Spontaneous Peritonitis Research Articles

FUNGAL PERITONITIS IN THE SETTING OF NECROTIZING PANCREATITIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous fungal peritonitis (SFP) is a fungal infection of ascitic fluid, defined as over 250 polymorphic neutrophils (PMNs) and fungal growth on culture. It has a high mortality rate and often is recognized late in clinical courses. SFP is commonly associated with cirrhosis or advanced end stage liver disease. This is due to perturbation of mucosal blood flow and bacterial growth in the intestines, and changes in the permeability of the mucosal wall of the gastrointestinal tract (1-3). However, amongst patients without cirrhosis, there is limited data describing patients with SFP. Herein we describe a patient with no history of cirrhosis presenting with necrotizing pancreatitis and ileus who developed SFP. CASE PRESENTATION: A 60-year-old woman with a past medical history of hypertension presented to our hospital unresponsive with septic shock. She was intubated, resuscitated, placed on vasopressors and treated with broad spectrum antibiotics. Further evaluation with laboratory data demonstrated a lipase > 4000 u/L. Computed tomography imaging was consistent with necrotizing pancreatitis, ileus and small bowel obstruction. Her course was complicated by development of a large phlegmon requiring cystogastrostomy for drainage, in addition to total parenteral nutrition (TPN). Despite drainage and antibiotics she continued to have worsening abdominal distension and vasopressor requirement. An abdominal ultrasound demonstrated loculated ascites with septations (a). An abdominal drain was placed with subsequent drainage of 2.2 liters of moss-colored ascitic fluid (b), with over 2000 PMNs and growth of Candida albicans, Enterococcus faecalis and Stenotrophomonas maltophilia. Her antibiotics were adjusted to fluconazole, oxacillin and minocycline. With subsequent drainage and appropriate antibiotics, her vasopressor requirement resolved, she was liberated from the ventilator and her mental status improved. DISCUSSION: We describe a patient who develops SFP without its commonly known risk factors. We suspect the use of broad-spectrum antibiotics during the patient's hospital course, in conjunction with mucosal breakdown of the enteral tract in the setting of ileus and severe necrotizing pancreatitis created a favorable environment for fungal overgrowth. TPN is not known to cause SFP specifically, but with fungal infections in general. Antibiotics in the setting of TPN use may have caused further alterations of microbial balance, increased fungal dominance (4-6) and resulted in microbial translocation and polymicrobial peritonitis. CONCLUSIONS: It is critical to recognize SFP in patients without liver disease. Other less common risk factors such as antibiotics, perturbation of the enteral tract with diseases such as pancreatitis, ileus and TPN can increase one's risk of SFP. Early recognition and treatment can improve patient outcomes in patients presenting with septic shock. REFERENCE #1: Patel D. et al. Spontaneous fungal peritonitis as a rare complication of ascites secondary to cardiac cirrhosis: a case report. Am J Case Report. 2019; 20:1526-1529. REFERENCE #2: Shizuma T. Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: a literature review. World J Hepatol. 2018 Feb 27; 10(2): 254-266. REFERENCE #3: Lahmer T., Brandi A., Rasch S., Schmid RM., Huber W. Fungal peritonitis: underestimated disease in critically ill patients with liver cirrhosis and spontaneous peritonitis. PLoS ONE. 2016 July 8; 11(7).4. Van Leeuwen PA, et al. Clinical significance of translocation. Gut. Jan 1994; 31(1 Suppl):S28-34). Doi: 10.1136/gut.35.1_suppl.s28.5. Bernhardt H, Zimmermann K, Knoke M. The continuous flow culture as an in vitro model in experimental mycology. Mycoses. 1999;42 Suppl 2:29-32. PMID: 10865900.6. Yang S. et al. A risk factor analysis of healthcare-associated fungal infections in an intensive are unit: a retrospective cohort study. BMC Infectious Diseases. 2013; 13(10) DISCLOSURES: No relevant relationships by Andrew Deitchman, source=Web Response No relevant relationships by Austin Hager, source=Web Response No relevant relationships by Diane Wang, source=Web Response

S3015 Primary Gastrointestinal T-cell Lymphoma Presenting as Spontaneous Perforation Peritonitis: A Case Report

S3015 Primary Gastrointestinal T-cell Lymphoma Presenting as Spontaneous Perforation Peritonitis: A Case Report

Prevalence of Spontaneous Bacteria Peritonitis in Patients with Hypoalbuminemia and Cirrhosis

