Ascitic Protein Research Articles

Prevalence of spontaneous bacterial peritonitis in asymptomatic inpatients with decompensated liver cirrhosis – a pilot study

To assess the prevalence of spontaneous bacterial peritonitis (SBP) in asymptomatic patients with decompensated liver cirrhosis. Patients (pts) with symptoms of decompensation of liver cirrhosis, ascites, and no signs indicating SBP were included to our study. Exclusion criteria include: 1/ clinical symptoms of infection, 2/ developing de novo or worsening hepatic encephalopathy, 3/ gastrointestinal bleeding within the last month, 4/ renal failure, 5/ antibiotic treatment or norfloxacin prophylaxis at admission. About 60 ml of ascitic fluid were drawn for lab examination. Pathologic assessment for atypical cells was also performed. 37 patients fulfilled inclusion criteria. Their mean age was 56.2 ± 12.1. The Child-Pugh classification revealed 13 (35.1%) patients of class B and 24 (64.9%) patients of class C. The mean Model for End-Stage Liver Disease score in this group was 16.6 ± 6.8. The mean ascitic protein content was 1.85 ± 1.09 g/dL and mean neutrophil count 144.8 ± 445.1/mm3. Ascitic fluid analysis revealed: signs of bacterascites in 6 of 37 (16.2%) pts; neutrocytic ascites in 1 of 37 (2.7%) pts; and 2 of 37 (5.4%) pts met criteria for SBP. C-reactive protein level was the best predictor of infection [SBP(+) 47.9 ± 40.9 versus SBP(-) 11.7 ± 5.1; p= 0.0005]. The prevalence of SBP in asymptomatic cirrhotics with ascites is low. We observed the trend towards more frequent occurrence of the infection in patients suffered from severe liver disease (Child-Pugh C group).

Spontane bakterielle Peritonitis

The spontaneous bacterial peritonitis (SBP) can be found in up to 20% of patients who are admitted to hospital due to liver cirrhosis or ascites. Risk factors are, apart from the severity of the liver disease, gastrointestinal bleeding, low ascites protein as well as a previous episode of SBP. If these risk factors are present, antibacterial prophylaxis is indicated in order to avoid the development of SBP. Patients with SBP complain about little discomforts. The only symptom is often the impairment of liver function, rarely exist abdominal discomforts. Diagnosis is made by abdominal puncture. SBP is proven if more than 250 granulocytes per mm 3 ascites are present. Treatment includes instant administration of suitable intravenous antibiotics. If a severe liver insufficiency is present, high-dose human albumin should be given in addition.

Abstract 2688: The expression of lung resistance protein (LRP) in patient ascites predicts platinum resistance in advanced epithelial ovarian carcinoma

Abstract The human lung resistance protein (LRP) is a multidrug resistance protein that has been shown to be overexpressed in numerous chemotherapy resistance models. The precise role of LRP in platinum-resistant epithelial ovarian cancer (EOC) has yet to be fully elucidated. In this study, we sought to determine LRP expression in the tumor cells of ovarian cancer patient ascites of chemotherapy-naïve patients with advanced EOC. After IRB approval was obtained, patient ascites was collected and evaluated for platinum sensitivity, and LRP expression using western blot and immunohistochemistry (IHC). Both patient ascites and primary tumor were treated with 50 uM carboplatin for 48h and cell viability was analyzed. LRP, activated Caspase 3, and tunnel were analyzed using IHC on samples treated with 50uM carboplatin and untreated. A total of 27 patients with advanced-stage EOC undergoing primary cytoreductive surgery at the University of Alabama at Birmingham were consented for the study. Ten patient ascites samples were deemed adequate for analysis. Of these, 3/10 (30%) had increased LRP levels in ascites samples demonstrated by strong IHC staining with capping and confirmed by western blot. These patient samples were platinum resistant as verified by cytotoxicity analysis. Two ascites specimens (20%) lacked LRP expression by IHC and western blot and demonstrated platinum sensitivity on cytotoxicity. Five ascites specimens (50%) displayed intermediate LRP staining and platinum cytotoxicity. Tumor cells in ascites treated with carboplatin had an inverse correlation of LRP staining and activated Caspase 3. There is a strong correlation between LRP expression in the ascites of patients with advanced EOC and platinum resistance in this ex vivo model. This protein may therefore predict poor prognosis disease unlikely to respond to adjuvant platinum therapy. Specifically targeting the LRP in a clinical model may reverse carboplatin resistance. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2688.

