Risk Factors Recurrence of Spontaneous Ascitic Fluid Infection (Slai) in Cirrhotic Patients

Introduction: After an episode of spontaneous infection of ascitic fluid (ISLA). The recurrence of ISLA at one year is greater than 70%. We studied the risk factors associated with the occurrence of recurrence. Patients and methods: this was a retrospective, descriptive and analytical study of patient files, hospitalized in the department for 12 months, the choice of the sample was of convenience. Results: We have 1347 patient files collected including 389 cases of cirrhosis. We had 37 files of cirrhotic patients with ISLA including 28 cures without recurrence of ISLA, 08 files of patients with recurrence of ISLA and 03 excluded, i.e. a hospital prevalence of recurrence of 0.6% and a prevalence in cirrhotic patients of 23.5%. The most common antecedents were: hospital contact recent (35.3%), the concept of iterative ascites punctures (32.3%), the presence of HCC (29.4%), hepatic encephalopathy (20.6%) and digestive hemorrhage (14.7%). In univariate analysis, recent digestive bleeding was associated with an increased risk of recurrence (OR 7.2, 95% CI 0.96 - 67.1). HBV (62.5%) is the main etiology of cirrhosis. The PNN rate at 250 - 499 mm3 (62.5%), the protein level 3 (75%). Patients on secondary prophylaxis with NORFLOXACIN were 25%. Recurrence of ISLA was treated with CEFTRIAXONE 2 g/24 hours. Conclusion: Recurrence of ISLA is serious, the predictive factors for recurrence are, hospital contact recent, the concept of iterative ascites punctures, the presence of HCC, the presence of hepatic encephalopathy and digestive bleeding.

Mean platelet volume as a novel predictor of systematic inflammatory response in cirrhotic patients with culturenegative neutrocytic ascites

AIM: To identify a mean platelet volume(MPV) cutoff value which should be able to predict the presence of bacterial infection.METHODS: An observational, analytic, retrospective study. We evaluated medical records of cirrhotic patients who were hospitalized from January 2012 to January 2014 at the Gastroenterology Department of "Hospital General de México Dr. Eduardo Liceaga", we included 51 cirrhotic patients with ascites fluid infection(AFI), and 50 non-infected cirrhotic patients as control group. Receiver operator characteristic curves were used to identify the best cutoff value of several parameters from hematic cytometry, including MPV, to predict the presence of ascites fluid infection.RESULTS: Of the 51 cases with AFI, 48 patients(94.1%) had culture-negative neutrocytic ascites(CNNA), 2(3.9%) had bacterial ascites, and one(2%)had spontaneous bacterial peritonitis. Infected patients had greater count of leucocytes and polymorphonuclear cells, greater levels of MPV and cardiac frequency(P < 0.0001), and lower mean arterial pressure compared with non-infected patients(P = 0.009). Leucocytes, polymorphonuclear count, MPV and cardiac frequency resulted to be good or very good predictive variables of presence of AFI in cirrhotic patients(area under the receiving operating characteristic > 0.80). A cutoff MPV value of 8.3 fl was the best to discriminate between cirrhotic patients with AFI and those without infection. CONCLUSION: Our results support that MPV can be an useful predictor of systemic inflammatory response syndrome in cirrhotic patients with AFI, particularly CNNA.

Sensitivity of diagnosis of spontaneous bacterial peritonitis is higher with the automated cell count method

BACKGROUND Spontaneous bacterial peritonitis(SBP)is one of the most important complications of patients with liver cirrhosis entailing high morbidity and mortality.Making an accurate early diagnosis of this infection is key in the outcome of these patients.The current definition of SBP is based on studies performed more than 40 years ago using a manual technique to count the number of polymorphs in ascitic fluid(AF).There is a lack of data comparing the traditional cell count method with a current automated cell counter.Moreover,current international guidelines do not mention the type of cell count method to be employed and around half of the centers still rely on the traditional manual method.AIM To compare the accuracy of polymorph count on AF to diagnose SBP between the traditional manual cell count method and a modern automated cell counter against SBP cases fulfilling gold standard criteria:Positive AF culture and signs/symptoms of peritonitis.METHODS Retrospective analysis including two cohorts:Cross-sectional(cohort 1)and case-control(cohort 2),of patients with decompensated cirrhosis and ascites.Both cell count methods were conducted simultaneously.Positive SBP cases had a pathogenic bacteria isolated on AF and signs/symptoms of peritonitis.RESULTS A total of 137 cases with 5 positive-SBP,and 85 cases with 33 positive-SBP were included in cohort 1 and 2,respectively.Positive-SBP cases had worse liver function in both cohorts.The automated method showed higher sensitivity than the manual cell count:80%vs 52%,P=0.02,in cohort 2.Both methods showed very good specificity(>95%).The best cutoff using the automated cell counter was polymorph≥0.2 cells×10^(9)/L(equivalent to 200 cells/mm^(3))in AF as it has the higher sensitivity keeping a good specificity.CONCLUSION The automated cell count method should be preferred over the manual method to diagnose SBP because of its higher sensitivity.SBP definition,using the automated method,as polymorph cell count≥0.2 cells×10^(9)/L in AF would need to be considered in patients admitted with decompensated cirrhosis.

Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis

Polymorphonuclear (PMN) cell count in the ascitic fluid is essential for the diagnosis and management of spontaneous bacterial peritonitis (SBP). To date, PMN cell count is routinely performed by traditional manual counting. However, this method is time-consuming, costly, and not always timely available. Therefore, considerable efforts have been made in recent years to develop an alternative test for a more rapid diagnosis and monitoring of SBP. The use of urinary reagent strips was proposed to achieve an "instant" bedside diagnosis of SBP. A series of reports evaluated the urine strip test for SBP diagnosis and reported promising results. However, a recent large multicenter study revealed a surprising lack of diagnostic effi cacy of the urine screening test for SBP diagnosis. Another method, more recently proposed as an alternative to the manual PMN count, is the measurement of lactoferrin in ascitic fluid, but the data available on the diagnostic value of this test are limited to a single study. However, both urinary reagent strips and ascitic lactoferrin tests are qualitative methods and need, therefore, to be further confirmed by standard cytology of the ascitic fluid. To date, the only quantitative method proposed as a valid alternative to manual PMN counting is automated blood cell counters, commonly used in all laboratories for blood cell counting. Data available in the literature on the diagnostic performance of this method are limited but very promising, and this tool seems to have the potential to replace the manual counting method.

Presence of hepcidin-25 in biological fluids: Bile,ascitic and pleural fluids

AIM: To examine body fluids such as ascitic fluid (AF),saliva,bile and pleural effusions for the presence of hepcidin using a novel radioimmunoassay (RIA).METHODS: Serum samples were collected from 25 healthy volunteers (mean age: 36 ± 11.9 years,11 males,14 females).In addition bile was obtained from 12 patients undergoing endoscopic retrograde cholangiopancreatography (mean age: 66.9 ± 16.7 years,M:F = 5:7).Saliva was collected from 17 healthy volunteers (mean age: 35 ± 9.9 years,M:F = 8:9).Pleural and AF were collected from 11 and 16 patients [(mean age: 72 ± 20.5 years,M:F = 7:4) and (mean age: 67.32 ± 15.2 years,M:F = 12:4)],respectively.All biological fluid samples (serum,exudative and transudative fluids) were tested for the presence of hepcidin-25 molecule using RIA.RESULTS: Hepcidin-25 was detected in all biological fluids tested.The mean ± SD hepcidin-25 in serum was 15.68 ± 15.7 ng/mL,bile 7.37 ± 7.4 ng/mL,saliva 3.4 ± 2.8 ng/mL,exudative fluid 65.64 ± 96.82 ng/mL and transudative fluid 14.1 ± 17.8 ng/mL.CONCLUSION: We provide clear evidence that hepcidin-25 is present in bile,saliva,pleural and ascitic fluids.Hepcidin is likely to play a role here in innate immunity.

Ascitic Fluid Analysis in the Differential Diagnosis of Ascites:Focus on Cirrhotic Ascites

Ascites is the pathologic accumulation of fluid within the peritoneal cavity.Because many diseases can cause ascites,in particular cirrhosis,samples of ascitic fluid are commonly analyzed in order to develop a differential diagnosis.The concept of transudate versus exudate,as determined by total protein measurements,is outdated and the use of serumascites albumin gradient as an indicator of portal hypertension is more accurate.Lactate dehydrogenase (LDH),vascular endothelial growth factor (VEGF),and other tumor markers can be helpful in distinguishing between malignant and benign conditions.Glucose and adenosine deaminase levels may support a diagnosis of tuberculous disease,and amylase level may indicate a diagnosis of pancreatitis.Given the specificity and sensitivity of laboratory results,accurate diagnosis should be based on both laboratory data and clinical iudgment.