Background and Aim: Spontaneous bacterial peritonitis (SBP) is one of the most serious complications of ascites, resulting in liver cirrhosis infection, accounting for approximately 25% of all bacterial infections. Within a diagnostic year, the mortality rate for spontaneous bacterial peritonitis ranges from 30% to 90%. The current study attempted to determine the prevalence of spontaneous bacterial peritonitis in patients with hypoalbuminemia and cirrhosis. Materials and Methods: This cross-sectional study was conducted on 112 cirrhosis with hypoalbuminemia patients at Medical Unit A, Hayatabad Medical Complex Peshawar and department of Gastroenterology AK CMH / Sheikh Khalifa bin Zaid Al Nahyan Hospital, Rawalakot Azad Kashmir. The duration of the study was six months from 5th January 2021 to 5th June 2021. All patients of either gender with liver cirrhosis and hypoalbuminemia aged 20 to 60 years were included in the study. Each individual was asked to provide written informed consent. Each patient's creatinine, albumin, and sodium levels were measured in the laboratory using urine and blood sample tests. Each patient's absence or presence of SBP was recorded according to the operational definition. For data analysis, SPSS version 20 was used. Results: Of the total 112 patients, 59 (52.7%) were male and 53 (473%) were female. The overall mean age of the patients was 43.51±4.58 years whereas male and female patients had 47.36±5.62 and 39.66±3.54 years respectively. The number of patients falling in class B and Child Push class C was 50 (44.6%) and 62 (55.4%) respectively. The prevalence of spontaneous bacterial peritonitis was 48 (42.9%). Out of 48 SBP patients, 29 (60.4%) were male and 19 (39.6%) were female. The prevalence of SBP was seen in 13 (27.1%) cases of Class B and 35 (72.9%) of Class C (Child-Pugh Class) respectively. Hypertension and diabetes mellitus as comorbidities were present in 11 (9.8%) and 25 (22.3%) cases respectively. Conclusion: In the current study, the prevalence of SBP was 42.9%. Our study revealed a higher prevalence of spontaneous bacterial peritonitis in cirrhosis patients. Also, a significant association has been found between spontaneous bacterial peritonitis and child Pugh Class C and Class B whereas SBP had no substantial connotation with gender, etiology, and even age but with disease duration. Keywords: Cirrhosis; Spontaneous Bacterial Peritonitis; Hypoalbuminemia

A case report of spontaneous biliary peritonitis with accessory liver lobe: rare presentation of a rare pathology

Spontaneous intrahepatic bile duct perforation with associated accessory liver lobe is an exceedingly rare condition with very few cases reported in the literature. Here we report a case of 76 years old man presenting with severe pain, abdominal distension since 3 days having jaundice and signs of peritonitis. Having undergone an exploratory laparotomy, 1 liter of bilious peritoneal fluid was seen with a perforation of left intra hepatic bile duct with a presence of an accessory lobe of liver. The gall bladder was contracted with multiple stones. Extrahepatic biliary duct was found normal intraoperatively. A cholecystectomy with resection of the accessory liver lobe was done. Post operatively patient had persistence of jaundice for which a magnetic resonance cholangiopancreatography was done, revealing a distal common bile duct calculus. Patient underwent endoscopic retrograde cholangiopancreatography with stone extraction on post operative day 10 relieving the symptoms. Patient is on regular follow up with no further complications. Awareness of such unusual occurrences is necessary for early diagnosis and instituting the appropriate treatment thereby reducing the mortality.

Study of Ascitic Fluid Micro RNA-155 in Patients with Spontaneous Bacterial Peritonitis

Background: In patients with cirrhosis, spontaneous bacterial peritonitis is the most common bacterial infection. This research aims at studying the ascititc fluid Micro RNA-155 as a possible biomarker in spontaneous peritonitis. Method: 187 liver cirrhosis and ascites were chosen, 97 SBP patients and 90 SBP patients, all patients had historical history, thorough and local examination, comprehensive investigations, abdominal ultrasonography, diagnostic abdominal paracentesis and Micro RNA-155 evaluation. Results: in SBP, the average value of TLC, Polymorphene, and RNA-155 was considerably greater than non SBP, but in the SBP group the average value of ascetic albumin, glucose, and protein was considerably lower than in the non-SBP group. For MiR-155, the optimal balance of sensitivity and specificity was 0.022 for ROC as a marker with sensitivity 60 percent and specificity 62.0 percent and surface area under curve 0.639. No statistically significant link exists among SBP patients among Micro RNA-155 with TLC, polymorphs, MELD score and Child Pugh score values. Conclusion; Although MiR-155 was increased in the ascetic fluid of SBP patients, and is a predictor for SBP development, it cannot be employed as diagnostic marker in the SBP, according to this research.