OC-037 Epidemiology and resistance patterns of culture-positive spontaneous bacterial peritonitis in Leeds 2006–2008

Introduction Spontaneous bacterial peritonitis (SBP) is a life threatening infection of ascitic fluid which occurs primarily in patients with pre-existing ascites in the setting of cirrhosis. Risk factors for developing SBP include: prior episode of SBP, gastrointestinal bleeding, ascitic total protein Escherichia coli (70%), Klebsiella species (10%), Proteus species (4%), Enterococcus faecalis (4%) and Pseudomonas species (2%).1 The choice of antimicrobial therapy must take into consideration the increasing frequency of hospital acquired infections, such as Clostridium difficile infection. Aim To identify the local epidemiology and resistance patterns of culture-positive SBP. Methods We retrospectively assessed the culture results of all ascitic fluid samples that grew a single organism in Leeds during the 3 years 2006–2008. Patients case notes were assessed to establish a diagnosis of SBP. An ascitic fluid neutrophil count ≥ 250/mm 3 in patients with liver disease was used to confirm the diagnosis of SBP.12 We excluded culture-negative SBP. Results Single organism positive ascitic cultures were identifed in 42 patients with liver disease and an ascitic fluid neutrophil count ≥250/mm 3 . Mean age 52.1 years, 32/42 male. Underlying liver disease was ALD 35/42, HCV 3/42, PBC 1/42, NAFLD 1/42, Cryptogenic 1/42 and Post transplant 1/42. At the time of diagnosis of SBP the mean ascitic total white cell count 5.25, mean ascitic neutrophil count 4.08, mean serum Na+ 129.6 mmol/l and mean serum creatinine 147 mmol/l. Overall Child score A 0, B 8/42, C 34/42 and mean MELD score 24.1. The isolated organisms were Escherichia coli 15, Klebsiella spp. 7, other coliforms 10, Gram positive organisms 8 (including Enterococcus 2, Corynebacterium spp. 2). The Gram-negative isolates were resistant to a number of antibiotics: ciprofloxacin 38% (13/34), cefuroxime 29% (10/34), amoxycillin 32% (11/34) and tazocin 17% (6/34). The 30-day mortality was 50%. Conclusion Empirical treatment regimes need to take into account local resistance patterns. Ciprofloxacin has been widely used for treatment and prophylaxis in SBP. Resistance has now become a significant problem.

Combinatorial Peptide Libraries Facilitate Development of Multiple Reaction Monitoring Assays for Low-Abundance Proteins

Low-abundance proteins present in biological fluids are often considered an attractive source of new disease biomarkers. Since such proteins are poorly observed in proteome-scale discovery experiments due to an overwhelming mass of high-abundance proteins, the development of quantitative multiple reaction monitoring (MRM) assays for low-abundance proteins is a challenging task. Here, we present a strategy that facilitates the development of MRM assays for large numbers of unpurified low-abundance proteins. Our discovery strategy is based on the reduction of the dynamic range of protein concentrations in biological fluids by means of one-bead one-compound combinatorial peptide libraries (CPL). Our 2D-LC-MS/MS approach allowed us to identify a total of 484 unique proteins in ovarian cancer ascites, and 216 proteins were assigned as low-abundance ones. Interestingly, 74 of those proteins have never been previously described in ascites fluid. Treatment with CPL allowed identification of a significantly higher number of unique peptides for low-abundance proteins and provided important empirical fragmentation information for development of MRM assays. Finally, we confirmed that MRM assays worked for 30 low-abundance proteins in the unfractionated ascites digest. Using a multiplexed MRM method, relative amounts of five proteins (kallikrein 6, metalloproteinase inhibitor 1, macrophage migration inhibitory factor, follistatin-related protein, and mesothelin) were determined in a set of ovarian cancer ascites. Multiplexed MRM assays targeting large numbers of proteins can be used to develop comprehensive panels of biomarkers with high sensitivity and selectivity, and to study complex protein networks.

