL) and medical therapy is recommended as standard of care for prevention of rebleeding. The results of previous meta-analyses on this topic are equivocal. AIM To assess the effects of EVL plus medical therapy vs. monotherapy (EVL or medical therapy alone) for secondary prevention in oesophageal varices. METHODS Electronic and manual searches were combined. The primary outcome measures were overall rebleeding (variceal and nonvariceal) and mortality. Random-effects meta-analyses were performed with subgroup, sensitivity, regression and sequential analyses to identify sources of intertrial heterogeneity and the robustness of the results. RESULTS Nine randomised trials were included. In total, 442 patients were randomised to combination therapy and 513 to monotherapy. Combination therapy reduced rebleeding (RR = 0.68; 95% CI = 0.54-0.85; number needed to treat eight patients). The result was confirmed in sequential and regression analyses, but not when limiting the analysis to trials with adequate selection bias control. No effect on overall mortality was identified (RR = 0.89; 95% CI = 0.65-1.21). Combination therapy reduced bleeding-related mortality (RR = 0.52; 95% CI 0.27-0.99; number needed to treat 33 patients) and the risk of rebleeding from oesophageal varices. Combination therapy increased the risk of serious adverse events in fixed, but not in random-effects meta-analyses. CONCLUSIONS The combination of endoscopic variceal ligation and medical therapy reduce the risk of rebleeding, but not overall mortality. Additional research is needed to determine why reduced rebleeding rates do not lead to reduced mortality.
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Affiliation(s)
- M Thiele
- Department of Internal Medicine, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
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69
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Yan AW, Schnabl B. Bacterial translocation and changes in the intestinal microbiome associated with alcoholic liver disease. World J Hepatol 2012; 4:110-8. [PMID: 22567183 PMCID: PMC3345535 DOI: 10.4254/wjh.v4.i4.110] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 11/13/2011] [Accepted: 04/24/2012] [Indexed: 02/06/2023] Open
Abstract
Alcoholic liver disease progresses through several stages of tissue damage, from simple steatosis to alcoholic hepatitis, fibrosis, or cirrhosis. Alcohol also affects the intestine, increases intestinal permeability and changes the bacterial microflora. Liver disease severity correlates with levels of systemic bacterial products in patients, and experimental alcoholic liver disease is dependent on gut derived bacterial products in mice. Supporting evidence for the importance of bacterial translocation comes from animal studies demonstrating that intestinal decontamination is associated with decreased liver fibrogenesis. In addition, mice with a gene mutation or deletion encoding receptors for either bacterial products or signaling molecules downstream from these receptors, are resistant to alcohol-induced liver disease. Despite this strong association, the exact molecular mechanism of bacterial translocation and of how changes in the intestinal microbiome contribute to liver disease progression remains largely unknown. In this review we will summarize evidence for bacterial translocation and enteric microbial changes in response to alcoholic liver injury and chronic alcoholic liver disease. We will further describe consequences of intestinal dysbiosis on host biology. We finally discuss how therapeutic interventions may modify the gastrointestinal microflora and prevent or reduce alcoholic liver disease progression.
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Affiliation(s)
- Arthur W Yan
- Arthur W Yan, Division of Gastroenterology, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
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70
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Teltschik Z, Wiest R, Beisner J, Nuding S, Hofmann C, Schoelmerich J, Bevins CL, Stange EF, Wehkamp J. Intestinal bacterial translocation in rats with cirrhosis is related to compromised Paneth cell antimicrobial host defense. Hepatology 2012; 55:1154-63. [PMID: 22095436 DOI: 10.1002/hep.24789] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 10/17/2011] [Indexed: 12/12/2022]
Abstract
UNLABELLED Liver cirrhosis is associated with bacterial translocation (BT) and endotoxemia. Most translocating bacteria belong to the common intestinal microbiota, suggesting a breakdown of intestinal barrier function. We hypothesized that diminished mucosal antimicrobial host defense could predispose to BT. Two rodent models of portal hypertension with increased BT were used, CCl(4)-induced ascitic cirrhosis and 2-day portal vein-ligated (PVL) animals. BT was assessed by standard microbiological techniques on mesenteric lymph nodes. Total RNA was isolated systematically throughout the intestinal tract, and expression of Paneth cell α-cryptdins and β-defensins was determined by real-time quantitative polymerase chain reaction (qPCR). To determine functional consequences, mucosal antimicrobial activity was assessed with a fluorescence-activated cell sorting assay. BT was detectable in 40% of rats with cirrhosis. Compared with the group without BT, these animals exhibited diminished intestinal Paneth cell α-cryptdin 5 and 7 expression. In contrast, PVL was associated with BT in all animals but did not affect antimicrobial peptides. The decrease in Paneth cell antimicrobials was most pronounced in the ileum and the coecum. Other antimicrobials showed no changes or even an induction in the case of BT at different sites. Antimicrobial activity toward different commensal strains was reduced, especially in the distal ileum and the cecum in experimental cirrhosis with BT (excluding PVL). CONCLUSION Compromised Paneth cell antimicrobial host defense seems to predispose to BT in experimental cirrhosis. Understanding this liver-gut axis including the underlying mechanisms could help us to find new treatment avenues.
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Affiliation(s)
- Zora Teltschik
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart and University of Tuebingen, Germany
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71
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Papp M, Vitalis Z, Altorjay I, Tornai I, Udvardy M, Harsfalvi J, Vida A, Kappelmayer J, Lakatos PL, Antal-Szalmas P. Acute phase proteins in the diagnosis and prediction of cirrhosis associated bacterial infections. Liver Int 2012; 32:603-11. [PMID: 22145664 DOI: 10.1111/j.1478-3231.2011.02689.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 10/26/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bacterial infections are common cause of morbidity and mortality in patients with cirrhosis. The early diagnosis of these infections is rather difficult. AIMS To assess the accuracy of acute phase proteins in the identification of bacterial infections. METHODS Concentration of C-reactive protein (CRP), procalcitonin (PCT), lipopolysaccharide-binding protein (LBP), sCD14 and antimicrobial antibodies were measured in serum of 368 well-characterized patients with cirrhosis of whom 139 had documented infection. Clinical data was gathered by reviewing the patients' medical charts. RESULTS Serum levels of CRP, PCT and LBP were significantly higher in patients with clinically overt infections. Among the markers, CRP - using a 10 mg/L cut-off value- proved to be the most accurate in identifying patients with infection (AUC: 0.93). The accuracy of CRP, however, decreased in advanced stage of the disease, most probably because of the significantly elevated CRP levels in non-infected patients. Combination of CRP and PCT increased the sensitivity and negative predictive value, compared with CRP on its own, by 10 and 5% respectively. During a 3-month follow-up period in patients without overt infections, Kaplan-Meier and proportional Cox-regression analyses showed that a CRP value of >10 mg/L (P = 0.035) was independently associated with a shorter duration to progress to clinically significant bacterial infections. There was no correlation between acute phase protein levels and antimicrobial seroreactivity. CONCLUSIONS C-reactive protein on its own is a sensitive screening test for the presence of bacterial infections in cirrhosis and is also a useful marker to predict the likelihood of clinically significant bacterial infections in patients without overt infections.
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Affiliation(s)
- Maria Papp
- 2nd Department of Medicine, Division of Gastroenterology, University of Debrecen, Debrecen, Hungary.
