Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis

Spontaneous bacterial peritonitis in a patient with gastric carcinoma

Spontaneous bacterial peritonitis (SBP) is classically described in patients with cirrhosis and nephrotic syndrome. However, SBP rarely occurs in patients with malignant ascites. We report a patient with gastric cancer with ascites, who developed SBP. Clinicians need to be aware of this complication in patients with malignant ascites.

Tumor necrosis factor and interleukin-6 in spontaneous bacterial peritonitis in cirrhosis: relationship with the development of renal impairment and mortality

Spontaneous bacterial peritonitis (SBP) is associated with an important production of inflammatory mediators. However, it is unknown whether there is a relationship between the abdominal production of these mediators and the development of renal impairment, one of the most important prognostic parameters in spontaneous bacterial peritonitis. We studied 52 cirrhotic patients at diagnosis and resolution of the infection, by measuring endotoxin, tumor necrosis factor (TNF), and interleukin-6 (IL-6) levels in plasma and ascitic fluid. Thirteen patients (25%) developed renal impairment. Patients developing renal impairment showed significantly higher plasma and ascitic fluid cytokine levels at diagnosis of infection than patients who did not (plasma TNF-alpha: 96.0+/-38.7 vs. 39.1+/-3.6 pg/mL, P=.0209; ascitic fluid TNF-alpha: 474.5+/-118.1 vs. 160.8+/-42.7 pg/mL, P=.0173; plasma IL-6: 6,635+/-2,897 vs. 458+/-109 pg/mL, P=.0004; ascitic fluid IL-6: 182,559+/-47,328 vs. 39,250+/-10,803 pg/mL, P=.0001). Independent predictors of development of renal impairment at diagnosis were: renal failure (blood urea nitrogen > 30 mg/dL or serum creatinine > 1.5 mg/dL) (P < .001), IL-6 levels in ascitic fluid (P < .001), and mean arterial pressure (P < .05). Ten of the 13 (77%) patients who developed renal impairment died during hospitalization, but only 2 of the 39 (5%) patients who did not (P=.0001). In addition, renal failure at diagnosis of the infection was the only independent predictor of hospital mortality (P < .001). In conclusion, the inflammatory response to the infection may be an important mechanism of renal impairment and the associated mortality in SBP.

Enterococcal bacteremia after transjugular intrahepatic portosystemic shunts (TIPS)

The objective of this study was to analyze a series of patients with Enterococcus faecium infection following transjugular intrahepatic portosystemic shunts (TIPS) in order to define the risk factors, outcome, and role of treatment including hepatic transplantation. This study is a case series from a tertiary referral center for liver transplantation. The medical records of four patients referred to one teaching hospital in San Francisco between 1990 and 1995 for evaluation or management of Enterococcal infection following TIPS were reviewed. A review of the microbiology records of all 314 patients who underwent TIPS at that institution and a MEDLINE search were performed to assess whether any other cases existed. The effect of therapy on survival was assessed, in particular, the repeated use of TIPS and prolonged courses of antibiotics. All four patients had thrombosis of their TIPS at the time of diagnosis of enterococcal bacteremia. All were treated with prolonged courses of intravenous antibiotics. One patient had echocardiographic evidence of subacute bacterial endocarditis with chronic aortic insufficiency. In all cases, liver transplantation was contraindicated in the acute setting because of uncontrolled endovascular infection. Two of four patients survived; these were the only two patients who had had a successful repeat TIPS. Enterococcal bacteremia is a rare complication following TIPS but carries a high mortality. It usually occurs in the setting of technically difficult TIPS with shunt thrombosis. Management should be focused on long term antibiotics and attempts at reestablishment of portal decompression with another TIPS. Liver transplantation should not be considered until the infection is cleared. Prophylaxis for Enterococcus species should be considered in technically difficult or unsuccessful TIPS.

Management of adult patients with ascites caused by cirrhosis

Ascites is the most common of the major complications of cirrhosis. The development of ascites is an important landmark in the natural history of cirrhosis and has been proposed as an indication for liver transplantation. The initial evaluation of a patient with ascites should include a history, physical evaluation, and abdominal paracentesis with ascitic fluid analysis. Treatment should consist of abstinence from alcohol, sodium restricted diet, and diuretics. This regimen is effective in approximately 90% of patients. The treatment options for the diuretic-resistant patients include serial therapeutic paracenteses, liver transplantation, and peritoneovenous shunting.

Serum/ascites albumin gradient: its value as a rational approach to the differential diagnosis of ascites

BACKGROUND

The utility of differentiating ascites into 'transudate' and 'exudate' has recently been challenged. The aim of the present study was to compare the diagnostic accuracy of the serum/ascites albumin gradient, proposed as a new biochemical criterion for the differential diagnosis of ascites, with the markers traditionally used for the classification of peritoneal fluid into transudate and exudate.