Management of ascites due to gastrointestinal malignancy

Ascites is the pathological accumulation of fluid within the abdominal cavity. The most common cancers associated with ascites are adenocarcinomas of the ovary, breast, colon, stomach and pancreas. Symptoms include abdominal distension, nausea, vomiting, early satiety, dyspnea, lower extremity edema, weight gain and reduced mobility. There are many potential causes of ascites in cancer patients, including peritoneal carcinomatosis, malignant obstruction of draining lymphatics, portal vein thrombosis, elevated portal venous pressure from cirrhosis, congestive heart failure, constrictive pericarditis, nephrotic syndrome and peritoneal infections. Depending on the clinical presentation and expected survival, a diagnostic evaluation is usually indicated as it will impact both prognosis and the treatment approach. Key tests include serum albumin and protein and a simultaneous diagnostic paracentesis, checking ascitic fluid, WBCs, albumin, protein and cytology. Median survival after diagnosis of malignant ascites is in the range of 1 to 4 months; survival is apt to be longer for ovarian and breast cancers if systemic anti-cancer treatments are available.

Role of Fluoroquinolones in the Primary Prophylaxis of Spontaneous Bacterial Peritonitis: Meta-Analysis

The use of antibiotics in the primary prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is controversial. Our purpose was to determine the beneficial effect of fluoroquinolones as compared with placebo in primary prophylaxis of SBP in high-risk patients with cirrhosis by using meta-analysis. Medline, Embase, Cochrane, and Web of Science databases were searched in all languages until August 2008 for randomized placebo-controlled studies evaluating the role of fluoroquinolones in primary prevention of SBP in patients with low protein ascites (total ascitic protein, <1.5 g/dL) and without history of SBP. Two investigators independently performed literature search and data extraction, and then another investigator independently reviewed whether the studies met prespecified criteria and rechecked data extraction. Odds ratios (Peto method) for the risk reduction with fluoroquinolones were calculated for each study and combined by using a random-effects model. Four randomized controlled studies met predefined criteria. The odds ratios for developing first episode of SBP, serious infections, and mortality with fluoroquinolone prophylaxis (n = 194) versus placebo (n = 190) were 0.18 (95% confidence interval [CI], 0.09-0.35), 0.18 (95% CI, 0.10-0.32), and 0.60 (95% CI, 0.37-0.97), respectively. All studies were unidirectional in showing the beneficial effect of fluoroquinolone prophylaxis. We were limited by finding few studies with relatively small sample sizes. Daily oral fluoroquinolone prophylaxis reduces the risk of development of first episode of SBP and mortality in cirrhotic patients with low total protein in the ascitic fluid. Fluoroquinolones might be advisable for the primary prophylaxis of SBP in selected high-risk patients with cirrhosis.