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72
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Corradi F, Brusasco C, Fernández J, Vila J, Ramirez MJ, Seva-Pereira T, Fernández-Varo G, Mosbah IB, Acevedo J, Silva A, Rocco PRM, Pelosi P, Gines P, Navasa M. Effects of pentoxifylline on intestinal bacterial overgrowth, bacterial translocation and spontaneous bacterial peritonitis in cirrhotic rats with ascites. Dig Liver Dis 2012; 44:239-44. [PMID: 22119621 DOI: 10.1016/j.dld.2011.10.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 10/12/2011] [Accepted: 10/16/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prophylaxis of spontaneous bacterial peritonitis with norfloxacin has been associated to development of antibiotic resistance. We investigated whether pentoxifylline compared to norfloxacin reduces bacterial translocation and spontaneous bacterial peritonitis in rats with CCl(4)-induced cirrhosis and ascites. METHOD After development of cirrhosis and ascites, animals were randomly allocated to receive pentoxifylline (16 mg/kg/d every 8h, oral route, n=13) or placebo (n=12) for 15 days. An additional group of 8 cirrhotic rats was given norfloxacin (5mg/kg/d for 15 days). Six healthy rats served as controls. Cecal flora and the prevalence of bacterial translocation and spontaneous bacterial peritonitis were analysed. Serum and ascitic fluid levels of TNF-alpha and cecal levels of malondialdehyde were also measured. RESULTS Pentoxifylline in comparison to placebo reduced intestinal bacterial overgrowth (21% vs. 67%, p=0.04), bacterial translocation to cecal lymph nodes (23% vs. 75%, p=0.03) and prevented spontaneous bacterial peritonitis (0% vs. 33%, p=0.04) by Enterobacteriaceae. Norfloxacin administration induced similar results. Pentoxifylline (0.18 ± 0.10 nmol/mg), but not norfloxacin (0.25 ± 0.13; p=0.02), significantly reduced cecal mucosal levels of malondialdehyde compared to placebo (0.33 ± 0.16; p=0.03). CONCLUSION In cirrhotic rats with ascites: (a) pentoxifylline as well as norfloxacin reduced intestinal bacterial overgrowth and bacterial translocation and prevented spontaneous bacterial peritonitis; (b) pentoxifylline, but not norfloxacin, reduced oxidative stress in cecal mucosal.
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Affiliation(s)
- Francesco Corradi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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73
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Ho YH, Chuang HC, Lay CJ, Wang CL, Tsai YS, Wang LS, Tsai CC. Polymicrobial bloodstream infection involving Aeromonas species: Analysis of 62 cases. Tzu Chi Med J 2011. [DOI: 10.1016/j.tcmj.2011.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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74
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Chuang HC, Ho YH, Lay CJ, Wang LS, Tsai YS, Tsai CC. Different clinical characteristics among Aeromonas hydrophila, Aeromonas veronii biovar sobria and Aeromonas caviae monomicrobial bacteremia. J Korean Med Sci 2011; 26:1415-20. [PMID: 22065896 PMCID: PMC3207043 DOI: 10.3346/jkms.2011.26.11.1415] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 09/06/2011] [Indexed: 12/04/2022] Open
Abstract
This study aimed to compare the clinical presentations of Aeromonas hydrophila, A. veronii biovar sobria and A. caviae monomicrobial bacteremia by a retrospective method at three hospitals in Taiwan during an 8-yr period. There were 87 patients with A. hydrophila bacteremia, 45 with A. veronii biovar sobria bacteremia and 22 with A. caviae bacteremia. Compared with A. hydrophila and A. veronii biovar sobria bacteremia, A. caviae bacteremia was more healthcare-associated (45 vs 30 and 16%; P = 0.031). The patients with A. caviae bacteremias were less likely to have liver cirrhosis (27 vs 62 and 64%; P = 0.007) and severe complications such as shock (9 vs 40 and 47%; P = 0.009) and thrombocytopenia (45 vs 67 and 87%; P = 0.002). The APACHE II score was the most important risk factor of Aeromonas bacteremia-associated mortalities. The APACHE II scores of A. caviae bacteremias were lower than A. hydrophila bacteremia and A. veronii biovar sobria bacteremia (7 vs 14 and 16 points; P = 0.002). In conclusion, the clinical presentation of A. caviae bacteremia was much different from A. hydrophila and A. veronii biovar sobria bacteremia. The severity and mortality of A. caviae bacteremia were lower than A. hydrophila or A. veronii biovar sobria bacteremia.
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Affiliation(s)
- Han-Chuan Chuang
- Division of Infectious Disease, Department of Medicine, Buddhist Taipei Tzu Chi General Hospital, Taipei, Taiwan
| | - Yu-Huai Ho
- Division of Infectious Disease, Department of Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Chorng-Jang Lay
- Division of Infectious Disease, Department of Medicine, Buddhist Dalin Tzu Chi General Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Lih-Shinn Wang
- Division of Infectious Disease, Department of Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yeong-Shu Tsai
- Division of Infectious Disease, Department of Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Chen-Chi Tsai
- Division of Infectious Disease, Department of Medicine, Buddhist Dalin Tzu Chi General Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
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75
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Verbeke L, Nevens F, Laleman W. Bench-to-beside review: acute-on-chronic liver failure - linking the gut, liver and systemic circulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:233. [PMID: 22104633 PMCID: PMC3334742 DOI: 10.1186/cc10424] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The concept of acute-on-chronic liver failure (ACLF) was introduced recently to describe a subset of patients with chronic liver disease presenting with profound deterioration of liver function and rapidly evolving multi-organ failure. ACLF is frequently accompanied by the development of severe inflammatory response syndrome and has a high mortality. To date, treatment options are limited and exclusively supportive. Over the last few years, some insights have been generated in the pathophysiology of ACLF. A key role for the interaction of innate immune dysfunction, enhanced bacterial translocation from the gut, and circulatory dysfunction has been proposed. In this respect, therapeutic strategies have been examined, with variable success, in experimental studies in animals and humans. This review focuses on potentially relevant pathophysiological elements in the development of ACLF and points out promising treatment modalities in ACLF.
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Affiliation(s)
- Len Verbeke
- Department of Liver and Biliopancreatic Disorders, University Hospital Gasthuisberg, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Ribeiro TC, Chebli JM, Kondo M, Gaburri PD, Chebli LA, Feldner ACA. Spontaneous bacterial peritonitis: How to deal with this life-threatening cirrhosis complication? Ther Clin Risk Manag 2011; 4:919-25. [PMID: 19209274 PMCID: PMC2621420 DOI: 10.2147/tcrm.s2688] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of cirrhosis. It occurs in 10% to 30% of patients admitted to hospital and recent studies tend to demonstrate that SBP incidence seems to be decreasing in its frequency. A bacterial overgrowth with translocation through the increased permeable small intestinal wall and impaired defense mechanisms is considered to be the main mechanism associated with its occurrence. The Gram-negative aerobic bacteria are the major responsible for SBP episodes and Gram-positive bacteria, mainly Staphylococcus aureus, are being considered an emergent agent causing SBP. The prompt diagnosis of SBP is the key factor for reduction observed in mortality rates in recent years. The clinical diagnosis of SBP is neither sensitive nor specific and the search for new practical and available tools for a rapid diagnosis of SBP is an important endpoint of current studies. Reagent strips were considered a promising and faster way of SBP diagnosis. The prompt use of empirical antibiotics, mostly cefotaxime, improves significantly the short-term prognosis of cirrhotic patients with SBP. The recurrence rate of SBP is high and antibiotic prophylaxis has been recommended in high-risk settings. Unfortunately, the long-term prognosis remains poor.