METHODS

Paired ascitic fluid and serum samples from 51 patients were examined with an established method for the diagnosis of the cause of ascitic fluid collection. Included in the study were 32 patients with ascites related to portal hypertension (cirrhosis, n = 28; 'cardiac' ascites, n = 2; Budd-Chiari, n = 2) and 19 patients with ascites not related to portal hypertension (peritoneal carcinomatosis, n = 17; tuberculous peritonitis, n = I; secondary bacterial peritonitis, n = 1). Specimens were collected during an episode of spontaneous bacterial peritonitis in 7 of 28 patients with cirrhosis. The serum/ascites albumin gradient was compared with ascitic fluid total protein, ascites/serum total protein ratio, ascites lactic dehydrogenase concentration, and ascites/serum lactic dehydrogenase ratio.

RESULTS

The diagnostic accuracy was 98% for the serum/ascites albumin gradient compared with only 52%-80% for the four other markers tested. In patients with infected ascites, diagnostic accuracy was 89% for the albumin gradient and < or = 50% for the four other markers.

CONCLUSIONS

The classification of ascites into transudate and exudate appears to be based on markers with low diagnostic accuracy. Differential diagnosis of ascites should be based on the serum/ascites albumin gradient, which is a reliable marker distinguishing ascites related to portal hypertension from all other causes of ascitic fluid collection, regardless of the presence of bacterial infection.

Spontaneous bacterial peritonitis: an update

OBJECTIVE

To describe spontaneous bacterial peritonitis (SBP) in the context of currently accepted criteria for diagnosis, treatment, and prevention.

DESIGN

A review of SBP and its associated etiopathogenic factors is presented.

MATERIAL AND METHODS

Numerous studies on mechanisms of disease, diagnosis, treatment, and prevention are discussed. Diagnostic and therapeutic algorithms are presented.

RESULTS

Peritonitis in patients with ascites in the absence of secondary causes, such as peforation of a viscus, occurs primarily in patients with end-stage liver disease. Enteric organisms, mainly gram-negative bacilli, probably translocate to regional lymph nodes to produce bacteremia and seeding of ascitic fluid. Signs and symptoms of peritonitis are usually subtle. The ascitic fluid polymorphonuclear leukocyte count is the best determinant for early diagnosis and treatment of SBP. Third-generation cephalosporins such as cefotaxime are considered the drugs of choice for treatment, whereas quinolones such as norfloxacin are used to decrease recurrence.

CONCLUSION

Despite increased awareness, early diagnosis, and prompt and effective antimicrobial therapy, SBP recurs frequently and is associated with a high mortality rate. Patients with SBP should be assessed for candidacy for liver transplantation.

Spontaneous bacterial peritonitis: an update on evaluation, management, and prevention

Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with cirrhotic ascites. Greater understanding of the pathogenesis and risk factors for the development of SBP recently has improved our ability to prevent and treat the infection. The decreased threshold for performing diagnostic paracentesis in cirrhotic patients coupled with the use of non-nephrotoxic antibiotics have resulted in decreasing mortality rates for patients with SBP. Despite these advances, recurrence is common and often fatal. Thus, the prevention of SBP by diuresis and oral antibiotic prophylaxis has recently been studied. This review summarizes the recent developments in SBP, with an emphasis on patient management and prevention of SBP.

Analysis of clinical course and prognosis of culture-positive spontaneous bacterial peritonitis and neutrocytic ascites. Evidence of the same disease

The clinical significance and prognosis of culture-negative neutrocytic ascites in cirrhotic patients is a controversial topic. In the present study, the clinical and humoral presentation and the short- and long-term prognosis were analyzed in 36 patients with cirrhosis and culture-positive spontaneous bacterial peritonitis and in 28 patients with cirrhosis and ascitic fluid polymorphonuclear count greater than 250/mm3, a negative ascitic fluid culture, and without previous antibiotic therapy. On admission there were no significant differences between groups related to age, sex, alcoholism, fever, abdominal pain, serum albumin, serum urea, serum creatinine, Child-Pugh score, polymorphonuclear count, and total protein concentration in ascitic fluid. A greater frequency of positive blood culture was found in patients with spontaneous bacterial peritonitis (15/21 vs 2/18) (P < 0.001). Mortality during the first episode was 36% in patients with spontaneous bacterial peritonitis and 46% in patients with culture-negative neutrocytic ascites (NS). Mortality during follow-up was high and survival probability at 12 months was 32% in spontaneous bacterial peritonitis and 31% in culture-negative neutrocytic ascites. The probability of recurrence at 12 months was 33% in spontaneous bacterial peritonitis and 34% in culture-negative neutrocytic ascites. Our results show that spontaneous bacterial peritonitis and culture-negative neutrocytic ascites are variants of the same disease with a high mortality and poor prognosis.