Effect of type 2 diabetic mellitus in the prognosis of acute-on-chronic liver failure patients in China.

BACKGROUNDAcute-on-chronic liver failure (ACLF) patients have a high short-term mortality rate, and the severity evaluation of ACLF is necessary for prognostication. Therefore, it was meaningful to evaluate the association between type 2 diabetic mellitus (DM) and ACLF and further explore the feasibility of using DM as a prognostic indicator in ACLF patients. The association between type 2 DM and the prognosis of patients with severe liver disease remains unclear.AIMTo examine the effect of type 2 DM on the prognosis of patients with ACLF.METHODSClinical data from 222 ACLF patients were collected and analyzed. The patients were categorized into two groups depending on whether they had DM or not, and the clinical data of ACLF patients were measured within 48 h after admission. Complications of ACLF were documented during treatment, such as hepatic encephalopathy, hepatorenal syndrome, acute upper gastrointestinal hemorrhage, and spontaneous peritonitis (SBP). Values of laboratory parameters, complication rates, and hospital mortality rates were compared between two groups.RESULTSAmong 222 ACLF patients, 38 cases were categorized into DM groups, the mean age was 56.32 years and 73.68% were male. The prognosis of ACLF patients was significantly correlated with DM in univariate [hazard ratio (HR) = 2.4, 95% confidence interval (CI) =1.5-3.7, P < 0.001] and multivariable analysis (HR = 3.17, 95%CI =1.82-5.523, P < 0.001). The incident of SBP (34.21% vs 13.59%, P = 0.038) and other infections like lung, urinary, blood, and cholecyst (44.74% vs 28.26%, P = 0.046) were higher in DM patients than non-DM counterparts. In addition, the ACLF patients with DM tended to have a high mortality rate (P < 0.001). Cumulative survival time was also significantly shorter in the ACLF patients with DM than non-DM.CONCLUSIONA significant association between DM and the prognosis of ACLF patients was found in China. The ACLF patients with DM had higher incidence of hospital mortality and infection than those without DM.

Moraxella Peritonitis in a Non-Peritoneal Dialysis Patient

<strong>Background:</strong> Spontaneous Bacterial Peritonitis is a serious complication of ascites in patients with liver cirrhosis. Most commonly, the cause is monomicrobial, the usual suspects being E. Coli, K. pneumoniae, and sometimes, S. pneumoniae. Moraxella, a gram-negative coccobacillus, is a rare cause of secondary bacterial peritonitis in patients undergoing peritoneal dialysis. In this paper, we present a patient with spontaneous bacterial peritonitis, with no history of peritoneal catheterization or peritoneal dialysis, with Moraxella spp. as the causative agent. To the best of our knowledge, this is the only reported case of spontaneous Moraxella peritonitis. <strong>Presentation:</strong> A 63-year-old gentleman, with alcoholic liver cirrhosis and chronic refractory ascites, was referred to the Emergency Room, from the Gastroenterology outpatient clinic, when he presented with the chief complaints of worsening abdominal distension and abdominal discomfort. Leukocytosis was noted and abdominal ultrasound showed moderate ascites. The patient underwent diagnostic and therapeutic paracentesis. The SAAG was calculated to be 0.8 with a total WBC count of 330 cells/mm3 (98% lymphocytes and 2% polymorphs). While the laboratory analysis of the ascitic fluid did not meet the criteria for spontaneous bacterial peritonitis (SBP), the cultures grew Moraxella spp. No other source of infection was identified. The patient was started on Doxycycline and Cefpodoxime for likely spontaneous bacterial peritonitis as sensitivities were not available, and the patient demonstrated clinical improvement, with a decrease in abdominal pain and tenderness, and a decrease in leukocytosis. He was discharged with an outpatient gastroenterology appointment and antibiotics for secondary prophylaxis. <strong>Discussion:</strong> Although rare, there is data to establish Moraxella as an often-encountered pathogen causing peritonitis in peritoneal dialysis patients. However, there is insufficient literature regarding its role in SBP, resulting in delays in establishing a diagnosis and in initiating treatment. A greater understanding of this organism will help further the knowledge of its pathogenicity and help recognize optimal antibiotic choices.