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Affiliation(s)
- Tarsila Cr Ribeiro
- Division of Gastroenterology, Department of Medicine of University Federal de São Paulo, UNIFESP, EPM, São Paulo, São Paulo, Brazil
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Sersté T, Bert F, Leflon-Guibout V, Chauvet C, Marcon E, Asselah T, Francoz C, Durand F, Lebrec D, Valla D, Moreau R, Nicolas-Chanoine MH. Detection of bacterial DNA in serum and ascitic fluid of asymptomatic outpatients with cirrhosis and non-neutrocytic ascites. Liver Int 2011; 31:494-8. [PMID: 21382159 DOI: 10.1111/j.1478-3231.2011.02448.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Bacterial DNA (bactDNA) has been found in serum and ascitic fluid (AF) of 30-40% of hospitalized patients with cirrhosis and non-neutrocytic ascites, but its prevalence in outpatients is unknown. The aim of this prospective study was to investigate the presence of bactDNA in AF and serum among cirrhotic outpatients with non-neutrocytic ascites. METHODS Thirty-one consecutive patients with cirrhosis and non-neutrocytic ascites, who underwent therapeutic paracentesis in our outpatient clinic, were enrolled over a 13-week period. Of these patients, 13 had a single paracentesis and 18 patients had several consecutive paracenteses (2-10) over the study period. Overall, 98 serum and non-neutrocytic AF specimens were obtained and tested for the presence of bactDNA by polymerase chain reaction amplification of the 16S ribosomal RNA gene. RESULTS The main causes of cirrhosis were alcohol (53.5%) and hepatitis C (30%). The median MELD score was 16 and there were 54.8% Child-Pugh C patients. BactDNA was negative in all samples from 28 of the 31 patients, including 15 patients with several paracentesis. One patient had a single AF sample culture positive and bactDNA positive for Streptococcus mitis, whereas the simultaneous blood sample was negative. For each of the last two patients, DNA from Lactococcus lactis was detected in a single blood sample but not in the simultaneous AF sample. CONCLUSIONS In contrast to that reported previously in hospitalized patients, bactDNA is rarely detected in serum and AF of outpatients with cirrhosis and non-neutrocytic ascites.
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Affiliation(s)
- Thomas Sersté
- Service d'Hépatologie, Hôpital AP-HP Beaujon, Clichy, France.
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78
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Kim BI, Kim HJ, Park JH, Park DI, Cho YK, Sohn CI, Jeon WK, Kim HS, Kim DJ. Increased intestinal permeability as a predictor of bacterial infections in patients with decompensated liver cirrhosis and hemorrhage. J Gastroenterol Hepatol 2011; 26:550-7. [PMID: 21332551 DOI: 10.1111/j.1440-1746.2010.06490.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM There have been no trials comparing the prophylactic effect of oral quinolone and intravenous cephalosporin antibiotics and elucidating the predictive factors for the occurrence of bacterial infections in cirrhotic patients with gastrointestinal bleeding in Asian-Pacific region. METHODS One hundred and thirteen patients with advanced liver cirrhosis and active gastrointestinal hemorrhage were enrolled in our study. The patients were randomly allocated into either the oral ciprofloxacin group (n = 50, 500 mg every 12 h) or the intravenous ceftriaxone group (n = 63, 2.0 g per day for 7 days). RESULTS Proven or possible infections were significantly more frequent in the patients in the oral ciprofloxacin group (34.0%) than the intravenous ceftriaxone group (14.3%, P = 0.002). The intestinal permeability index (IPI, mean [SD]) measured the day after admission was significantly higher in the patients with proven or possible infections (1.45 [0.96]) compared with the no infection group (0.46 [0.48], P <0.01). By multivariate analysis, oral ciprofloxacin prophylaxis and higher IPI at the time of inclusion were independent and significant predictors for proven or possible infections. By receiver operating characteristic curve analysis, the best cutoff value of IPI for the prediction of the occurrence of bacterial infection was 0.62%. CONCLUSIONS The frequency of proven or possible infections was significantly lower in the intravenous ceftriaxone group compared with the oral ciprofloxacin group. The IPI measured the day after admission is a good clinical parameter predicting the occurrence of infection in these patients.
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Affiliation(s)
- Byung Ik Kim
- Department of Internal Medicine, Sungkyunkwan University Kangbuk Samsung Hospital, Seoul, South Korea
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79
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Reginato TJB, Oliveira MJA, Moreira LC, Lamanna A, Acencio MMP, Antonangelo L. Characteristics of ascitic fluid from patients with suspected spontaneous bacterial peritonitis in emergency units at a tertiary hospital. SAO PAULO MED J 2011; 129:315-9. [PMID: 22069130 PMCID: PMC10868938 DOI: 10.1590/s1516-31802011000500006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 01/10/2011] [Accepted: 04/15/2011] [Indexed: 12/20/2022] Open
Abstract
CONTEXT AND OBJECTIVE Spontaneous bacterial peritonitis (SBP) is a complication of ascites, especially in cirrhosis. Ascitic fluid with 250 or more neutrophils/mm³ is an acceptable criterion for diagnosis, even when bacterial fluid cultures are negative. The aims here were to estimate SBP frequency among emergency room patients based on cellular criteria and evaluate the biochemical profile of these fluids. DESIGN AND SETTING Retrospective study at a public tertiary hospital. METHODS Laboratory records of patients with ascites attended in emergency rooms between November 2001 and November 2006, from whom ascitic fluid samples were sent to the laboratory due to suspected SBP, were evaluated. The 691 samples included were divided into group A (presumed SBP: ≥ 250 neutrophils/mm³; n = 219; 31.7%) and group B (no presumed SBP: < 250 neutrophils/mm³; n = 472; 68.3%). Patients' sex and age; ascitic fluid characteristics (numbers of neutrophils, leukocytes and nucleated cells); bacteriological characteristics; and protein, lactate dehydrogenase, adenosine deaminase and glucose concentrations were evaluated. RESULTS Among group A cultured samples, 63 (33.8%) had positive bacterial cultures with growth of pathogens commonly associated with SBP. In total, the group A samples showed higher lactate dehydrogenase levels than seen in the group B samples. The latter presented predominance of lymphocytes and macrophages. CONCLUSION Among the ascitic fluid samples with clinically suspected SBP, 31.7% fulfilled the cellular diagnostic criteria. Positive bacterial isolation was found in 33.8% of the cultured samples from the presumed SBP group.
