EVALUATION OF PROGNOSTIC FACTORS IN DECOMPENSATED LIVER CIRRHOSIS WITH ASCITES AND SPONTANEOUS BACTERIAL PERITONITIS.

UNLABELLED: Mortality in spontaneous bacterial peritonitis (SBP) decreased significantly from 90% in 1970 to 10-30% today, but SBP still remains a complication with a poor prognosis. Although there are new preventive measures, such as early diagnosis and treatment with albumin, the introduction of new antibiotics, the prognosis of patients with decompensated cirrhosis and SBP remains poor, with a mortality rate of 20-40%. The installation of an episode of spontaneous bacterial peritonitis reduces the survival rate at 1 year to 30% and to 20% at 2 years. PURPOSE: In this context, the identification of patients with increased risk of death is extremely important in order to improve prognosis. MATERIAL AND METHODS: The prospective study included 153 patients with cirrhosis admitted to the Institute of Gastroenterology and Hepatology Iasi from 1 January to 31 December 2010, reevaluated during 2 years. Criteria for the diagnosis of SBP were the presence of a number > 250 PMN / mmc. The presence of ascites and/or upper gastrointestinal bleeding (UGB) marks the decompensated cirrhosis. To assess the severity of cirrhosis, there were used Child-Pugh and MELD scores. Diagnostic paracentesis and ascites fluid cultures were performed in all hospitalized patients with ascites and also in case of signs and symptoms of SBP, before and after antibiotic treatment. Lack of response to empirical therapy was considered in those cases with a decrease in the number of neutrophils < 25% from baseline. RESULTS: Identification of patients with increased risk of death is extremely important to improve prognosis. In peripheral leukocytosis and in the ascites fluid, low hemoglobin can be considered predictors of mortality in patients with PBS. Child-Pugh score, increased levels of bilirubin and creatinine and hyponatremia are independent risk factors of mortality in patients with SBP. Bacteremia and lack of therapeutic response are independent risk factors of mortality associated with SBP. Recent history of variceal bleeding, severity of infection and the degree of hepatic and renal impairment influence short-term prognosis of patients with SBP. CONCLUSIONS: Identification of patients with increased risk of death is extremely important to improve prognosis. Therefore, it is important to identify prognostic factors in patients with bacterial infection and cirrhosis, in order to identify high risk patients and to prevent complications and death.

Assessing the risk of decompensation by ascites and spontaneous bacterial peritonitis in cirrhosis.

AIM: The current trend is to analyze predictive factors of transition from compensated to decompensated stage by the onset of ascites and later of spontaneous bacterial peritonitis (SBP), which would make possible an early diagnosis of liver cirrhosis at the compensated stage. The aim of the study is to evaluate patients with liver cirrhosis, assessing the rate and the risk factors of decompensation by ascites and SBP. MATERIAL AND METHODS: The prospective study included patients with cirrhosis of different etiologies admitted to a ward of the Institute of Gastroenterology and Hepatology of Iasi in the period 1st January 2010-31st December 2010, which were reassessed clinically and in laboratory for 2 years. The essential criteria for the diagnosis of SBP were the presence of > 250 PMN/mm3. Compensated cirrhosis was defined as the absence of ascites. The presence of ascites and/or upper gastrointestinal hemorrhage (UGH) marks the state of decompensated cirrhosis. To assess the severity of liver cirrhosis there were used Child-Pugh score and MELD score. Diagnostic paracentesis and ascitic fluid sampling were performed at admission to hospital and during hospitalization, in the event of signs and symptoms of SBP, after antibiotic treatment. Macroscopic, biochemical (albumin, protein), cytological (cellularity) and bacteriological (smear and culture) investigations of the ascetic fluid were performed. Lack of response to empirical treatment was considered in cases of general condition deterioration and decreased PMN < 25% of baseline. RESULTS: By comparing the mean values of patients with and without SBP, it is noted that bilirubin and creatinine were significantly higher in patients with SBP, and total protein, albumin and prothrombin time were significantly lower in patients with SBP, these biochemical parameters correlate with the degree of hepatic impairment and may be considered risk factors for SBP. In relation to the mentioned elements, the most important predictors of PBS risk are low protein concentration in ascitic fluid under 1g/dl, increased levels of serum bilirubin and low platelet count. Impaired liver function, infectious complications, and previous episodes of SBP, UGH are risk factors for an episode of SBP. Empirical therapy of nosocomial SBP with third-generation cephalosporins is often inefficient due to the high prevalence of multiresistant (MR) bacteria. CONCLUSIONS: Assessment of clinically significant portal hypertension (PHT) and the degree of hepatic impairment may stratify patients with cirrhosis according to the risk of decompensation, making possible the identification of high risk patients. The knowledge of the risk factors in SBP is important not only to identify patients who could benefit from preventive therapy, but also in understanding the pathogenesis of the disease.