Differential analysis of different study types in clinical safety evaluation of Xuebijing Injection

This study aimed to comprehensively analyze and compare the differences of different clinical study types currently published in the safety evaluation of Xuebijing Injection. Six databases, namely the Cochrane Library, PubMed, EMbase, CNKI, VIP and Wanfang database, were electronically retrieved to collect all types of studies on the safety of Xuebijing Injection, including randomized controlled trials, case-controlled studies, cohort studies, systematic reviews, and centralized monitoring studies of clinical safety(hospital), in order to comprehensively and objectively evaluate the safety of Xuebijing Injection, and analyze the differences of different research results. A total of 211 literatures were included, involving a total of 46 384 patients treated with Xuebijing Injection, and 423 adverse reactions(ADRs) occurred. They included 191 randomized controlled trials, 3 cohort studies, 15 systematic reviews, and 2 centralized monitoring studies of clinical safety(hospital), and the incidence of adverse reactions was 2.54%(common), 2.31%(common), 0.95%(occasionally), and 0.50%(occasionally). More than half of the 423 cases of ADRs occurred in skin and adnexal system(151 cases) and gastrointestinal system(65 cases), including such manifestations as rash, skin itching, nausea and vomiting, diarrhea. The degree of ADRs was mild. Randomized controlled trials showed that the incidence of ADR was the highest when Xuebijing Injection was used for malignant tumor and multiple organ failure. And the systematic evaluation showed that the incidence of ADR was the highest when Xuebijing Injection was used for spontaneous peritonitis of liver cirrhosis. In conclusion, different study types could lead to significant differences in the results of drug safety evaluation. Sample size, study type, and quality control are the main factors for biased results. Due to large sample size and high-quality, centralized monitoring studies become the better clinical safety evaluation model of drugs at present, and full life cycle management could more objectively reflect drug safety and guide clinical rational drug use.

Effect of vitamin D deficiency on spontaneous peritonitis in cirrhosis: a meta-analysis

IntroductionFew studies have reported the relationship between spontaneous peritonitis in cirrhosis and vitamin D, and the result is not very convincing.AimTo conduct a meta-analysis to clarify the relationship between vitamin D and spontaneous peritonitis.Material and methodsArticles published up to 1 October 2019 in the PubMed, Medline, and Embase databases were searched. According to the inclusion and exclusion criteria, relevant statistical data were extracted and analysed by STATA.ResultsSix articles met the inclusion criteria. It was demonstrated that the average 25(OH)D level in spontaneous peritonitis patients was 2.36 less than that in control individuals (SMD = –2.36, 95% CI: –3.92, –0.8, I2 = 97.2%, p < 0.01). Moreover, it found that spontaneous peritonitis patients were 4.33 times more likely to be vitamin D deficient than controls (OR = 4.33, 95% CI: 1.57, 11.93, I2 = 50.1%, p = 0.111). Sensitivity analysis showed that the meta-analysis results were stable and reliable.ConclusionsVitamin D may be an importantly protective factor in spontaneous peritonitis.

A prediction model for outcome in patients with HBV-ACLF based on predisposition, injury, response and organ failure

We aimed to develop a prediction model based on the PIRO concept (Predisposition, Injury, Response and Organ failure) for patients with Hepatitis B Virus (HBV) related acute-on-chronic liver failure (ACLF). 774 patients with HBV related ACLF defined in the CANONIC study were analyzed according to PIRO components. Variables associated with mortality were selected into the prediction model. Based on the regression coefficients, a score for each PIRO component was developed, and a classification and regression tree was used to stratify patients into different nodes. The prediction model was then validated using an independent cohort (n = 155). Factors significantly associated with 90-day mortality were: P: age, gender and ACLF type; I: drug, infection, surgery, and variceal bleeding; R: systemic inflammatory response syndrome (SIRS), spontaneous bacteria peritonitis (SBP), and pneumonia; and O: the CLIF consortium organ failure score (CLIF-C OFs). The areas under the receiver operating characteristics curve (95% confidence interval) for the combined PIRO model for 90-day mortality were 0.77 (0.73–0.80). Based on the scores for each of the PIRO components and the cut-offs estimated from the classification and regression tree, patients were stratified into different nodes with different estimated death probability. Based on the PIRO concept, a new prediction model was developed for patients with HBV related ACLF, allowing stratification into different clusters using the different scores obtained in each PIRO component. The proposed model will likely help to stratify patients at different risk, defining individual management plans, assessing criteria for specific therapies, and predicting outcomes.