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Affiliation(s)
| | - Marcelo José Andrade Oliveira
- MD. Clinical Pathologist, Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Luiz César Moreira
- BSc. Biologist. Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Antonieta Lamanna
- BSc. Biologist. Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | | | - Leila Antonangelo
- MD, PhD. Clinical Pathologist and Professor, Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
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80
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Úbeda M, Muñoz L, Borrero MJ, Díaz D, Francés R, Monserrat J, Lario M, Lledó L, Such J, Álvarez-Mon M, Albillos A. Critical role of the liver in the induction of systemic inflammation in rats with preascitic cirrhosis. Hepatology 2010; 52:2086-95. [PMID: 21105108 DOI: 10.1002/hep.23961] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Systemic activation of the inflammatory immune system contributes to the progression of cirrhosis with ascites. Immune cells become activated after interacting at the mesenteric lymph nodes (MLNs) with bacteria translocated from the gut, and thereafter reach the bloodstream through recirculation. It is unknown whether systemic activation of the immune system is present in pre-ascitic cirrhosis, in which gut bacterial translocation has not been described. The purpose of this study was to determine whether systemic activation of the immune system initiates in rats with compensated carbon tetrachloride (CCl(4))-induced cirrhosis, and if so to establish the activation site of immune cells. We studied the activation status of immune cells in peripheral blood, MLNs, and hepatic lymph nodes (HLNs). Systemic inflammation was present in rats with cirrhosis, as shown by expansion (P < 0.01) of circulating total and inflammatory monocytes and recently activated CD134(+) T helper (T(h)) cells. The same populations of cells were increased (P < 0.01) in MLNs and HLNs. Bacterial translocation was absent in rats with cirrhosis or control rats, but bacterial DNA fragments were present in the MLNs of 54% of rats with cirrhosis. The liver was the source of activated immune cells present in the blood, as shown by the direct correlation between activated T(h) cells in the blood and HLNs, but not in MLNs, and the normalization by gut decontamination with antibiotics of activated cells in MLNs, but not in the blood or HLNs. CONCLUSION In experimental cirrhosis, systemic activation of the immune system occurs before ascites development and is driven by recirculation of cells activated in HLNs. In addition, in compensated cirrhosis, bacterial DNA fragments reach the MLNs, where they elicit a local inflammatory response.
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Affiliation(s)
- María Úbeda
- Laboratory of Immune System Disease, Department of Medicine, University of Alcalá, Alcalá de Henares, Madrid Spain
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81
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Bellot P, García-Pagán JC, Francés R, Abraldes JG, Navasa M, Pérez-Mateo M, Such J, Bosch J. Bacterial DNA translocation is associated with systemic circulatory abnormalities and intrahepatic endothelial dysfunction in patients with cirrhosis. Hepatology 2010; 52:2044-52. [PMID: 20979050 DOI: 10.1002/hep.23918] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 08/06/2010] [Indexed: 12/12/2022]
Abstract
UNLABELLED Presence of bacterial DNA in noninfected patients with cirrhosis and ascites is associated with a marked inflammatory response including activation of the inducible form of nitric oxide synthase and release of nitric oxide, similar to that observed in patients with spontaneous bacterial peritonitis. Although presence of bacterial DNA is associated with an impaired prognosis, no information is available regarding its hemodynamic consequences. Systemic and hepatic hemodynamics before and after a liquid test meal were assessed in a series of 75 noninfected patients with cirrhosis (55 with ascites). Bacterial DNA was measured by polymerase chain reaction. Bacterial DNA was detected only in patients with ascites. Clinical data and liver function were similar in ascitic patients with presence (n = 21) or absence of bacterial DNA (n = 34). Bacterial-DNA(+) patients had significantly lower mean arterial pressure (P = 0.002) and systemic vascular resistance (P = 0.03) than bacterial-DNA(-) patients. Cardiac output, cardiopulmonary pressures, hepatic venous pressure gradient (HVPG), and hepatic blood flow were similar in both groups. Thirty minutes after the test meal, in response to increased blood flow caused by postprandial hyperemia, there was a significantly greater increase in HVPG and impaired hepatic vasorelaxation in bacterial-DNA(+) as compared with bacterial-DNA(-) patients, which indicates hepatic endothelial dysfunction. Indeed, the increase in HVPG after the test meal significantly correlated with serum bacterial DNA concentration. CONCLUSION Presence of bacterial DNA, a marker of bacterial translocation, is associated with aggravation of peripheral vasodilation and with worsening of intrahepatic endothelial dysfunction.
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Affiliation(s)
- Pablo Bellot
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
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Altered intestinal function precedes the appearance of bacterial DNA in serum and ascites in patients with cirrhosis: a pilot study. Eur J Gastroenterol Hepatol 2010; 22:1228-34. [PMID: 20512041 DOI: 10.1097/meg.0b013e32833b4b03] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Bacterial translocation seems to precede the occurrence of overt bacterial infection in patients with cirrhosis. The presence of bacterial DNA in blood and ascites correlates with bacterial translocation and is frequent in patients with advanced cirrhosis without overt infection. Our aim was to search for bacterial DNA in patients with cirrhosis both with and without ascites, and to study its correlation with abnormal intestinal motility or permeability and the presence of bacterial overgrowth. METHODS Blood and ascites samples were obtained on day 1, and blood samples were taken twice a day for the following 3 days. Bacterial DNA was assayed by polymerase chain reaction using universal primers for rRNA 16 s. Oro-caecal transit time and bacterial overgrowth were assessed with Lactulose H(2) breath testing. Intestinal permeability was assessed by determining urinary lactulose and mannitol excretion with high performance liquid chromatography. RESULTS We studied seven patients (six were male, age range was 42-78 years). Aetiology was alcohol in four, HCV in two, HBV in one; ascites was present in four and Child-Pugh grade was A in four and B in three. All patients had increased intestinal permeability, six had decreased transit time and one had bacterial overgrowth. In only one patient (with ascites), polymerase chain reaction was positive for bacterial DNA both in ascites and serum for all 4 days on which samples were taken. CONCLUSION Increased intestinal permeability and abnormal motility were frequent without evidence of bacterial translocation in cirrhosis even without ascites. They are likely to be facilitators for bacterial translocation and thus precede it.
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83
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Presence of anti-microbial antibodies in liver cirrhosis--a tell-tale sign of compromised immunity? PLoS One 2010; 5:e12957. [PMID: 20886039 PMCID: PMC2944893 DOI: 10.1371/journal.pone.0012957] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Accepted: 08/24/2010] [Indexed: 12/21/2022] Open
Abstract
Background Bacterial translocation plays important role in the complications of liver cirrhosis. Antibody formation against various microbial antigens is common in Crohn's disease and considered to be caused by sustained exposure to gut microflora constituents. We hypothesized that anti-microbial antibodies are present in patients with liver cirrhosis and may be associated with the development of bacterial infections. Methodology/Principal Findings Sera of 676 patients with various chronic liver diseases (autoimmune diseases:266, viral hepatitis C:124, and liver cirrhosis of different etiology:286) and 100 controls were assayed for antibodies to Saccharomyces cerevisiae(ASCA) and to antigens derived from two intestinal bacterial isolates (one gram positive, one gram negative, neither is Escherichia coli). In patients with liver cirrhosis, we also prospectively recorded the development of severe episodes of bacterial infection. ASCA and anti-OMP Plus™ antibodies were present in 38.5% and 62.6% of patients with cirrhosis and in 16% and 20% of controls, respectively (p<0.001). Occurrence of these antibodies was more frequent in cases of advanced cirrhosis (according to Child-Pugh and MELD score; p<0.001) or in the presence of ascites (p<0.001). During the median follow-up of 425 days, 81 patients (28.3%) presented with severe bacterial infections. Anti-microbial antibody titers (p = 0.003), as well as multiple seroreactivity (p = 0.036), was associated with infectious events. In logistic regression analysis, the presence of ascites (OR:1.62, 95%CI:1.16–2.25), co-morbidities (OR:2.22, 95%CI:1.27–3.86), and ASCA positivity (OR:1.59, 95%CI:1.07–2.36) were independent risk factors for severe infections. A shorter time period until the first infection was associated with the presence of ASCA (p = 0.03) and multiple seropositivity (p = 0.037) by Kaplan-Meier analysis, and with Child-Pugh stage (p = 0.018, OR:1.85) and co-morbidities (p<0.001, OR:2.02) by Cox-regression analysis. Conclusions/Significance The present study suggests that systemic reactivity to microbial components reflects compromised mucosal immunity in patients with liver cirrhosis, further supporting the possible role of bacterial translocation in the formation of anti-microbial antibodies.
