2 articles
The clinical value of admission intra-abdominal pressure in patients with decompensated liver cirrhosis and refractory ascites remains insufficiently defined, particularly in relation to the different phenotypes of ascitic fluid infection.
An exploratory observational analysis was performed on a structured dataset that included 100 patients with decompensated liver cirrhosis, refractory ascites, and a Child-Pugh class C score. All patients had the results of the diagnostic paracentesis performed at admission and the transvesical measurement of intra-abdominal pressure available. Ascitic fluid phenotypes were defined on the basis of the polymorphonuclear cell count and the ascitic culture result: spontaneous bacterial peritonitis, bacterascites, and sterile ascites. Intra-abdominal hypertension was defined as an intra-abdominal pressure ≥12 mmHg. The primary objective was the comparison of admission intra-abdominal pressure among phenotypes. The secondary objectives consisted of examining the associations between admission intra-abdominal pressure and acute kidney injury, sepsis, acute-on-chronic liver failure, and the need for intensive care.
The cohort included 22 patients with spontaneous bacterial peritonitis, 10 with bacterascites, and 68 with sterile ascites. Median admission intra-abdominal pressure differed significantly among phenotypes, being highest in spontaneous bacterial peritonitis and lower in bacterascites and sterile ascites: 16.9 (15.2–17.9), 13.4 (11.7–15.4), and 13.4 (12.1–14.6) mmHg, respectively (p<0.001). Intra-abdominal hypertension was present in all patients with spontaneous bacterial peritonitis, in 60.0% of those with bacterascites, and in 75.0% of those with sterile ascites. In adjusted logistic models, each 1-mmHg increase in admission intra-abdominal pressure was independently associated with spontaneous bacterial peritonitis (odds ratio [OR] 3.06; 95% confidence interval [CI] 1.56–6.02), any infected ascites (OR 1.56; 95% CI 1.20–2.02), sepsis (OR 2.12; 95% CI 1.44–3.12), acute-on-chronic liver failure (OR 1.43; 95% CI 1.09–1.86), and the need for intensive care (OR 1.40; 95% CI 1.06–1.83), but not with acute kidney injury (OR 0.91; 95% CI 0.73–1.14).
Higher admission intra-abdominal pressure was associated with a higher probability of spontaneous bacterial peritonitis and with a more severe in-hospital course. Admission intra-abdominal pressure did not show an independent association with acute kidney injury and appears to reflect mainly infectious and general clinical severity.
Bacterial infections in cirrhotic patients represent a major clinical problem, occuring 4-5 times more frequently compared to the general population and increasing mortality by leading to acute on chronic liver failure, subsequent decompensation, and multiorgan failure. The study’s purpose is to determine the possibilities of laparoscopy in the treatment of spontaneous bacterial peritonitis with decompensated liver cirrhosis.
A retrospective descriptive study was conducted on 82 patients diagnosed with liver cirrhosis and spontaneous bacterial peritonitis, who were admitted to the Constantin Tibirna Surgery department No2, Holy Trinity Municipal Clinical Hospital and the Scientific Research Laboratory of Hepatic Surgery, Nicolae Testemițanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova, between January 2012 and December 2021. Patients who underwent surgical drainage of the abdominal cavity by laparoscopy with postoperative peritoneal lavage with antibiotics were selected. All patients received standard treatment for the correction of liver function and complications of portal hypertension. The data were extracted from the medical records of the hospital archive, and the patient database was compiled. Data analysis was performed using simple statistical calculations.
Positive ascitic fluid bacterial culture was in 29.2% (24 patients), while 70.7% (58 patients) had culture-negative ascites and peritonitis. The most frequent bacterial species was E. coli, present in 54.1% (13 patients). Mortality was 8.5% (7 patients) due to progressive liver failure. Recurrence of ascites and peritonitis at 1 month was 6.0% (5 patients).
The laparoscopic approach in spontaneous bacterial peritonitis in patients with decompensated liver cirrhosis allows for better sanitation of the abdominal cavity, improves peritoneal absorption, and deserves establishment as clinical practice for patients with ascites and peritonitis and cirrhosis.