Spontaneous Bacterial Peritonitis and Secondary Bacterial Peritonitis—a Comprehensive Review

Spontaneous bacterial peritonitis (SBP) and secondary bacterial peritonitis are life-threatening complications of cirrhosis if not recognized immediately and managed appropriately. SBP occurs in ~ 3.5 to 10% of patients with cirrhosis and ascites, whereas secondary bacterial peritonitis occurs in 5%. Prompt recognition of SBP variants is vital for tailoring therapy to decrease mortality rate from 90 to 20%. Our objective is to provide an update on the recent publications to elucidate the variants of SBP and provide a management algorithm for the potentially life-threatening complications of cirrhosis. The general guidelines for the management of spontaneous bacterial peritonitis are mostly unchanged, but there are newer data regarding trends in bacteriology and pathogens and newer prophylactic strategies. Spontaneous fungal peritonitis, spontaneous bacterial empyema, and secondary bacterial peritonitis can be clinically challenging if not diagnosed promptly. Nutrition is an under-recognized but important aspect of the management of ascites and SBP prevention. Emerging options for the management of diuretic refractory ascites and infection management are discussed in detail. Early diagnosis and treatment of SBP and secondary bacterial peritonitis are usually associated with good outcomes, but mortality remains as high as 40%. There is a higher risk of other decompensating cirrhotic events after the initial episode of SBP or secondary bacterial peritonitis that portends poor prognosis. The emphasis should be to identify the precipitating cause and focus on the modifiable risk factors to improve outcomes and survival. Newer strategies for SBP prophylaxis and ascites management appear promising until liver transplantation. Personalized approach is crucial to improve the morbidity, quality of life, and mortality in every patient with decompensated cirrhosis.

S2648 Spontaneous Peritonitis and When to Escalate Therapy From Bacterial to Fungal: A Case Report and Review of the Literature

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is a disease seen in patients with decompensated liver cirrhosis and can be deadly. Clear diagnostic criteria have been established with ascites showing >250 PMNs/mm at which point of time empiric antibiotic therapy should be initiated. Spontaneous fungal peritonitis (SFP) can present similarly to SBP, yet the diagnosis is often delayed and outcomes are poor. We present a case of a patient with SFP was misdiagnosed as SBP, followed but criteria that can distinguish those at high risk for SFP for whom early antifungal therapy could be considered. CASE DESCRIPTION/METHODS: A 67 yr old man with a history of decompensated NASH cirrhosis, CKDIII and diabetes presented to our hospital with acute kidney injury and abdominal pain, after having been discharged 2 weeks prior for a C. difficile infection and ascites requiring paracentesis. Signs and symptoms on arrival suggested spontaneous bacterial peritonitis with abdominal distension and tenderness and ceftriaxone was started empirically. Nephrology was consulted for kidney injury and diagnosed hepatorenal syndrome type 1. His initial paracentesis ascites fluid showed >4000 PMNs/mm3, confirming SBP. On day 2 he underwent hemodialysis and developed altered mental status, respiratory distress and hypotension and was emergently transferred to the ICU for intubation and antibiotic escalation to vancomycin, cefepime and metronidazole for septic shock. At 48 hours he underwent second paracentesis for which ascites fluid showed 3600 PMNs/mm3, suggesting failure of SBP therapy. Candida glabrata grew from initial paracentesis culture on day 3 and empiric micafungin was initiated. By day four with worsening clinical status and dismal prognosis, he was made comfort care after discussion with family. DISCUSSION: Effective medical therapy has been established for SBP, but such is lacking for spontaneous fungal peritonitis (SFP). In cases where SBP therapy fails, SFP should be seriously considered. Mortality for SFP remains significant at 50–100%, thought to be due to the delay in culture-based fungal therapy initiation. Literature suggests antifungal initiation at 48 hours does little to change initial prognosis and thus earlier initiation should be sought when possible. Ascitic fluid fungal PCR should be pursued for early diagnosis when SFP is suspected. We will present criteria that can delineate patients at high risk for SFP so that early empiric antifungal therapy can be initiated in attempt to improve overall prognosis.