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84
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Bacterial translocation to mesenteric lymph nodes increases in chronic portal hypertensive rats. Dig Dis Sci 2010; 55:2244-54. [PMID: 19834810 DOI: 10.1007/s10620-009-1001-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Accepted: 09/21/2009] [Indexed: 12/12/2022]
Abstract
PURPOSE Bacterial translocation is a frequent complication in portal hypertension related to cirrhosis in the human clinical area. The aim of this study was to verify the existence of intestinal bacterial translocation to mesenteric lymph nodes in male Wistar rats with triple partial portal vein ligation during short- (48 h) and long-term (1 month) postoperative evolution. RESULTS At 48 h, ileal total aerobes bacteria (p < 0.001) and Lactobacillus decrease in sham-operated (SO) and portal hypertensive (PH) rats. At 1 month, ileal Enterococci and Streptococcus sp. show a statistically significant decrease in SO- and PH-rats. Lactobacillus decreases in the colon in SO- (p < 0.01) and in PH-rats (p < 0.001). At 1 month, colonic Enterococci decreases compared to control (p < 0.001) and SO-rats (p < 0.01). These intestinal microfloral changes are associated with bacterial translocation to mesenteric lymph nodes at 48 h (50%; p = 0.004) and 1 month (100%; p < 0.001) of postoperative evolution in PH-rats. CONCLUSIONS The enlargement of the stenosed portal tract related to triple partial portal vein ligation in the rat, since it increases the resistance to the portal blood flow, may be a key factor involved in one of the pathological consequences of portal hypertension, as is bacterial translocation to mesenteric lymph nodes.
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85
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Khan J, Pikkarainen P, Karvonen AL, Mäkelä T, Peräaho M, Pehkonen E, Collin P. Ascites: aetiology, mortality and the prevalence of spontaneous bacterial peritonitis. Scand J Gastroenterol 2010; 44:970-4. [PMID: 19440927 DOI: 10.1080/00365520902964739] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the aetiology, prognosis and prevalence of spontaneous bacterial peritonitis (SBP) in patients hospitalized for ascites. The validity of an elevated (>11 g/l) serum-ascites albumin gradient (SAAG) in the diagnostic work-up was evaluated. Mortality trends were observed over two periods of time. MATERIAL AND METHODS A total of 231 consecutive patients who underwent diagnostic paracentesis between February 1994 and December 1998 and January 2005 and March 2007 were included in the study. The definition of SBP comprised polymorphonuclear cell count >250/mm(3) without evidence of other intra-abdominal source of infection. SAAG was obtained and the Child-Pugh classification applied. Survival rates were obtained from medical records. RESULTS The most common causes of ascites were alcohol liver cirrhosis (n=143; 62%), malignancy (n=30; 13%), non-alcoholic cirrhosis (n=11; 5%) and malignancy with cirrhosis (n=11; 5%). The prevalence of SBP in cirrhosis was 6.7% (95% CI 2.8-10.5%). Overall mortality rates at 1 month, 6 months and 1 year were 22%, 40% and 48%, respectively, and remained unchanged between the intervals. Patients with grade C liver disease had higher 1-month (26% versus 6%), and 6-month (44% versus 27%) mortality rates than grade B patients, but commensurate 1-year mortality (49% versus 47%). SAAG was >or=11 g/l in 85% of patients with obvious portal hypertension and in 30% with malignancy, ascites albumin level <or=9 g/l in 69% and 20%, respectively. CONCLUSIONS Mortality in patients with ascites was high. The occurrence of SBP was relatively low in our series, with a high proportion of alcoholic cirrhosis. SAAG was inaccurate in differentiating ascites caused by portal hypertension or malignancy.
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Affiliation(s)
- Jahangir Khan
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital and Medical School, University of Tampere, Tampere, Finland
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86
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Testro AG, Gow PJ, Angus PW, Wongseelashote S, Skinner N, Markovska V, Visvanathan K. Effects of antibiotics on expression and function of Toll-like receptors 2 and 4 on mononuclear cells in patients with advanced cirrhosis. J Hepatol 2010; 52:199-205. [PMID: 20006396 DOI: 10.1016/j.jhep.2009.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 06/30/2009] [Accepted: 07/02/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Toll-like receptors (TLRs) are critical to innate immune responses. TLR4 recognises Gram-negative bacteria, whilst TLR2 recognises Gram-positive. We examined TLR expression and function in cirrhosis, and whether this is affected by antibiotic therapy. METHODS Sixty-four subjects were included (23 controls and 41 Child-Pugh C cirrhotic patients). Thirty patients were taking norfloxacin or trimethoprim-sulfamethoxazole as prophylaxis against bacterial peritonitis and 11 were not. In a second study, 8 patients were examined before and after commencement of antibiotics. Monocyte expression of TLR2 and 4 was determined by flow cytometry. Monocytes from the patients with paired samples were stimulated using TLR ligands and TNF-alpha production measured. RESULTS Patients not taking antibiotics had significantly decreased TLR4 expression compared with controls (0.74 vs. 1.0, p=0.009) and patients receiving antibiotics (0.74 vs. 0.98, p=0.02). There were no differences with regard to TLR2. In the patients with paired samples, TLR4 expression increased (0.74-1.49, p=0.002) following antibiotic use, whilst again, there was no change in TLR2 expression (0.99 vs. 0.92, p=0.20). TLR4-dependent TNF-alpha production increased following antibiotic use (1077 vs. 3620pg/mL, p<0.05), whilst TLR2-dependent production was unchanged. CONCLUSIONS TLR4 expression is decreased in patients with Child-Pugh C cirrhosis, but is restored by antibiotics targeting enteric Gram-negative bacteria. TLR4-dependent cytokine production also increases significantly following antibiotic therapy. This suggests that the high incidence of Gram-negative infection in cirrhotic patients is in part due to down-regulation of the TLR4-dependant immune response and that the efficacy of antibiotic prophylaxis is contributed to by modulation of innate immunity.
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Affiliation(s)
- Adam G Testro
- Department of Medicine, The University of Melbourne, Austin Health, Vic., Australia.
