Low Ascitic Protein Research Articles

Severe Mitral Stenosis Presenting as Chronic Liver Disease: A Rare Case Report

High Serum Ascites Albumin Gradient (SAAG) ascites in severe rheumatic mitral stenosis is very uncommon. Hereby, the authors present a similar case with this rare combination. The present case report describes a 42-year-old male with no history of hypertension or diabetes, but occasional alcohol consumption, who presented to department with complaints of recurrent anasarca over the past five years. The electrocardiogram showed an irregular R-R interval with no P waves, indicating atrial fibrillation. Ascitic fluid analysis revealed a high serum ascites albumin gradient with low ascitic protein levels. The patient responded well to treatment and was discharged with appropriate medications. He was referred to a higher centre with cardiothoracic surgical facilities for mitral valve replacement and tricuspid annuloplasty. The present case report highlights the uniqueness of the combination of severe rheumatic mitral stenosis and ascites.

A253 PRIMARY PROPHYLAXIS FOR SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED CIRRHOTIC PATIENTS WITH LOW PROTEIN ASCITES AND RENAL DYSFUNCTION OR LIVER FAILURE: A RETROSPECTIVE REVIEW FROM A TERTIARY CENTRE IN BRITISH COLUMBIA

Abstract Background Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection that can occur in patients with cirrhosis and ascites. The benefits of primary prophylaxis with antibiotics for SBP have been demonstrated in patients with cirrhosis presenting with gastrointestinal (GI) bleeding; patients hospitalized for other reasons with an ascitic protein less than 10 g/L; and patients with ascitic protein less than 15 g/L with either impaired renal function (serum creatinine greater than 106 µmol/L, BUN greater than 8.9 mmol/L, or serum sodium less than or equal to 130 mEq/L) or liver failure (Child-Pugh score greater than or equal to 9 or bilirubin greater than 50 umol/L). Purpose To evaluate the rate of primary prophylaxis in patients discharged from a tertiary care hospital with low protein ascites and impaired renal function or liver failure, and subsequent episodes of SBP, hospitalizations, or deaths. Method A retrospective chart review at St. Paul’s Hospital in Vancouver, British Columbia, from November 2019 to August 2021 was conducted. Hospitalized patients with cirrhosis who had an ascitic protein less than 15 g/L and met criteria for either renal dysfunction or liver failure were included in the study. The rate of primary prophylaxis prescribed in eligible patients as well as the subsequent incidence of SBP, hospitalizations, or all-cause mortality were evaluated. Patients were followed up to 12 months after the index paracentesis. Result(s) A total of 279 patients with cirrhosis were hospitalized during the study period. 69 patients underwent a diagnostic paracentesis and 41 patients met the inclusion criteria for primary SBP prophylaxis. 28 patients were excluded with most common reasons being ascitic protein above 15 g/L (n=12), no documented ascitic protein concentration (n=9), or index paracentesis met the criteria for the diagnosis of SBP (n=5). Of the patients included, 37 (90.2%) did not receive primary prophylaxis. 8 of these patients (21.6%) developed subsequent SBP. 30 patients (81.1%) were hospitalized at least once in the following 12 months. 18 (48.6%) died during the follow-up period with 1 death attributed to SBP. 4 patients (9.76%) received primary prophylaxis and were prescribed either ciprofloxacin or trimethoprim/sulfamethoxazole. None of these patients developed SBP, however, 3 (75%) were hospitalized and died from other causes. Conclusion(s) The rate of primary prophylaxis for SBP in hospitalized patients with low protein ascites and impaired renal function or liver failure at our institution is low. The guarded prognosis in this subset of patients is also demonstrated. Further studies are needed to assess the root causes for the lack of primary prophylaxis given. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