Insufficient sensitivity of reagent strips for spontaneous bacterial peritonitis

We read with interest the study of Nousbaum and colleagues, which reported a low sensitivity of the Multistix 8 reagent strip in the diagnosis of spontaneous bacterial peritonitis (SBP).1 It is noteworthy that overall prevalence of SBP in this study was only 5.5%, significantly lower than in all previous studies focussing on diagnostic accuracy of different reagent strips, where prevalence of SBP ranged between 7% and 23%. Can this simple statistical bias explain the differences in diagnostic sensitivity of different reagent strips? Recently, we terminated a similar study comparing Multistix 10 SG and Combur reagent strips for their diagnostic value of SBP in the inpatient setting at 2 tertiary care centers. We found 16 cases of SBP in 194 paracenteses summing up to a prevalence of SBP of 8.2% in inpatients and comparing well with the subset of inpatients in the study of Nousbaum et al. (9%). Sensitivity of Multistix 10 SG was even worse in our setting (31%) and only slightly better for Combur reagent strips (44%). Although at a different level, this finding is in accordance with the study of Campillo et al.2 who reported better performance of Combur reagent strips. When comparing different parameters between false-negative and true-positive results in our patients with SBP, we found significantly higher mean ascitic protein content in patients with falsenegative results than in patients with true-positive results (3.4 versus 2.1 g/dL for Multistix 10 SG and 3.8 versus 2.0 g/dL for Combur reagents strips, respectively). Therefore, we speculate that leukocyte esterase in both test systems may be inhibited by high ascitic protein content thereby decreasing diagnostic sensitivity of SBP. As stated by Nousbaum et al., reagent strips were designed for detecting urinary tract infection. Because proteinuria above 1 g/L is a rare condition, urinary protein content is unlikely to interfere with detection of leukocytes by these reagent strips. In ascites, however, higher protein concentrations may cause insufficient sensitivity of reagent strips to detect SBP. Thus, we fully agree with Nousbaum et al. that it is premature to replace standard ascitic analyses by reagent strips due to their low sensitivity in detecting SBP.

Norfloxacin and trimethoprim–sulfamethoxazole therapy have similar efficacy in prevention of spontaneous bacterial peritonitis

Although norfloxacin (N) is widely accepted as the drug of choice for spontaneous bacterial peritonitis (SBP) prophylaxis, there is data to suggest that trimethoprim-sulfamethoxazole (TS) may be similarly effective. However, no studies have compared the efficacy and safety of N and TS in SBP prophylaxis. The aim of this retrospective analysis was to compare outcomes in patients who received either N or TS for the prevention of SBP. Records of all cirrhotic patients prescribed either N or TS for SBP prevention between April 2001 and May 2004 were reviewed. Data collected included age, sex, Child-Pugh score, ascitic protein concentration, etiology of liver disease, infections (SBP, bacteremia, and extraperitoneal infections), side-effects, and survival. Sixty-nine patients (18 female, 51 male), mean age 53.9 +/- 10.6 years, were prescribed N (n = 37) or TS (n = 32). The Child-Pugh score, model for end-stage liver disease score, and the prevalence of a low ascitic protein (<15 g/L) were similar between the groups (12.0 vs 12.4, 19.7 vs 18.2, and 78% vs 84%, respectively, P > 0.05). Fourteen (38%) infections occurred in the N group and 16 (50%) in the TS group (P > 0.05). Eight patients (21.6%) in the N group and nine (28%) in the TS group developed SBP (P > 0.05). The rates of liver transplantation (10 vs 13), adverse events (two in each group) and death (13 vs 14) were similar in the two treatment groups. Our findings suggest N and TS have similar efficacy in preventing SBP. This has significant implications for both the cost of SBP prophylaxis and the prevalence of fluoroquinolone resistance in patients with cirrhosis.