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87
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Lay CJ, Zhuang HJ, Ho YH, Tsai YS, Wang LS, Tsai CC. Different clinical characteristics between polymicrobial and monomicrobial Aeromonas bacteremia--a study of 216 cases. Intern Med 2010; 49:2415-21. [PMID: 21088342 DOI: 10.2169/internalmedicine.49.4117] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Part of Aeromonas bacteremia is polymicrobial infection. However, a clinical comparison of monomicrobial and polymicrobial Aeromonas bacteremia has not hitherto been reported. METHODS A retrospective analysis of medical records of patients with Aeromonas bacteremia at three large referral hospitals in Taiwan for an 8-year period (2001-2008) was conducted. RESULTS There were 154 patients with monomicrobial Aeromonas bacteremia and 62 patients with polymicrobial Aeromonas bacteremia. In the polymicrobial infections, E. coli was the most common combined pathogen (42%), followed by Klebsiella spp. (24%) and Enterobacter spp. (16%). Multivariate logistic regression analysis revealed solid cancer as the risk factor for polymicrobial Aeromonas bacteremia, with male gender and cirrhosis as risk factors for monomicrobial Aeromonas bacteremia. However, of all types of solid cancer, hepatoma was associated with monomicrobial Aeromonas bacteremia. APACHE II score was the most important prognostic factor in both groups. CONCLUSION Aeromonas bacteremia in patients with cirrhosis or male gender tended to be monomicrobial. Polymicrobial Aeromonas bacteremia was associated with solid cancers. In either polymicrobial or monomicrobial Aeromonas bacteremia, prognosis could be predicted according to disease severity measured by APACHE II score.
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Affiliation(s)
- Chorng-Jang Lay
- Division of Infectious Disease, Department of Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
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88
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Holzer T, Gervaz P, Spahr L, McKee T, Bucher P, Morel P. Phlegmonous colitis: another source of sepsis in cirrhotic patients? BMC Gastroenterol 2009; 9:94. [PMID: 20003486 PMCID: PMC2800109 DOI: 10.1186/1471-230x-9-94] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 12/15/2009] [Indexed: 11/29/2022] Open
Abstract
Background The clinical relevance of phlegmonous colitis (PC), a rare autopsy finding in cirrhotic patients, is poorly documented. We postulated that PC might be a source of sepsis in patients with portal hypertensive colopathy (PHC). Case presentation We report three cirrhotic patients who were admitted with abdominal sepsis and who illustrate, to various degrees, the clinico-pathological sequence of colonic alterations associated with portal hypertension. Two cirrhotic patients with PHC developed gram-negative bacteraemia and quickly responded to intravenous antibiotics. Another cirrhotic patient underwent emergency colectomy for PC, and subsequently died from multiple organ failure. Histological alterations in the operative specimen included: a) mucosal ulcerations; b) disseminated micro-abscesses in the submucosa; and c) a severe vasculopathy leading to complete obliteration of submucosal blood vessels. Conclusions These data suggest that cirrhotic patients with PHC may progress towards PC, which, in turn, may be the cause for life-threatening sepsis.
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Affiliation(s)
- Thomas Holzer
- Department of Surgery, Geneva University Hospital and Medical School, 1211 Geneva, Switzerland.
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89
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Uchiyama-Tanaka Y. Colon irrigation causes lymphocyte movement from gut-associated lymphatic tissues to peripheral blood. Biomed Res 2009; 30:311-4. [PMID: 19887728 DOI: 10.2220/biomedres.30.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
It is well established that the intestine is an important site responsible for the local immune system. It is speculated that people suffering from constipation and carrying fecal residues in the intestine may have a decreased function of this immune system. In this study, colon irrigation, which is cleansing of the colon using a simple hydrotherapy instrument, was performed in 10 subjects with or without the disease. The number of leukocytes and their demarcation were then evaluated. The number and ratio of lymphocytes increased significantly after irrigation. This result suggested that colon irrigation might induce lymphocyte transmigration from gut-associated lymphatic tissues into the circulation, which may improve colon and immune system function.
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90
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Tandon P, Moncrief K, Madsen K, Arrieta MC, Owen RJ, Bain VG, Wong WW, Ma MM. Effects of probiotic therapy on portal pressure in patients with cirrhosis: a pilot study. Liver Int 2009; 29:1110-5. [PMID: 19490420 DOI: 10.1111/j.1478-3231.2009.02020.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent literature has supported the role of bacterial translocation as a mediator of splanchnic vasodilatation and portal hypertension. The objective of this study was to determine whether the probiotic VSL#3 would reduce portal pressure in patients with cirrhosis. METHODS Eight patients with compensated or very early decompensated cirrhosis and hepatic venous pressure gradient (HVPG) >10 mmHg, received 2 months of VSL#3 (3600 billion bacteria daily). The HVPG, intestinal permeability, endotoxin, tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, renin and aldosterone were measured at baseline and study end. RESULTS There was no change in the HVPG or intestinal permeability from baseline to study end but there was a trend to reduction in plasma endotoxin (P=0.09), a mild but significant increase in serum TNF-alpha (P=0.02) and a significant reduction in plasma aldosterone (P=0.03). CONCLUSIONS Within the limitations of small sample size, there does not appear to be a benefit of probiotic therapy for portal pressure reduction in patients with compensated or early decompensated cirrhosis. The reductions in endotoxin and aldosterone suggest possible beneficial effects of probiotics for this patient population. The clinical significance of the small but unexpected increase in TNF-alpha is unclear. Future studies are planned in patients with decompensated cirrhosis.
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Affiliation(s)
- Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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91
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Tazi KA, Quioc JJ, Abdel-Razek W, Tellier Z, Guichard C, Ogier-Denis E, Lebrec D, Moreau R. Protein array technology to investigate cytokine production by monocytes from patients with advanced alcoholic cirrhosis: An ex vivo pilot study. Hepatol Res 2009; 39:706-15. [PMID: 19473436 DOI: 10.1111/j.1872-034x.2009.00498.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIM In patients with advanced cirrhosis, little is known about the ability of peripheral blood monocytes to spontaneously produce signaling proteins such as cytokines. The aim of this ex vivo study was to evaluate cytokine production under baseline conditions and after stimulation by lipopolysaccharide (LPS), a toll-like receptor (TLR) agonist. METHODS Peripheral blood monocytes were isolated from patients with advanced alcoholic cirrhosis (without ongoing bacterial infections) and normal subjects. Cells were left unstimulated or were stimulated with LPS. The abundance of 24 cytokines was measured using a filter-based, arrayed sandwich enzyme-linked immunosorbent assay (ELISA) in the supernatant of cultured monocytes. RESULTS Cirrhotic monocytes spontaneously produced six proteins (TNF-alpha, IL-6, IL-8, MCP-1, RANTES and Gro), whereas normal monocytes produced only small amounts of IL-8 and RANTES. Analyses with the online gene set analysis toolkit WebGestalt (http://bioinfo.vanderbilt.edu/webgestalt) found enrichment for the six proteins in the human gene ontology subcategory (http://www.geneontology.org), Kyoto Encyclopedia of Genes and Genome pathways (http://www.genome.ad.jp/kegg/) and BioCarta pathways (http://www.biocarta.com/genes/index.asp) consistent with a proinflammatory phenotype of cirrhotic monocytes resulting from activated TLR signaling. Interestingly, LPS-elicited TLR engagement further increased the production of the six proteins and did not induce the secretion of any others, in particular the anti-inflammatory cytokine IL-10. LPS-stimulated normal monocytes produced TNF-alpha, IL-6, IL-8, MCP-1, RANTES, Gro and IL-10. CONCLUSION In patients with advanced cirrhosis, peripheral blood monocytes spontaneously produce proinflammatory cytokines, presumably in response to unrestricted TLR signaling.
