The Most Recent Progression of Ascites and SBP

Ascites is a common complication of cirrhosis, and is associated with a significant increased portal pressure. The mortality rate in cirrhotic patients hospitalized with ascites is approximately 40% at 2 years. Ascites that is refractory to diuretic therapy requires either repeated large-volume paracentesis combined with plasma volume expansion. Today, Professor Anuchit Chutaputti from Phramongkutklao Hospital, Bangkok, Thailand, expounded on the SBP as a common and severe complication in patients with cirrhotic ascites. SBP is a bacterial infection of ascitic fluid which arises in the absence of any other source of sepsis within the peritoneums. Numerous studies suggest that 8%~27% of hospitalized patients with cirrhosis and ascites have SBP, with in-hospital mortality ranging from 20%~40%. Patients with an ascitic fluid polymorphonuclear leukocyte count of greater than 250/mm3 should be considered to have SBP regardless of ascitic fluid culture results. The condition must be diagnosed and treated promptly. Hence, the use of urine reagent strips for diagnosis of SBP by detection of leukocyte esterase activity, by colorimetric method, in the ascitic fluid has been suggested. Recently, a comparison between the reagent strip results and the corresponding cytological and bacteriological analysis of the ascitic fluid. The sensitivity varies (45%~100%) depending on the type of the strip and the cut-off used for diagnosis. However, regarding the low sensitivity and the high risk of false negatives, especially in patients with SBP and low polymorphonuclear count, the reagent strip test cannot be recommended for the diagnosis of SBP.

Professor Chutaputti emphasized that empirical antibiotic therapy must be initiated immediately after the diagnosis of the infection was made. Since Gram-negative aerobic bacteria from the family of Enterobacteriaceae and non-enterococcal Streptococcus spp. are the most common causative organisms, the initial empirical antibiotic therapy of SBP should cover these organisms. In one third of patients with SBP, renal impairment develops despite treatment of their infection with non-nephrotoxic antibiotics. This deterioration of renal function is the most sensitive predictor of in-hospital mortality. The result of a prospective study shows that the development of bacterial-induced renal failure in patients with cirrhosis and ascites is related to the model for end-stage liver disease (MELD) score, and to both the severity and the lack of resolution of the infection.

He also pointed out that the risk of developing SBP was greater in those with a coexisting gastrointestinal hemorrhage, a previous episode of SBP or low ascitic protein levels. Antibiotic prophylaxis should be administered to cirrhotic patients with gastrointestinal hemorrhage, independently of the presence or absence of ascites to prevent bacterial infection and improve survival. In cirrhotic patients without a past history of SBP and in whom ascitic fluid protein concentration is less than 10 g/L, primary antibiotic prophylaxis reduces the incidence of SBP, nevertheless, there is no improvement in survival. However, it is justified that antibiotic prophylaxis should be considered in patients with low-protein ascites or bilirubin greater than 2.5 mg/dL during hospitalization. Cirrhotic patients with more advanced disease have greater risk to develop SBP. Since the 2-year survival of cirrhosis with SBP is grim, liver transplantation is the only option to improve survival.