Bacterial infections in cirrhosis

A bakteriális infekciók a májcirrhosis jól ismert szövődményei, jelentősen emelik a mortalitást. A májelégtelenség súlyossága és a gastrointestinalis vérzés fontos hajlamosító tényezők. A leggyakoribb fertőzések a spontán bakteriális peritonitis, a húgyúti és légúti fertőzések, valamint a sepsis. A kórokozók között azonos arányban fordulnak elő Gram-negatív és -pozitív baktériumok. Gastrointestinalis vérzés esetén (varix vagy nem varix eredetű) az ascites meglététől vagy hiányától függetlenül rövidtávú profilaktikus antibiotikus kezelés (per os norfloxacin vagy ciprofloxacin) javasolt (primer prevenció) . A kórházi kezelés ideje alatt gastrointestinalis vérzés hiányában is megfontolandó a norfloxacin adása alacsony ascites proteintartalom esetén. A spontán bakteriális peritonitis empirikus kezelésében iv. III. generációs cephalosporin adása javasolt, mely a tenyésztési lelet alapján célzott antibiotikus kezelésre váltható. A kezelés időtartama 5–8 nap. Jó alternatíva lehet az amoxicillin/klavulánsav kombináció, valamint korábban spontán bakteriális peritonitis profilaxisban nem részesülő betegek esetén valamely kinolonszármazék is. Az iv. megkezdett antibiotikus kezelés megfelelő klinikai javulás mellett 2 nap múlva per os kezelésre váltható. Veseelégtelenség társulása esetén kiegészítő albuminkezelés szükséges. Hosszú távú antibiotikum-profilaxis a spontán bakteriális peritonitis epizód lezajlását követően a gyakori kiújulás veszélye miatt minden betegnél indokolt (szekunder prevenció) . A „szelektív intestinalis dekontaminációra” leginkább a per os adott, elsősorban rosszul felszívódó fluorokinolonszármazék, a norfloxacin javasolt. A per os adott ciprofloxacin vagy méginkább a levofloxacin, ez utóbbi Gram-pozitívak ellen is hatékony, megfelelő alternatíva lehet. Trimetoprim/sulfamethoxazole adása csak abban az esetben jön szóba, ha a beteg nem kaphat kinolonszármazékot. A kezelést az ascites eltűnéséig; az ascites perzisztálása esetén a beteg élete végéig vagy a májtranszplantációig kell folytatni. A rezisztens törzsek kialakulásának veszélye miatt hosszútávú profilaxis spontán bakteriális peritonitisen még át nem esett asciteses cirrhosisos betegekben nem javasolt, akkor sem, ha az ascites terápia refrakter, vagy pedig fehérjetartalma alacsony.

Management of Patients With Cirrhosis in Southern California

Cirrhosis is an important medical and public health concern. A paucity of data exists on how patients with cirrhosis are managed. Our aims were to determine how cirrhosis is managed and whether current management practices follow established recommendations. A questionnaire was mailed to Southern California Society of Gastroenterology members. Most had practiced for more than 15 years (67%) in a private practice setting (69%). Proportions of physicians who followed established guidelines versus those who had not were compared using chi test. Hepatitis A, hepatitis B, influenza, and pneumococcus vaccinations were recommended by most respondents. Ninety-one percent of respondents routinely screened patients for hepatocellular carcinoma. A significantly greater proportion of respondents screened for hepatocellular carcinoma using either alpha-fetoprotein or ultrasound every 6 months (P < 0.05). Seventy-six percent recommended antibiotic prophylaxis in patients with prior spontaneous bacterial peritonitis, whereas less than half recommended prophylaxis in patients with ascitic protein fluid <1 g/dL, current variceal bleed, and those on the liver transplant list. Sixty-seven percent of respondents performed screening esophagogastroduodenoscopy upon diagnosis of cirrhosis. Most respondents did not recommend repeating endoscopy in 1 to 2 years if a patient was found to have small varices (P < 0.05), and would repeat an endoscopy if large varices were found (P < 0.05). The management of patients with cirrhosis in the community varied and did not always conform to established guidelines. These results should be confirmed in a larger group of physicians, and the rationales for physicians accepting or rejecting established guidelines should be further assessed.

Conduite à tenir devant une ascite

Ascites is the most common complication of cirrhosis. Approximately 50% of patients with compensated cirrhosis will develop ascites over a 10-year period. Ascites is associated with increased risks of infections, renal failure and poor long-term outcome. Abstinence from alcohol, salt restriction and diuretics are the mainstays of the therapy, and these measures are effective in approximately 90% of the patients. Treatment options for diuretic-resistant patients include serial therapeutic paracentesis and transjugular intrahepatic portosystemic stent-shunts. Patients eligible for liver transplantation should undergo evaluation for this procedure after development of ascites. A diagnostic paracentesis should be performed on hospital admission in any cirrhotic patient with ascites to investigate the presence of spontaneous bacterial peritonitis. In patients with an ascetic fluid PMN cell count > 250/mm 3, antibiotic therapy (cefotaxime or amoxicillin-clavulanic acid) and albumin infusion need to be started before obtaining the results of ascites or blood cultures. Prophylactic antibiotic administration is recommended in cirrhotic patients hospitalized with upper gastrointestinal haemorrhage or low ascites protein (i.e. < 10 g/l) and in patients recovering from an episode of spontaneous bacterial peritonitis.

