الفهرس 
CHRONIC LIVER DISEASEOnly 14 pages are availabe for public view
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Abstract
T
he current study was designed to assess the frequency, clinical profile, bacteriological patterns and outcome of spontaneous bacterial peritonitis and other variants of ascitic fluid infections in patients with liver cirrhosis admitted to Tropical Medicine department at Ain Shams University hospitals. The study also investigated the bacterial isolates and antibiotic sensitivity and resistance patterns in patients with ascites due to chronic liver disease during the one year period starting from June 2017 to May 2018.
Eighty-seven patients were enrolled in this study. All of them were subjected to Complete history taking, thorough clinical examination, laboratory investigations including (complete blood picture, C reactive protein, liver and renal profiles, abdominal ultrasonography, ascitic fluid sampling for ascitic cell count, biochemical assay (ascitic fluid albumin, LDH, glucose and total proteins levels) and ascitic fluid culture and sensitivity.
The studied patients were classified into two groups:
group A included patients with infected ascites diagnosed by fever, abdominal tenderness, leukocytosis, elevated CRP, ascitic cell count and ascitic culture and sensitivity. Those patients received empirical antibiotics in the form of third generation cephalosporins till the result of the ascitic culture and sensitivity. The response was monitored by improvement of clinical signs (fever and abdominal tenderness) and improvement of ascitic cell count taken after 48 hours from the start of antibiotic treatment.
group B included patients with non-infected ascites.
The frequency of ascitic fluid infection among the 87 studied patients was 31% (27 patients). These 27 patients had infected ascites which was either symptomatic e.g: abdominal pain and fever, or asymptomatic.
Among the 27 patients with infected ascites, 17 patients were males (63%) and 10 patients were females (37%) and Among the 60 patients with non-infected ascites, 36 patients were males (60%) and 24 patients were females (40%). The mean and SD of age among the studied patients in group A and group B was 52.11±12.99 years and 53±4.77 years respectively. Hepatitis C virus was the most common etiology of chronic liver disease in patients of group A (66%) and group B (68%).
In the current study, the main presenting symptom among the patients with ascitic fluid infection was abdominal pain which was presented in (37%). The most common clinical sign was lower limb edema which was presented in (81%) of patients on general examination. While on abdominal examination, 78% of patients had tense ascites. Additionally, jaundice, fever and hepatic encephalopathy were noted in patients with infected ascites at a frequency of 37%, 30% and 26% respectively. Abdominal pain, fever, lower limb edema and tense ascites were found to have significant statistical difference when compared with patients with non-infected ascites.
All cases of chronic liver disease were diagnosed according to clinical, biochemical, and/or imaging findings. The severity of cirrhosis was categorized by Child-Pugh’s classification where Child class B was represented in 41% of patients with infected ascites and Child class C was represented in 59% of patients with infected ascites. Moreover, 59% of patients with infected ascites had MELD score between 10-19.
As regard the laboratory findings, the total leucocytic count was significantly higher in patients with infected ascites (9.15) than in patients with non-infected ascites (6.71). Total bilirubin and direct bilirubin were significantly higher in patients with AFI (T.bil 4.7±5.84, D.bil 3.23±3.94) than in patients with non-infected ascites. Direct bilirubin (1.39 mg/dl±1.97) and serum albumin was significantly lower in patients with AFI (2.19±0.43) than in patients with non-infected ascites (2.45±0.54). Serum magnesium, INR and CRP were significantly higher in patients with AFI (2.06±0.44, 1.88±1.11 and 59.02±2.75 respectively) than in patients with non-infected ascites (1.83±0.34, 1.51±0.32 and 24.19±39.31 respectively).
As regards abdominal ultrasonography, coarse liver was detected in all patients; hepatomegaly and splenomegaly were detected in 74% and 63% of patients with infected ascites respectively, and hepatic focal lesions, portal vein thrombosis, occluded hepatic veins and inferior vena caval thrombosis were detected in 44%, 22%, 11% and 4% of patients with infected ascites respectively. On the other hand, the frequencies of hepatomegaly, splenomegaly, hepatic focal lesions, portal vein thrombosis, occluded hepatic veins and inferior vena caval thrombosis among the patients with non-infected ascites were 27%, 57%, 27%, 12%, 23% and 10% respectively.
Regarding the ascitic fluid samples that were collected under complete aseptic conditions before the start of any antimicrobial treatment for patients with suggestion of SBP, all of the collected samples were tinged yellow in color except for the two bloody samples that were collected from two patients with ruptured HCC.
The ascitic cell count was significantly higher in patients with AFI (550±865) than in patients with non-infected ascites (58±4). In addition, ascitic fluid LDH was significantly higher in patients with AFI (180±442 IU/L) than in patients with non-infected ascites (80±55 IU/L). While ascitic fluid glucose was significantly lower in patients with AFI (118±46 mg/dl) than in patients with non-infected ascites (145±41 mg/dl). However, no statistically significant difference in the level of ascitic fluid protein and ascitic fluid albumin was detected between the patients with infected ascites and the patients with non-infected ascites.
The ascitic culture and sensitivity taken from the studied patients showed that 74% of patients with infected ascites had culture negative neutrocytic ascites, 22% of patients with infected ascites had monomicrobial bacterascites and 4% of patients with infected ascites had polymicrobial bacterascites. E.coli was the most frequently isolated micro-organism (7%).
As regards the upper gastrointestinal endoscopy, 30% of patients with infected ascites had no esophageal varices or fundal varices, 33% had small or medium sized esophageal varices and 26% had large risky esophageal varices banded. Also, 7% of patients with infected ascites had fundal varices injected.
Among the 27 studied patients with infected ascites, 12 patients responded to the first-line antibiotic therapy (third generation Cephalosporins), 10 patients responded to the second-line antibiotic therapy (9 patients responded to Meropenem where two of them were culture-based and one patient responded to Piperacillin/Tazobactam), three patients responded to culture-based Linezolide and one patient responded to culture-based Ciprofloxacin and one patient was asymptomatic Non-neutrocitic bacterascites who did not receive antibiotic treatment.