An Unusual Cause of Recurrent Pleural Effusion

Abstract Cryptococcus neoformans is a yeast that can cause severe infection in the immunocompromised. It is commonly associated with meningitis in patients with underlying HIV infection; however, infections can occur in other immunosuppressed hosts as well as the immunocompetent. Pulmonary disease is well described, but recurrent pleural effusion and empyema are rare. We describe a case in a non–HIV-infected, nontransplant cirrhotic patient presenting with recurrent pleural effusions and cryptococcal empyema. The patient is a 66-year-old man with cirrhosis, diabetes, and kidney disease who presented with 3 months of dyspnea complicated by recurrent pleural effusion and low protein ascites after treatment of hepatitis C virus. Routine cultures from multiple thoracenteses were unrevealing. Fungal culture ultimately grew C. neoformans/gattii. His serum cryptococcal antigen titer was 1:40, and chest imaging revealed several pulmonary nodules. He was admitted for evaluation of disseminated disease and central nervous system involvement, which was unremarkable. He was started on oral fluconazole 200 mg daily dosed for his renal function and was doing well in outpatient follow-up. Patients with cirrhosis tend to have a higher incidence of cryptococcal disease and are more likely to have disseminated infection with higher mortality. It is possible that deficiencies in complement and cytokine levels as well as leukocyte function may contribute to this increased risk. Effusions are an uncommon manifestation of pulmonary cryptococcosis and, as with the case in our patient, may resemble hepatic hydrothorax, leading to a delay in antifungal therapy. In conclusion, patients with liver disease have an increased risk of cryptococcosis. A high index of suspicion must be maintained for infection and should be considered in patients with recurrent effusions.

SPONTANEOUS BACTERIAL PERITONITIS

Objectives: To record frequency of spontaneous bacterial peritonitis in patientsof liver cirrhosis with low ascitic protein contents. Methodology: This study included 81 patientswith liver cirrhosis with low ascitic proteins level. All the patients were evaluated for the presenceof spontaneous bacterial peritonitis which was described as frequency distribution table. StudyDesign: Cross Sectional Study. Setting: Medical wards of DHQ and Allied Hospitals (PunjabMedical College) Faisalabad. Duration of Study: 11th May 2011 to 10th November 2011.Results: Spontaneous bacterial peritonitis was present among 29 (35.8%) patients and wasnot present among 52 (64.2%) patients. Conclusion: All the patients with low ascitic proteinlevel should be evaluated for the presence of spontaneous bacterial peritonitis and antibioticprophylaxis should be considered.

Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any significant intraperitoneal infection, accounting for approximately 10-30% of bacterial infections in hospitalized patients. SBP develops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm3 in ascites after paracentesis. If SBP is diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review describes the pathophysiology, diagnosis, treatment, and prevention of SBP.

Low ascitic fluid total protein levels is not associated to the development of spontaneous bacterial peritonitis in a cohort of 274 patients with cirrhosis

Background: Spontaneous bacterial peritonitis (SBP) is a complication to decompensated cirrhosis. Fluoroquinolones may prevent SBP. However, predictive markers for SBP are wanted. Guidelines suggest that patients with ascitic fluid protein below 15 g/l receive fluoroquinolones to prevent SBP. This study aimed to assess the clinical utility of low ascitic fluid protein in predicting SBP in patients with cirrhosis and ascites.Methods: A total of 274 patients with cirrhosis and ascites underwent paracentesis between January 2010 and June 2015. Patients were followed until two years, development of SBP, initiation of ciprofloxacin, death or liver transplantation. Data were compared between groups of patients with ‘high’ or ‘low’ ascitic protein.Results: SBP developed in 31 patients (11.3%). No difference in mean ascitic fluid protein levels were found (SBP, mean: 8.5 g/l and no SBP 8.2 g/l, p = .825). SBP developed at equal rates in patients with ‘high’ or ‘low’ ascitic protein (10.8% (≤15 g/l) and 14.0% (>15 g/l), p = .599). The same trend was observed when adjusting the threshold below 10 g/l (11.9% (≤10 g/l) and 10.2% (>10 g/l), p = .697).Conclusions: Low ascitic fluid protein does not predict SBP in patients with cirrhosis and ascites. Better markers are needed.

Clinical characteristics and outcome of cirrhotic patients with high protein concentrations in ascites: a prospective study.

The protein concentration in ascites is usually low in cirrhosis because capillarization and defenestration of the sinusoids limit diffusion of large proteins from plasma to the space of Disse. However, some cirrhotic patients have high-protein ascites (HPA). The aim of this study was to describe and compare the characteristics and prognosis between cirrhotic patients with HPA (>20 g/l) and patients with low-protein ascites (LPA). In this longitudinal observational prospective cohort study, all consecutive cirrhotic patients with ascites hospitalized in our tertiary liver center were included and followed for up to 2 years, provided that they had no other cause of HPA. HPA was defined as protein concentrations of more than 20 g/l. Among 107 patients included, 19 (17.8%) had HPA. HPA patients had more refractory ascites (63 vs. 34%), better liver functions, and a higher 1-year transplant-free survival rate compared with LPA patients (P<0.05). Portal hypertension parameters were not different. During follow-up, 47% of HPA patients were treated by transjugular intrahepatic portosystemic shunts versus 18% of LPA patients, whereas 15 LPA patients required liver transplantation for end-stage liver disease versus only one HPA patient. We observed higher protein filtration and less pericellular, centrilobular, and sinusoidal fibrosis in cirrhotic HPA livers compared with LPA livers. Almost 20% of cirrhotic patients with ascites have HPA (>20 g/l). These patients have better liver functions and a higher 1-year survival than those with LPA, even though ascites are more often refractory.