Usefulness of routine analysis of ascitic fluid at the time of therapeutic paracentesis in asymptomatic outpatients: Results of a multicenter prospective study

The guidelines of the American Association for the Study of Liver Diseases recommend performing exploratory paracentesis on each patient with cirrhosis and chronic ascites. The aim of the study was to evaluate the prevalence of spontaneous bacterial peritonitis and culture-negative neutrocytic ascites in a large population of consecutive asymptomatic cirrhotic ascitic ambulatory patients. Patients with cirrhosis and tense ascites hospitalized from January to September 2000 in 5 hepatogastroenterology units prospectively underwent an exploratory paracentesis with cytobacteriological, biochemical and bedside inoculation into aerobic and anaerobic blood culture bottles. Patients studied were not receiving antibiotics except for norfloxacin and had no obvious sign of infection such as fever or hypothermia, chills, unusual abdominal tenderness, de novo or worsening hepatic encephalopathy, recent gastrointestinal bleeding, acute renal failure or marked arterial hypotension. Clinical and biological findings and ascitic fluid cytological and bacteriological results were evaluated at each exploratory paracentesis. The results are given in mean +/- standards deviations with range. Sixty-seven cirrhotic patients (48M/19F, mean age 59 +/- 9 years) had 270 therapeutic paracenteses, preceded by an exploratory aspiration. Fifty-nine patients (88%) had alcoholic cirrhosis. Twenty-five patients (37.3%) received norfloxacin. At first paracentesis 41 (61.2%) and 26 (38.8%) patients were class B and C respectively according to the Child-Pugh classification; the mean Child-Pugh score was 9 +/- 1.5. None had suspicion of infection. The mean number of paracenteses was 5 +/- 4.3 per patient; 59.6% of the paracenteses (161) were compensated with human albumin. Ascitic protein concentration was 17.5 +/- 8.6 g/l, ascitic fluid cell count and number of neutrophils were 127 +/- 155/mm3 and 5.9 +/- 14/mm3 (0-60), respectively. No patient had spontaneous bacterial peritonitis nor culture-negative neutrocytic ascites; 10 cases of monomicrobial bacterascites were observed, all with commensal germs. In the absence of obvious signs of infection, the prevalence of spontaneous bacterial peritonitis and culture-negative neutrocytic ascites in asymptomatic cirrhotic outpatients with ascites is near 0%. Moreover, for 100 large volume paracenteses, not performing exploratory paracentesis corresponds to a savings of 5,500 euros, without risk for these patients.

Spontaneous bacterial peritonitis: a historical perspective: Kerr DNS, Pearson DT, Read AE. Infection of ascitic fluid in patients with hepatic cirrhosis [Gut 1963; 4: 394–398]; Conn HO. Spontaneous peritonitis and bacteremia in Laennec's cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome [Ann Intern Med 1964; 60: 568–580

Spontaneous bacterial peritonitis: a historical perspective: Kerr DNS, Pearson DT, Read AE. Infection of ascitic fluid in patients with hepatic cirrhosis [Gut 1963; 4: 394–398]; Conn HO. Spontaneous peritonitis and bacteremia in Laennec's cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome [Ann Intern Med 1964; 60: 568–580