Significance and regulation of gastric secretion of platelet-activating factor (PAF-acether) in man

Platelet-activating factor (PAF) has been implicated in the pathogenesis of acute inflammatory and ulcerative diseases of the upper gastrointestinal tract. In the present study, we compared the gastric output of PAF and its precursors with gastric acid output, in patients with various upper gastrointestinal tract diseases and healthy controls. PAF and precursors were also extracted from gastric biopsies from subjects with chronic gastritis and/or gastric colonization by Helicobacter pylori. Under basal conditions, hourly gastric PAF output increased in esophagitis and erosive gastritis, but not in duodenal ulcer or Zollinger-Ellison syndrome. In the gastric juice of duodenal ulcer patients, PAF output rose after secretin, but in patients with Zollinger-Ellison syndrome, PAF was only detected when gastric acid secretion had been reduced by antisecretory drugs and no concurrent changes were observed in serum gastrin levels. After pentagastrin, patients and controls exhibited a significant decrease in PAF output and a negative correlation was found between PAF and acid outputs (r = -0.57, p < 0.01). When PAF was incubated with gastric juice in vitro, it underwent degradation irrespective of the medium pH. We found no relation between the outputs of PAF and precursors and the severity of gastritis or gastric colonization by H. pylori. Overall, these results suggest that PAF might be released in the stomach by gastric epithelial cells and could be responsible for mucosal injury of the upper gastrointestinal tract.

Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis

Forty-one episodes of ascitic fluid infection were treated with cefotaxime 2 g intravenously every 8 hr, and ascitic fluid and serum were sampled 6, 12, 24, 48, and 96 hr after the first dose of antibiotic. Concentrations of cefotaxime and desacetyl cefotaxime were measured in ascitic fluid and serum by high-performance liquid chromatography. There was essentially 100% penetration of cefotaxime and metabolite from serum into ascitic fluid at all time points. Ascitic fluid was sterilized in 94% of episodes after the first dose of antibiotic. The ascitic fluid concentration of cefotaxime 6 hr after the first dose of antibiotic was greater than 20 times the minimal inhibitory concentration of the drug for 90% of the isolated flora. This rapid ascitic fluid penetration of cefotaxime in high concentration explains the rapid sterilization of ascitic fluid by the drug in the setting of bacterial peritonitis and obviates the need to give a loading dose or intraperitoneal injection.

Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients

In an attempt to determine the optimal duration of therapy of spontaneous bacterial peritonitis, 100 patients with neutrocytic ascites and suspected spontaneous bacterial peritonitis were randomized to short-course vs. long-course treatment groups. Empiric therapy was initiated before the results of ascitic fluid culture were available. Of the 90 patients who met strict criteria for spontaneous bacterial peritonitis or culture-negative neutrocytic ascites, 43 were randomized to a group receiving 5 days and 47 to a group receiving 10 days of single-agent cefotaxime, 2 g IV every 8 hours. Infection-related mortality (0% vs. 4.3%), hospitalization mortality (32.6% vs. 42.5%), bacteriologic cure (93.1% vs. 91.2%), and recurrence of ascitic fluid infection (11.6% vs. 12.8%) were not significantly different between the 5- and 10-day treatment groups, respectively. Recurrence rates were comparable to the values reported in the literature. The cost of antibiotic and antibiotic administration were significantly lower in the short-course group. Short-course treatment of spontaneous bacterial peritonitis is as efficacious as long-course therapy and significantly less expensive.

Participation of phosphoinositides in gastric mucosal protection by colloidal bismuth subcitrate against ethanol-induced injury

The mechanism of gastric mucosal protection by an antiulcer agent, colloidal bismuth subcitrate (CBS), against ethanol-induced injury was investigated using in vivo and in vitro systems. The experiments in vivo were conducted with groups of rats with and without indomethacin pretreatment, and the animals received either a dose of CBS (100 mg/kg) or a vehicle (saline), followed 30 min later by ethanol. In the in vitro studies, gastric mucosa segments were cultured in the presence of CBS, ethanol, or both. The results of in vivo experiments revealed that in the absence of CBS, ethanol caused extensive gastric hemorrhagic lesions which were significantly reduced following CBS pretreatment and this effect of CBS was not prevented by indomethacin. The data obtained with gastric mucosal culture established that in comparison to the controls, ethanol caused a 27% decrease in mucin synthesis, while mucin synthesis in the presence of CBS increased by 48%. The increase in mucin synthesis evoked by CBS was accompanied by the enhanced metabolism of mucosal phosphoinositides, as reflected by a decrease in PI (15%) and PIP2 (30%), and an increase in IP1 (26%) and IP3 (67%). In contrast, ethanol, which exhibited detrimental effect on mucin synthesis, caused a decrease in PIP (35%), IP2 (47%) and IP3 (38%), and an increase in PIP2 (80%), and IP1 (51%). However, when the mucosal culture was carried out in the presence of both CBS and ethanol, the detrimental changes evoked by ethanol on mucin synthesis were prevented, and the phosphoinositide and inositide phosphate distribution patterns were quite similar to those in the mucosa cultured in the presence of CBS only.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic paracentesis. A potent clinical tool

Diagnostic paracentesis is a potent diagnostic tool capable of rapidly detecting portal hypertension and peritonitis. Gram's stain and chemical analysis of ascitic fluid add additional information by determining the predisposition to SBP, the presence of organisms, and the severity of peritonitis. In patients with a narrow A-GRAD, the chemical analysis, cell count and differential, and cytology will add direction for the work-up if the etiology is not apparent and confirmation if it is. This information should be available within a few hours of admission if the paracentesis and blood are obtained immediately. The results should optimize patient care and minimize costs.