The role of rifaximine in the prevention of the spontaneous bacterial peritonitis.

UNLABELLED: Cirrhosis is characterized by an increased susceptibility to infection. Spontaneous bacterial peritonitis (SBP) is the most common infectious complication, the main causes being the bowel bacterial overpopulation, the increased intestinal permeability and bacterial translocation. Antibiotic prophylaxis with Norfloxacin increases the rate of PBS with G+ multiresistant bacteria. PURPOSE: To demonstrate the advantage of using rifaximin, nonresorbable broad spectrum antibiotic, in SBP prophylaxy. MATERIAL AND METHODS: The study is a prospective case-control, which included 46 patients diagnosed with Child class C cirrhosis and refractory ascites, based on clinical, biological, ultrasound and endoscopic findings, followed over a period of 6 months. Protein level in ascitic fluid (AF) was higher 14 g/dl. SBP was defined as the presence of > 250 PMN/mm3. Patients were divided into 2 groups, group 1 comprised 22 patients who received rifaximin treatment during the study for a previous episode of hepatic encephalopathy (HE), and group 2 consisted of 24 patients who did not receive antibiotic treatment during follow-up. RESULTS: Rifaximin significantly decreases the polymorpho-nucleares (PMN) in ascitic fluid from patients, one single case of neutroascitic SBP with negative cultures were recorded in this group, with a net improvement of the general condition. In group 2 who did not follow any antibiotic treatment, SBP was recorded in 4 patients, an increase of PMN in ascitic fluid at 14 patients, an approximately constant value in 4 patients, a decrease in 2 subjects. CONCLUSIONS: The study suggests that rifaximin causes a significant decrease in PMN in AF, producing a decrease in SBP frequency and improvement of life in cirrhotic patients with refractory ascites. In this study, the effects of rifaximin on intestinal bacterial overpopulation and bacterial translocation, decisive factors in SBP, are consistent with literature data. Use of rifaximin as an alternative method to prevent SBP deserves more attention.

The influence of antibiotic treatment on the dynamics of oxidative stress in spontaneous bacterial peritonitis.

UNLABELLED: Bacterial infections play an important role in liver cirrhosis complications, being together with variceal bleeding and hepatic encephalopathy an important cause of morbidity and mortality in cirrhotic patients. Spontaneous bacterial peritonitis (SBP) is a major complication of liver cirrhosis, with a significant mortality. Recent studies have demonstrated the involvement of oxygen free radicals in the pathogenesis of liver cirrhosis, but the role of oxidative stress in the development of SBP is not very clear yet. PURPOSE: This study aims to evaluate the role of oxidative stress in the pathogenesis of spontaneous bacterial peritonitis and its changes after therapy. MATERIAL AND METHODS: The study is a prospective case-control, which included 33 patients divided into 3 groups: group I- 10 patients with decompensated cirrhosis and SBP, group II - 17 patients diagnosed with decompensated liver cirrhosis with ascites, and group Ill - 6 patients with compensated liver cirrhosis. The control group consisted of 19 healthy subjects recruited from hospital staff, adapted to patients by age and sex. Malonildyaldehida (MDA), a product of lipid peroxidation, was dosed in the blood and ascitic fluid of patients by assay thiobarbituric acid reactive substances (TBARS). RESULTS: Serum MDA significantly increased in the group with decompensated cirrhosis and SBP compared with the control group. MDA levels in ascitic fluid showed a statistically significant increase in the SBP group compared with patients without SBP. There was a decrease of MDA after 6 months of antibiotic treatment compared with the initial stage, while MDA values increased in the absence of treatment. CONCLUSIONS: The study demonstrates the increased oxidative stress markers in the blood and ascitic fluid of cirrhotic patients with SBP, which can be considered a predictor of SBP and also a marker of treatment response. KEYWORDS: SPON-