Budd Chiari Syndrome associated with angiomyolipoma of the liver

We wish to report an unusual complication of hepatic angiomyolipoma. The patient was admitted to this Hospital with a two-week history of progressive abdominal pain, distension and peripheral oedema. Laboratory evaluation revealed albumin 30 g/l, bilirubin 48 μmol/l, AST 114 iu/l, INR 1.55, Cr 137 μmol/l and ascitic protein 25 g/l. CT abdomen (Fig. 1) demonstrated a 8.0×9.7×7.3 cm hypoattenuating mass in the central liver, involving segments 4a, 6, 7 and 8. There was associated extensive ascites and caudate lobe hypertrophy. Ultrasound, triphasic CT and MRI showed patent portal veins with hepatopetal flow. The hepatic veins were poorly visualised and CT scan suggested thrombus in the left hepatic vein. On subsequent venography it was not possible to cannulate the hepatic veins and there was extrinsic compression of the inferior vena cava with pressures of 20 mmHg below and 16 mmHg above the lesion. The right atrial pressure was 9 mmHg. Targeted tru-cut™ percutaneous ultrasound guided biopsy of the hepatic mass following correction of coagulopathy was consistent with the diagnosis of hepatic angiomyolipoma.

Spontaneous bacterial peritonitis in the Czech Republic

The objective of the study was to assess the prevalence and more detailed data pertaining to the incidence of spontaneous bacterial peritonitis (SBP) in the Czech Republic. The authors examined 99 patients with cirrhosis of the liver and ascites. SBP was diagnosed in a high percentage--35 patients, i.e. 35.4%. It was found more frequently in patients with an alcoholic etiology of cirrhosis who had a history of subfebrile and febrile temperatures and increasing trend of ascites. For the diagnosis the increase of leucocytes in serum and C reactive protein levels may prove useful. Lower values of total protein and albumin in ascites predispose to the development of this infection. Reduction of the number of thrombocytes in the group of patients with SBP indicates the influence of portal hypertension in the etiology of this disease.

Spontaneous bacterial peritonitis in the Czech Republic: prevalence and aetiology.

The aim of the study was to determine the prevalence and detailed data concerning the incidence of spontaneous bacterial peritonitis in the Czech Republic. Ninety-nine patients with liver cirrhosis and ascites were examined. Spontaneous bacterial peritonitis was diagnosed in 35 patients (35.4%). It was revealed more often in patients with alcoholic aetiology of cirrhosis whose anamnesis involved sub-febrile or febrile states and the deterioration of ascites. Elevated serum leucocyte counts and increased levels of C-reactive protein can contribute to the diagnosis. A low level of total protein and albumin in ascites predisposes to the increase of this infection. The reduction of the platelet count in a set of patients with spontaneous bacterial peritonitis indicates the influence of portal hypertension in the aetiology of the disease.

Small intestinal bacterial overgrowth versus antimicrobial capacity in patients with spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis (SBP) is a serious infection in cirrhotic patients with ascites. Both defects in the host defense mechanisms and the enhancement of the offensive factor (small intestinal bacterial overgrowth (SIBO)) may contribute to the development of SBP. Therefore, the aim of this study was to evaluate the role of SIBO versus various antimicrobial capacities in the pathogenesis of SBP in cirrhotic patients. Forty-five cirrhotic patients were enrolled in this study. Bacterial overgrowth was evaluated by breath hydrogen test (BH2T). The hepatic reticuloendothelial system phagocytic index (HRESPI) was measured by intravenously injected colloid suspensions. The Child-Pugh scores in the SBP group were higher than in the non-SBP group (10.5 +/- 2.0 versus 8.0 +/- 1.8, P < 0.01). The ascitic protein concentration was significantly lower in the SBP group than in the non-SBP group (897 +/- 425 mg/l versus 1,325 +/- 453 mg/l, P < 0.01). Furthermore, the serum C3 concentration was lower in the SBP group than in the non-SBP group (43.1 +/- 13.6 ng/dl versus 73.2 +/- 26.4 ng/dl, P < 0.01). The serum C4 concentration was also lower in the SBP group than in the non-SBP group (12.4 +/- 4.0 ng/dl versus 16.9 +/- 6.6 ng/dl, P < 0.05). The incidence of SIBO was higher in the SBP group than in the non-SBP group (68.2% versus 17.4%, P < 0.01). HRESPI values were significantly higher in the two groups of cirrhotic patients than in the normal reference. However, there were no statistical differences in HRESPI between the two groups (8.4 +/- 2.8 min in the SBP group versus 7.9 +/- 2.8 min in the non-SBP group). The results of this study showed that the hepatic reticuloendothelial function is impaired in cirrhotic patients, but the degree of impairment does not differ between patients with and without previous history of SBP. Lower ascitic total protein, lower serum C3 and C4 concentrations, and presence of SIBO are all risk factors for SBP. Based on the results of our study, defects in the host defense mechanisms and the enhancement of the offensive factor (SIBO) may act in concert for the development of SBP.