Role of hepatic venous pressure gradient in the overall management process of portal hypertension

Portal hypertension is a common complication of many chronic liver diseases and an important factor affecting the clinical prognosis of patients. Portal hypertension can bring a series of serious complications such as esophagogastric varices, gastrointestinal bleeding, ascites, spontaneous peritonitis, renal insufficiency, hypersplenism, and hepatopulmonary syndrome. Hepatic venous pressure gradient is the best clinical indicator that indirectly reflects the portal venous pressure. Currently, it is the gold standard test for diagnosing clinically significant portal hypertension. In addition, the hepatic venous pressure gradient has important application value in predicting the degree of liver cirrhosis, the risk and prognosis of portal hypertension variceal bleeding, ascites production, portal hypertension drugs reduction, and antiviral drugs efficacy. At the same time, individualized treatment based on portal pressure gradient has important theoretical and clinical significance, and provides new clinical ideas in the overall management of patients with portal hypertension.

Comparative study between spontaneous fungal peritonitis and spontaneous bacterial peritonitis in patients with end stage liver disease

Comparative study between spontaneous fungal peritonitis and spontaneous bacterial peritonitis in patients with end stage liver disease

Current Status and Prospects of Spontaneous Peritonitis in Patients with Cirrhosis.

Spontaneous bacterial peritonitis (SBP) is a common cirrhotic ascites complication which exacerbates the patient's condition. SBP is caused by gram-negative bacilli and, to a lesser extent, gram-positive cocci. Hospital-acquired infections show higher levels of drug-resistant bacteria. Geographical location influences pathogenic bacteria distribution; therefore, different hospitals in the same country record different bacteria strains. Intestinal changes and a weak immune system in patients with liver cirrhosis lead to bacterial translocation thus causing SBP. Early diagnosis and timely treatment are important in SBP management. When the treatment effect is not effective, other rare pathogens should be explored.

Comparative study between spontaneous fungal peritonitis (SFP) and spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease (ESLD)

Background: Bacterial infections in end stage liver disease are common and associated with increased mortality. Although extensive research has elucidated the impact of bacterial infections as the major precipitating event leads to increased frequency of liver-related complications and mortality in these patients. Objective: Evaluating the clinical and laboratory characters, risk factors, and outcome of fungal and bacterial peritonitis in cirrhotic patients with end stage liver disease (ESLD). Patients and Methods: This cross sctional study enrolled 60 patients with liver cirrhosis and ascites. Fifty patients were culture-positive spontaneous peritonitis, including 12 with spontaneous fungal peritonitis (SFP), and 38 culture-positive spontaneous bacterial peritonitis (SBP), and 10 patients without clinical or laboratory evidence of peritonitis as a control group, during the study period, between 1st February 2018 and 30th May 2019. We compared the clinical, laboratory findings, Child–Pugh scores, model for end stage liver disease (MELD) score, risk factors, and mortality rates between patients with spontaneous peritonitis associated with fungal culture-positive ascites, and those with spontaneous peritonitis associated with bacterial culture-positive ascites. Results: Patients of the current study were critically ill. The mean duration of ESLD in the studied patients was 4.75 ± 1.8 year, 57 patients (95.0%) were Child score C, and 3 patients (5%) were Child score B. The mean MELD score was 23.32 ± 5.49. All patients with evidence of peritonitis were Child C, and mean MELD scores were 22.6 ±5.7 and 26.1±4.5 in SBP and SFP groups respectively. Jaundice, GI bleeding and hepatic encephalopathy were significantly for clinical presentation and predictors of mortality in SFP group compared to SBP and control group. Lower levels of hemoglobin (Hb), S. albumin and platelets count and increased level of total leukocytic count (TLC), international normalized ratio (INR), and bilirubin were significantly higher in SFP group compared to SBP and control group. Duration of ESLD and hospital admission was significant in SFP compared to SBP and control group. HCC was evident in SFP group (66.7%) that was highly significant in comparison to SBP (28.9%), and control group (20%). Overall mortality rate among the studied groups was 45%, the mortality rate was significantly increased in SFP group (75%) compared to SBP (42.1%), and control group (20%).The mean MELD score significantly increased in non-survival group compared to survival group . The duration of ESLD significantly increased in non-survival group compared to survival group. Conclusion: Prolonged and severe underlying liver disease with a high Child- Pugh or MELD score, renal impairment, HCC, and onset of severe sepsis have been reported as risk factors in increased mortality in patients with SFP than in SBP. In SFP, mortality was associated not only with the severity of the underlying liver disease, but also with delay in diagnosis and initiation of antifungal therapy.