Antibiotic prophylaxis in cirrhosis: Good and bad.

Patients with cirrhosis, particularly those with decompensated cirrhosis, are at increased risk of bacterial infections that may further precipitate other liver decompensations including acute-on-chronic liver failure. Infections constitute the main cause of death in patients with advanced cirrhosis, and strategies to prevent them are essential. The main current strategy is the use of prophylactic antibiotics targeted at specific subpopulations at high risk of infection: prior episode of spontaneous bacterial peritonitis, upper gastrointestinal bleeding, and low-protein ascites with associated poor liver function. Antibiotic prophylaxis effectively prevents not only the development of bacterial infections in all these indications but also further decompensation (variceal bleeding, hepatorenal syndrome) and improves survival. However, antibiotic prophylaxis is also associated with a clinically relevant and increasing drawback, the development of infections due to multidrug-resistant organisms. Several strategies have been suggested to balance the risks and benefits of antibiotic prophylaxis. Antibiotic stewardship principles such as the restriction of antibiotic prophylaxis to subpopulations at a very high risk for infection, the avoidance of antibiotic overuse, and early deescalation policies are key to achieve this balance; nonantibiotic prophylactic measures such as probiotics, prokinetics, bile acids, statins, and hematopoietic growth factors could also contribute to ameliorate the development and spread of multidrug-resistant bacteria in cirrhosis. (Hepatology 2016;63:2019-2031).

Infection spontanée du liquide d’ascite au cours de la cirrhose

Spontaneous bacterial peritonitis (SBP) is a severe complication occurring in patients with cirrhosis, and is associated with high mortality. Liver transplantation should be considered after a first episode of SBP. Gram-negative bacilli are the major cause of SBP, however there is an increasing trend of Gram-positive cocci related SBP. Management includes empirical antibiotic treatment and albumin infusion. The choice of antibiotics depends on the site of acquisition (community-acquired vs nosocomial or health-care associated infection) and local resistance profile, due to the emergence of drug-resistant bacteria. Secondary prophylaxis is recommended after resolution of SBP and reduces recurrence and mortality. Primary prophylaxis in patients with low protein ascites (<15 g/L) should be restricted to patients with severe cirrhosis awaiting for liver transplantation.

Prevalence of spontaneous bacterial peritonitis in liver cirrhosis with ascites

IntroductionSpontaneous 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.MethodsThirty 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.ResultsThe 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).ConclusionIt 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.

Diagnosis and management of bacterial infections in decompensated cirrhosis

Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamase-producing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.

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.

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.

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

Spontaneous Bacterial Peritonitis.

Spontaneous bacterial peritonitis (SBP) is the prototypical ascitic fluid infection occurring in patients with advanced liver disease and ascites. The key to successful treatment of SBP is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops, particularly those individuals at high risk for infection. A high index of suspicion should lead to early diagnostic paracentesis and ascitic fluid analysis. Treatment of SBP involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP. SBP typically involves infection with a single organism, with Escherichia coli, Klebsiella spp, and Streptococcus spp responsible for nearly three fourths of cases. The treatment of choice is cefotaxime 2 g given intravenously every 8 hours for a total of 5 days. The antibiotic regimen is adjusted based on the results of ascitic fluid cultures. Other antibiotic regimens for SBP are less well studied. Given the significant morbidity and mortality rates associated with SBP, efforts to prevent its development and recurrence with antibiotic prophylaxis are warranted. The most extensively studied form of prophylaxis involves selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin. Individuals with low-protein ascites (ascitic fluid total protein < 1g/dL) benefit from SID with norfloxacin 400 mg daily during times of hospitalization. Long-term primary prophylaxis during outpatient management of individuals awaiting liver transplantation with severe ascites and advanced liver failure should also be considered. Patients with cirrhosis and upper gastrointestinal bleeding should receive norfloxacin 400 mg twice daily for 1 week following their bleed. Those individuals surviving an episode of SBP should be treated with norfloxacin 400 mg daily until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery. Although the infection-related mortality associated with SBP has decreased to less than 10%, hospitalization-related mortality remains as high as 30% as a result of the severe underlying liver disease in which the infection arises and the marked generation of cytokines and nitric oxide resulting from the infection. Recently, the simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality. Further improvement in the outcomes of SBP will require treatments targeting this cytokine cascade rather than the development of more potent antibiotics.