Use of a Variety of Biological Parameters in Distinguishing Cirrhotic from Malignant Ascites

Twenty-two different protein measurements were taken in the serum and ascitic fluid of fifty consecutive patients in an attempt to investigate which tests are the most reliable for the differential diagnosis of ascites. Serum and ascitic fluid total proteins (TPR), albumin (ALB), lactate (LAC), ferritin (FER), C3 and C4 complement factors, C-reactive protein (CRP), ceruloplasmin (CER), alpha2-macroglobulin (alpha2MG), haptoglobin (HAP), alpha1-antitrypsin (alpha1AT), alpha1-acid glycoprotein (alpha1AG), transferrin (TRF), immunoglobulins IgG, IgA, IgM and cytokines such as interleukin-1alpha (IL-1alpha), interleukin-1beta (IL-1beta), interleukin-2 (IL-2), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-alpha) were measured to distinguish between malignant and cirrhotic ascites. Correlations and non-parametric Mann-Whitney tests were used for ascitic fluid:serum ratio comparisons between the two groups. Multivariate analyses were used to determine the most significant biochemical ratio predictors for the differential diagnosis and a recursive partitioning model was constructed. Highly positive correlations (r>0.50) were found between the ratios IgA, IgG, IgM, CER, alpha2 MG, HAP, alpha1AT, alpha1AG and TRF. There was evidence that TPR, ALB, LAC, FER, IgG, CER, alpha2MG, alpha1AT, alpha1AG, TRF and IL-8 ascitic fluid:serum ratios are significnatly higher in patients with malignant neoplasms than in cirrhotics. In the recursive partitioning model the most significant parameters were found to be the ratios of albumin and IL-1alpha. The model fitted allowed for 100% correct classification of ascites. In conclusion, we have shown that a simple and very accurate model based on two ascitic fluid: serum measurements is able to differentiate between malignant and non-malignant ascites.

Discrimination between malignant and nonmalignant ascites using serum and ascitic fluid proteins in a multivariate analysis model.

Our objectives were to study the value of different proteins in the serum and ascitic fluid and assess their potential in discriminating between malignant and nonmalignant ascites in a model that could be developed to aid clinical diagnosis. In all, 57 different measurements (30 in serum and 27 in ascitic fluid) including erythrocyte sedimentation rate, number of white blood cells, cytokines, interleukin-1a (IL-1a), IL-1b, IL-2, IL-6, IL-8, tumor necrosis factor-alpha, immunoglobulins (IgG, IgA, IgM), complement factors C3 and C4, acute-phase proteins such as alpha1-acid glycoprotein, alpha2-macroglobulin, alpha1-antitrypsin, haptoglobin, C-reactive protein, ferritin, ceruloplasmin and transferin, were performed in 61 patients with ascites (25 with malignant exudates, 13 with nonmalignant exudates, and 23 with transudates). Patients with sepsis were excluded. Correlation tests and one-way ANOVAs were used for comparisons between different groups. Discriminant analyses were used to assess the significance of each parameter in the differentiation process. Correct classification of 100% of cases required the use of all 57 ascitic fluid measurements in the model, which was not considered practical in clinical diagnosis. Discriminant analysis showed that five ascitic fluid measurements-total protein, LDH, TNF-alpha, C4, and haptoglobin-were sufficient for a model to correctly classify 89% of cases. Cross-validation showed that 70% of unknown cases were correctly classified using this model. In conclusion, we have shown that five easily taken protein measurements in the ascitic fluid can differentiate to a large extent between cases with ascites and have proposed a relatively simple statistical model with these parameters that could be developed to be extremely useful in the clinical setting.