Comparative study between spontaneous fungal peritonitis (SFP) and spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease (ESLD)

Background: Bacterial infections in end stage liver disease are common and associated with increased mortality. Although extensive research has elucidated the impact of bacterial infections as the major precipitating event leads to increased frequency of liver-related complications and mortality in these patients. Objective: Evaluating the clinical and laboratory characters, risk factors, and outcome of fungal and bacterial peritonitis in cirrhotic patients with end stage liver disease (ESLD). Patients and Methods: This cross sctional study enrolled 60 patients with liver cirrhosis and ascites. Fifty patients were culture-positive spontaneous peritonitis, including 12 with spontaneous fungal peritonitis (SFP), and 38 culture-positive spontaneous bacterial peritonitis (SBP), and 10 patients without clinical or laboratory evidence of peritonitis as a control group, during the study period, between 1st February 2018 and 30th May 2019. We compared the clinical, laboratory findings, Child–Pugh scores, model for end stage liver disease (MELD) score, risk factors, and mortality rates between patients with spontaneous peritonitis associated with fungal culture-positive ascites, and those with spontaneous peritonitis associated with bacterial culture-positive ascites. Results: Patients of the current study were critically ill. The mean duration of ESLD in the studied patients was 4.75 ± 1.8 year, 57 patients (95.0%) were Child score C, and 3 patients (5%) were Child score B. The mean MELD score was 23.32 ± 5.49. All patients with evidence of peritonitis were Child C, and mean MELD scores were 22.6 ±5.7 and 26.1±4.5 in SBP and SFP groups respectively. Jaundice, GI bleeding and hepatic encephalopathy were significantly for clinical presentation and predictors of mortality in SFP group compared to SBP and control group. Lower levels of hemoglobin (Hb), S. albumin and platelets count and increased level of total leukocytic count (TLC), international normalized ratio (INR), and bilirubin were significantly higher in SFP group compared to SBP and control group. Duration of ESLD and hospital admission was significant in SFP compared to SBP and control group. HCC was evident in SFP group (66.7%) that was highly significant in comparison to SBP (28.9%), and control group (20%). Overall mortality rate among the studied groups was 45%, the mortality rate was significantly increased in SFP group (75%) compared to SBP (42.1%), and control group (20%).The mean MELD score significantly increased in non-survival group compared to survival group . The duration of ESLD significantly increased in non-survival group compared to survival group. Conclusion: Prolonged and severe underlying liver disease with a high Child- Pugh or MELD score, renal impairment, HCC, and onset of severe sepsis have been reported as risk factors in increased mortality in patients with SFP than in SBP. In SFP, mortality was associated not only with the severity of the underlying liver disease, but also with delay in diagnosis and initiation of antifungal therapy.

Acid suppression therapy and its association with spontaneous bacterial peritonitis incidence: A systemic review and meta-analysis.

It is well known that the use of proton pump inhibitor (PPI) is widespread in patients with liver cirrhosis. PPI counteracts H2 receptor inhibitor (H2 RA) with its strong acid suppression effect. However, there is always a concern that PPI use may increase spontaneous bacteria peritonitis (SBP) development in cirrhotic patients. We aimed to investigate the association between acid suppression therapy (i.e. PPI or H2 RA) and SBP through meta-analysis. We searched PubMed, Medline, Web of Science, Cochrane library, and Embase for relevant studies published up to April 2019. Pooled OR and 95% CI were calculated by a random-effects model. Funnel plots and Egger's tests were performed for the evaluation of publication bias. Non-parametric "trim-and-fill" tests were conducted for sensitivity analysis. A total of 20 original articles including 9566 cirrhotic patients were analyzed. The overall meta-analysis highlighted that PPI use was associated with the risk of SBP (pooled OR 1.77, 95% CI 1.49-2.11). The conclusion was irrespective of study methods, whereas the result was inconsistent only in South America. However, the conclusion might not be stable enough and should be extrapolated with caution. Unlike PPI, we found H2 RA was not associated with SBP (pooled OR 1.06, 95% CI 0.75-1.48). In conclusion, PPI use, but not H2 RA, will increase the incidence of SBP in cirrhotic patients. In addition, H2 RA might be beneficial for patients who require long-term acid suppression therapy.