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Affiliation(s)
- Khalid A Tazi
- INSERM, U773, Centre de Recherche Bichat-Beaujon CRB3, Paris, France
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92
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Vlachogiannakos J, Saveriadis AS, Viazis N, Theodoropoulos I, Foudoulis K, Manolakopoulos S, Raptis S, Karamanolis DG. Intestinal decontamination improves liver haemodynamics in patients with alcohol-related decompensated cirrhosis. Aliment Pharmacol Ther 2009; 29:992-9. [PMID: 19210289 DOI: 10.1111/j.1365-2036.2009.03958.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endotoxaemia is commonly seen in cirrhotic patients with ascites and this may be associated with increased portal pressure. AIM To investigate the effect of intestinal decontamination on liver haemodynamics in alcohol-related cirrhotic patients with ascites. METHODS We included 30 patients. At day 0, systemic and splanchnic circulation endotoxin levels were determined and HVPG measurement performed. Patients received rifaximin (1200 mg/day) for 28 days. At day 29, systemic and splanchnic circulation endotoxin levels were determined and HVPG measurement performed again. RESULTS Median (range) plasma endotoxin levels decreased significantly after rifaximin administration both in systemic [1.45(0-3.1) vs. 0.7(0-2.7), P < 0.0001] and splanchnic circulation [1.8(0-3.4) vs. 0.8(0-2.1), P < 0.0001]. Meanwhile, the difference seen in endotoxin levels between the splanchnic and systemic circulation at day 0 (P = 0.001) was not noted at day 29 (P = 0.137). HVPG measurement was possible in 28 patients. Median (range) HVPG values were 18 mmHg (12.7-26.3) on day 0 vs. 14.7 mmHg (7-20) on day 29 (P < 0.0001). HVPG decreased after rifaximin in 23, remained stable in two and increased in three patients. CONCLUSION Hepatic venous pressure gradient values decreased significantly after intestinal decontamination with rifaximin in patients with alcohol-related decompensated cirrhosis and this might have been achieved through significant reduction of plasma endotoxin levels.
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Affiliation(s)
- J Vlachogiannakos
- 2nd Department of Gastroenterology, Evangelismos Hospital, Athens, Greece.
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93
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Cohen MJ, Sahar T, Benenson S, Elinav E, Brezis M, Soares-Weiser K. Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding. Cochrane Database Syst Rev 2009:CD004791. [PMID: 19370611 DOI: 10.1002/14651858.cd004791.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis is frequent among cirrhotic patients, associated with significant morbidity and mortality. Selective intestinal decontamination employing antibiotics is a proposed prophylactic measure. While data regarding this modality among cirrhotic patients with gastrointestinal bleeding exist, there is insufficient data synthesis regarding cirrhotic patients with ascites and no gastrointestinal bleeding. OBJECTIVES To assess whether antibiotic prophylaxis decreases spontaneous bacterial peritonitis and mortality among cirrhotic patients with ascites and no gastrointestinal bleeding. SEARCH STRATEGY We identified relevant randomised trials by searching trial registries of The Cochrane Hepato-Biliary Group and The Cochrane Collaboration, medical literature search engines, and reviewing all literature we found on the topic until February 2009. SELECTION CRITERIA We searched for randomised clinical trials assessing prophylactic treatment among adult cirrhotic patients with ascites and no gastrointestinal bleeding, comparing antibiotic therapy with no intervention, placebo, or with another antibiotic regimen. DATA COLLECTION AND ANALYSIS Three independent authors searched for and collected the trials and extracted relevant data. Four other independent authors validated the findings and assessed them. The studies were assessed for design, patient and intervention characteristics, and quality. A meta-analysis was performed to estimate measures of association between antibiotic prophylaxis and spontaneous bacterial peritonitis or mortality. MAIN RESULTS Nine trials were included in the review. Seven trials, comparing antibiotics to placebo or no treatment, were meta-analysed. Systematic bias in design or publication is suggested by trial results. The randomisation results suggest that the probability that true randomisation took place in all trials is very small and the report of most trials regarding design was poor. The proportion of participants with spontaneous bacterial peritonitis varied between the trials from 15% to 50%. The calculated relative risks (95% confidence interval) of spontaneous bacterial peritonitis and mortality among patients treated with antibiotics compared with no treatment/placebo were 0.20 (0.11 to 0.37) and 0.61 (0.43 to 0.87). There were very few reports of adverse events. AUTHORS' CONCLUSIONS The pooled estimates suggest that antibiotic prophylaxis might be prudent among cirrhotic patients with ascites and no gastrointestinal bleeding. However, poor trial methodology and report coupled with findings suggesting systematic bias in publication and design reflect the fragility of these findings. Potential hazard to society and the patients themselves from resistant pathogens should be considered when promoting long-lasting antibiotic prophylaxis. It seems that recommending antibiotic prophylaxis is still far from being a substantiated prevention strategy. Trials of better design, well reported, and of longer follow-up are greatly needed.
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Affiliation(s)
- Matan J Cohen
- Center for Clinical Quality & Safety, Hadassah Medical Center, Ein Kessem Campus, Box 53, POB12000, Jerusalem, Israel, 91120.
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Abstract
Since its initial description in 1964, research has transformed spontaneous bacterial peritonitis (SBP) from a feared disease (with reported mortality of 90%) to a treatable complication of decompensated cirrhosis, albeit with steady prevalence and a high recurrence rate. Bacterial translocation, the key mechanism in the pathogenesis of SBP, is only possible because of the concurrent failure of defensive mechanisms in cirrhosis. Variants of SBP should be treated. Leucocyte esterase reagent strips have managed to shorten the ‘tap-to-shot’ time, while future studies should look into their combined use with ascitic fluid pH. Third generation cephalosporins are the antibiotic of choice because they have a number of advantages. Renal dysfunction has been shown to be an independent predictor of mortality in patients with SBP. Albumin is felt to reduce the risk of renal impairment by improving effective intravascular volume, and by helping to bind pro-inflammatory molecules. Following a single episode of SBP, patients should have long-term antibiotic prophylaxis and be considered for liver transplantation.
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95
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Laudanno OM, Cesolari JA, Godoy A, Sutich E, Sarangone S, Catalano J, San Miguel P. Bioflora probiotic in immunomodulation and prophylaxis of intestinal bacterial translocation in rats. Dig Dis Sci 2008; 53:2667-70. [PMID: 18320321 DOI: 10.1007/s10620-007-0179-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Accepted: 12/20/2007] [Indexed: 12/12/2022]
Abstract
UNLABELLED The immunomodulator effect of Bioflora probiotic on T (CD4+) and B (CD20) lymphocytes in gastrointestinal mucosa and intestinal bacterial translocation was studied using Wistar rats (n = 10 per group). Two experiments were used: (I) stress with immobilization and water immersion at 22 degrees C for 7 h plus the application of indomethacin (Indo) 10 mg/kg SC every 24 h for 3 days (comparator group), and (II) stress experiment I with the addition of 1 mL of Bioflora applied through a orogastric tube every 12 h for 3 days. At the 4th day, in asepsis, a dissection laparotomy of liver, spleen, mesenteric lymphatic nodes, and cecum was performed for microbiological culture, and stomach, ileum, and colon were also dissected for immunohistochemical and quantification of CD4+ and CD20. Findings in experiment I revealed cecum bacterial overdevelopment of 6 x 10(10) +/- 2.3 x 10(9) colony-forming units (CFU) (P < 0.01) and positive cultures in liver, spleen, and all mesenteric lymphatic nodes. On the other hand, in the group treated with Probiotic Bioflora, cecum without overdevelopment (3 x 10(6) +/- 1.3 x 10(5) CFU), negative cultures in liver and spleen, and in lymphatic nodes two positive and eight negative cultures for E. coli and P. vulgaris (P < 0.01) were observed. Immunohistochemistry revealed a relevant increase of T lymphocytes (CD4+) in ileum and colon. CONCLUSIONS Bioflora probiotic was shown to be an intestinal immunomodulator that induced increased T (CD4+) lymphocytes that also offer prophylaxis of intestinal bacterial translocation in a stressed rat model.