Drainage by urostomy bag after blockage of abdominal drain in patients with cirrhosis undergoing hepatectomy

Abdominal drainage was previously recommended as a post-hepatectomy procedure for patients with cirrhosis.This report introduces a simple technique that prevents leakage of ascitic fluid after cirrhotic hepatectomy complicated by blockage of the abdominal drain.In 59 patients who had had cirrhotic hepatectomy complicated by leakage of ascites in the drain site after drainage removal between January 2001 and April 2011,31 underwent suture ligation(sutured group) and 28 were given urostomy bag at the abdominal drainage site(drainage group).The mean length of postoperative hospital stay in the drainage group was shorter than in the sutured group(16.11±2.61 vs 34.23±4.86 days,P=0.000).Meanwhile,the drainage group showed decreased postoperative complications,including leakage of ascites,wound infection,and collection of ascites.Drainage by urostomy bag can prevent prolonged leakage of ascitic fluid after the blockage of abdominal drains in patients undergoing cirrhotic hepatectomy.

Chylous Ascites:A Review of Pathogenesis,Diagnosis and Treatment

Chylous ascites(CA)is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity.This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction.The underlying etiologies for CA have been classified as traumatic,congenital,infectious,neoplastic,postoperative,cirrhotic or cardiogenic.Since malignancy and cirrhosis account for about two-thirds of all the cases of CA in Western countries,in this article we have attempted to reclassify CA based on portal and non-portal etiologies.The diagnosis of CA is based on the distinct characteristic of the ascitic fluid which includes a milky appearance and a triglyceride level of>200 mg/dL.The management consists of identifying and treating the underlying disease process,dietary modification,and diuretics.Some studies have also supported the use of agents such as orlistat,somatostatin,octreotide and etilefrine.Paracentesis and surgical interventions in the form of transjugular intrahepatic portosystemic shunt(commonly known as TIPS),peritoneal shunt,angiography with embolization of a leaking vessel,and laparotomy remain as treatment options for cases refractory to medical management.

Expression of Annexin-1 in patients with endometriosis

Background Annexin-1 was identified as an endometriosis-related protein by comparative proteomics in previous study. As an endogeneous anti-inflammatory mediator, Annexin-1 has been shown to regulate the immune response, cell proliferation and apoptosis. To investigate whether Annexin-1 is involved in the pathogenesis of endometriosis, we examined the expression of Annexin-1 in eutopic endometrium of women with or without endometriosis, and detected its expression in peritoneal fluids of those with endometriosis. Methods Eutopic endometrium samples from twenty-five women with endometriosis and those from sixteen age-matched women without endometriosis were collected. Peritoneal fluids were obtained from ten patients with endometriosis. The expression of Annexin-1 protein in eutopic endometrium was detected by immunohistochemistry and Western blotting, and mRNA detected by real-time PCR. Annexin-1 protein in the peritoneal fluids was detected by Western blotting.Results Annexin-1 mRNA and protein were overexpressed in eutopic endometrium of endometriosis without significant differences between the proliferative and secretory phase. Immunohistochemistry showed that Annexin-1 protein was expressed mainly in endometrial glandular celts throughout the menstrual cycle. Annexin-1 protein was detected in the peritoneal fluids of all the ten patients with endometriosis. Conclusions Annexin-1 is overexpressed in eutopic endometrium and presents in the peritoneal fluids of patients with endometriosis, and may play a role in the pathogenesis of endometriosis.

Non-typhoidal salmonella:an unusual cause of spontaneous bacterial peritonitis in decompensated cirrhosis

Salmonella typhimurium, a non-typhoidal salmonella, is an unusual cause of spontaneous bacterial peritonitis (SBP). It isusually reported in asymptomatic patients with normal or high ascitic fluid protein levels with underlying immunosuppression,as high opsonic activity in the ascitic fluid of these patients protects them from the usual organisms causingspontaneous bacterial peritonitis, unless they are exposed to a particularly virulent organism like salmonella. We report acase of culture-proven non-typhoidal salmonella in a patient with decompensated cirrhosis, with low protein and withoutany underlying immunosuppression, and no other source to explain its origin.