Spontaneous ascitic infection in different cirrhotic groups: prevalence, risk factors and the efficacy of cefotaxime therapy.

To investigate the prevalence of spontaneous ascitic infection (SAI) in different cirrhotic groups, the risk factors for development of SAI, and the efficacy of cefotaxime therapy. A prospective study. In-patient clinic of a university hospital. Eighty cirrhotic patients with ascites were assigned to four groups: hepatitis B or D virus-related 34, alcoholic 18, hepatitis C virus-related 14, miscellaneous 14. Paracentesis was performed on 80 patients during 92 consecutive hospitalizations. Ascitic fluid was cultured by the method of bedside inoculation of blood culture bottles with ascites. The patients with SAI were treated with cefotaxime (2 g, three times daily, intravenously) for 5 days. Frequency of SAI in cirrhotic groups; clinical, bacteriological and biochemical findings of SAI; rate of recovery-from infection. Twenty SAI episodes (22%) were found in 16 patients; 8 episodes were spontaneous bacterial peritonitis, 2 bacterascites, and 10 culture-negative neutrocytic ascites. SAI occurred more frequently in patients with hepatitis B or D virus-related liver cirrhosis (32%) than in the alcoholic (6%, P < 0.05), hepatitis C virus-related (14%) or miscellaneous (14%) cirrhotic groups in multivariate analysis, independent predictive factors associated with the development of SAI are chronic hepatitis B virus infection, ascitic fluid total protein and serum bilirubin. Escherichia coli was obtained in 5 of 10 positive ascitic fluid cultures. Cure of the infection was achieved in 95% of episodes. Hospitalization mortality rate in infected patients was 20%. Spontaneous ascitic infection occurs in approximately 20% of cirrhotic patients hospitalized with ascites. The patients with low ascitic protein concentration, high serum bilirubin level or hepatitis B virus cirrhosis are more predisposed to SAI. Cefotaxime may be an effective first-choice antibiotic for ascitic fluid infection.

Diuresis increases ascitic fluid opsonic activity in patients who survive spontaneous bacterial peritonitis

Patients with low protein ascites and deficient ascitic fluid opsonic activity have been shown to be unusually predisposed to development of spontaneous bacterial peritonitis. Survivors of spontaneous peritonitis frequently develop recurrent infection. Diuresis has been shown to increase the ascitic fluid opsonic activity of patients who have never had spontaneous bacterial peritonitis. Patients with adequate opsonic activity are protected from ascitic fluid infection. Theoretically, the subset of patients who develop spontaneous peritonitis may have such severe liver disease that (i) their ascites is refractory to diuretic therapy or (ii) their ascitic fluid opsonic activity does not increase in response to diuresis. In this study, opsonic activity and concentrations of total protein and complement components were measured in the ascitic fluid of 11 patients who were hospitalized with spontaneous bacterial peritonitis and who responded to oral diuretics. The mean values of all of these parameters were found to increase significantly comparing the end-of-diuresis samples to the specimens that were diagnostic of ascitic fluid infection. Patients who survive spontaneous bacterial peritonitis are able to increase their ascitic fluid total protein and opsonic activity in response to diuresis. This increase in endogenous antimicrobial activity may help prevent recurrence of ascitic fluid infection.

Characterization of Ascites Present at Cesarean Section

Ascites has been reported at cesarean section delivery in pregnancies complicated by preeclampsia. The frequency and composition of peritoneal fluid collections in pregnancy have not previously been described. This descriptive study evaluated presence, composition, and characteristics of ascites present in 41 women undergoing cesarean delivery for a variety of indications. Twenty-six women had sufficient quantities of peritoneal fluid to be collected immediately after opening the parietal peritoneum. The protein content of the fluid was analyzed. The presence of fluid was not related to labor preceding delivery. All preeclamptic women in this study had fluid obtainable at cesarean section. Large volume ascites was noted in five preeclamptic women whose fluid had low total protein content, consistent with a transudate. Intrahepatic portal hypertension is one possible explanation of the large volume and low protein ascites in some preeclamptic patients. Ultrasonic measurements in preeclamptic patients and normotensive pregnant women showed uniform portal vein diameters and Doppler-derived portal vein flow velocities in all patients. The physiology of peritoneal fluid production in complicated and normal pregnancy remains unexplained.