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Affiliation(s)
- O M Laudanno
- Experimental Gastroenterology, Medical Sciences Faculty, School of Medical Sciences, Cochabamba 2090, Rosario, Argentina.
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96
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Bellot P, Francés R, Such J. Translocación de productos de origen bacteriano en la cirrosis. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:508-14. [DOI: 10.1157/13127094] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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97
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Neugebauer H, Hartmann P, Krenn S, Glück T, Schölmerich J, Straub R, Wiest R. Bacterial translocation increases phagocytic activity of polymorphonuclear leucocytes in portal hypertension: priming independent of liver cirrhosis. Liver Int 2008; 28:1149-57. [PMID: 18662280 DOI: 10.1111/j.1478-3231.2008.01829.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Bacterial translocation (BT) to mesenteric lymph nodes (MLN) in cirrhosis has been linked to impaired host defence. Phagocytosis by polymorphonuclear leucocytes (PMNLs) is the primary event in the killing of bacteria but has not been investigated in relation to the presence of BT. METHODS Mesenteric lymph nodes were harvested sterile and assessed for BT by culture techniques. Study groups included ascitic cirrhotic rats (LC), healthy controls (Con) as well as portal-vein-ligated (PVL) rats 2 days (acute PVL with and without norfloxacin) or 3 weeks after surgery (chronic PVL). PMNLs were isolated from systemic blood and the capacity to phagocytose opsonized Escherichia coli was evaluated by FACS analysis. RESULTS No BT was observed in Con and chronic PVL animals but 11/20 LC (55%) and six out of six acute PVL (100%) presented with BT. In the presence of BT, PMNL from PVL as well as LC rats showed significantly increased phagocytic activity as compared with controls. In contrast, PMNL from animals without BT, whether PVL or LC, exhibited phagocytic activity similar to those from control rats. The number of PMNLs involved in the phagocytic process was significantly increased only in portal-hypertensive rats with but not without BT as compared with controls. Norfloxacin did prevent BT in acute PVL animals, thereby correcting the increase in phagocytic capacity in PMNL. CONCLUSIONS Cirrhosis per se is not associated with alterations of the phagocytic capacity of PMNL. The occurrence of BT, however, increases the phagocytic capacity of PMNL, being observed likewise in prehepatic portal hypertension, indicating an in vivo'priming' of PMNL by BT independent of cirrhosis.
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Affiliation(s)
- Hermann Neugebauer
- Department of Internal Medicine, School of Medicine, University Hospital, Regensburg 93042, Germany
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98
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Abstract
Modulation of intestinal flora through the use of probiotics is an emerging therapeutic strategy in the management of chronic liver diseases. This article focuses on the pathophysiologic basis for using probiotics in liver disease and reviews the existing literature on the subject. The role of probiotics is examined in the following areas: a) prevention of infection, b) the hyperdynamic circulatory state of cirrhosis, c) hepatic encephalopathy, d) liver function, and e) nonalcoholic fatty liver disease.
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99
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Perrella A, Grattacaso S, Gnarini MR, D'Antonio A, Sbreglia C, Atripaldi L, Conti P, Perrella O. Increase of granzyme B-positive cells in ascitic fluid of patients with spontaneous bacterial peritonitis. Hepatol Res 2008; 38:410-4. [PMID: 18021232 DOI: 10.1111/j.1872-034x.2007.00276.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Spontaneous bacterial peritonitis (SBP) occurs as a direct consequence of bacteria entering ascitic fluid (AF) from the intestinal lumen trough in several ways, including the hematogenous and mesenteric lymph nodes route. There are few studies on the cytokine profile of ascitic-derived mononuclear cells of patients with SBP, particularly on granzyme B (GZB). The aim of the present study was to verify whether patients with SBP have GZB-positive cells, whether they are increased in patients with aseptic ascites, and their trend after antibiotic treatment. We enrolled 36 consecutive patients (24 males and 12 females) with SBP on histologically-proven hepatitis C virus cirrhosis (group A) and 20 patients (11 males and nine females with ascites, but without evidences of SBP (group B). The diagnosis of SBP was made according to the following criteria: positive colture in AF or blood (at least two cultures) and neutrophils in AF (>250 mL polymorphonuclear leukocytes). For these patients we used ELISpot to assay GZB production on purified mononuclear cells in ascitesand peripheral blood, coupled with tumor necrosis factor-alpha tested using ELISA. A non-parametric statistical analysis was used to assess significant differences and correlations. We found positive culture in all of the patients with SBP (80% Escherichia coli; 20% Enterococcus faecium). Furthermore, the patients in group A had a higher number of GZB spot-forming colonies than the patients in group B (P < 0.001). GZB-positive cells were lower in the peripheral blood than those found in the AF of patients with SBP, while no differences were found between blood and AF in group B. Furthermore, after antibiotic treatment, GZB was reduced in the patients with SBP (P < 0.05). In conclusion, GZB may be an important mediator of the immune response towards bacteria in AF and could be used as a diagnostic tool.
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Affiliation(s)
- Alessandro Perrella
- Department Infectious Disease and Immunology, Hospital D.Cotugno, Naples, Italy
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100
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Koulaouzidis A, Bhat S, Karagiannidis A, Tan WC, Linaker BD. Spontaneous bacterial peritonitis. Postgrad Med J 2007; 83:379-83. [PMID: 17551068 PMCID: PMC2600063 DOI: 10.1136/pgmj.2006.056168] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 01/25/2007] [Indexed: 12/20/2022]
Abstract
Spontaneous bacterial peritonitis (SBP) is the infection of ascitic fluid in the absence of any intra-abdominal, surgically treatable source of infection. Despite timely diagnosis and treatment its reported incidence in ascitic patients varies between 7-30%. Ascitic paracentesis remains the chief diagnostic procedure. Automated cell counters have the same diagnostic accuracy as the manual measurement of white cells. Lately, the use of leucocyte reagent strips (dipsticks) has emerged as a useful alternative. Examination of the fluid is not complete unless the sample is inoculated in blood culture bottles. Treatment is currently with third-generation cephalosporins or oral quinolones. Following a single episode of SBP patients should have long term antibiotic prophylaxis.
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Affiliation(s)
- A Koulaouzidis
- Gastroenterology Department, Warrington General Hospital, Cheshire, UK.
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