2231 Spontaneous Fungal Peritonitis- A Rare Complication of Ascites Secondary to Right Heart Failure: A Case Report

INTRODUCTION: Spontaneous fungal peritonitis is an infection which occurs in patients with liver cirrhosis.Spontaneous fungal peritonitis is uncommon in a patient with cardiac ascites because of high protein content and low risk of infections.We present the second known case of SFP in a patient with cardiogenic ascites. CASE DESCRIPTION/METHODS: 52-year-old female with past medical history of COPD was admitted to the hospital with a two-week history of abdominal pain and dyspnea.Labratory findings showed WBC count of 7,900/mm3, ANC of 6936/mm3, hemoglobin 15.8, platelet count 406 × 103/mm3, creatinine 0.9mg/dL, total bilirubin 3.40 mg/dL, direct bilirubin 2.30 mg/dL, ammonia of 51. Initial imaging of CT abdomen and pelvis showed bilateral pleural effusions, moderate ascites, and liver cirrhosis. ECHO showed left ventricular ejection fraction of 55%, dilated right ventricle, moderate tricuspid regurgitation with right ventricular systolic pressure of 76 mm Hg. Diagnostic and therapeutic ultrasound guided paracentesis was done and 400 mL of fluid was removed and sent for analysis and culture. Patient was empirically started on ceftriaxone for possible spontaneous bacterial peritonitis. Ascitic fluid analysis showed hazy fluid with WBC count of 23,000, 92% of polymorphic cells and 8% of mononuclear cells. Preliminary cultures from ascitic fluid grew Candida glabrata, and patient was started on caspofungin, and diagnosis of spontaneous fungal peritonitis was made. The patient gradually responded to antifungals. DISCUSSION: Cardiac cirrhosis is defined by signs and symptoms of chronic liver disease along with history of heart failure. Ascites due to heart failure is considered low risk for infections because of the high protein content in the ascitic fluid. Ascitic fluid retrieved by diagnostic paracentesis should be analyzed for lactate dehydrogenase, cytology, total cell count and differential, total protein, albumin, bacterial and fungal culture sensitivities. Along with bacterial gram stain and culture sensitivity, fungal stain and culture sensitivities are necessary due to an increasing prevalence of SFP in patients with cirrhosis. Common species causing SFP is Candida albicans, and other causative fungal agents being Candida glabrata, Candida krusei. Risk factors for SFP include elevated Child-Pugh and MELD scores, use of prophylactic antibiotics for SBP, low ascitic fluid protein (&lt; 1 g/dL), hepatorenal syndrome. Treatment with echinocandins is recommended as soon as the diagnosis is made.

2495 Spontaneous Fungal Peritonitis Secondary to Candida glabrata in a Patient With Cardiac Cirrhosis

INTRODUCTION: Spontaneous fungal peritonitis (SFP) is an uncommon, but serious complication of liver cirrhosis. In one study, the one-month mortality rate was 73.3% as compared to 28% in SBP alone. The mortality remains high despite appropriate antifungal therapy partly due to delayed diagnosis. CASE DESCRIPTION/METHODS: We present a case of a 67 years-old male patient who presented with acute confusion and worsening abdominal distension for unknown duration. He has history of heart failure with reduced ejection fraction secondary to ischemic cardiomyopathy and liver cirrhosis presumed secondary to heart failure. He was found to have acute hepatic encephalopathy, anasarca, acute kidney injury, and septic shock. Abdominal exam showed tender, distended abdomen with positive fluid thrill. Spontaneous bacterial peritonitis (SBP) was suspected and ascitic fluid analysis was sent. It reported nucleated cells 3766/uL, 80% neutrophils, SAAG 1.7, glucose &lt;20 mg/dl, and total protein 3.2 g/dl. Computed tomography of abdomen and pelvis without contrast showed massive ascites, but there was no evidence of bowel perforation (Figure 1). He was treated with Vancomycin and Zosyn for SBP and lactulose for hepatic encephalopathy. On day 3, gram stain of ascitic fluid reported budding yeast, and he was started on anidulafungin. The final culture reported Candida glabrata. Bacterial and fungal blood cultures were negative. Despite treatment, his encephalopathy persisted, and he had rapid accumulating ascitic fluid. Ascitic fluid culture was repeated which reported the same. A repeat CT abdomen showed perihepatic hematoma and free intraperitoneal air (Figure 2). He underwent exploratory laparotomy that revealed duodenal perforation. Despite surgical repair and antifungal, septic shock progressed, and patient died from multi-organ failure. Candida glabrata was sensitive to anidulafungin on retrospective review of sensitivity report. DISCUSSION: Although initial ascitic fluid analysis suggested secondary peritonitis, CT scan was negative for perforation or loculated infection. Our case highlights the high mortality rate of Candida peritonitis despite appropriate treatment. It is likely secondary to delayed antifungal and undiagnosed bowel perforations.