Henz S, Bühler H, Pirovino M
Medizinische Klinik, Kantonsspital Olten.
Schweiz Med Wochenschr. 1995 Dec 9;125(49):2379-86.
Spontaneous bacterial peritonitis (SBP) is a frequent complication of cirrhosis with ascites. As clinical symptoms are often mild or lacking, the condition may not be perceived in otherwise severely ill patients. This study focuses on diagnostic and prognostic aspects in 25 patients with 26 episodes of SBP. A microbiological diagnosis was established in 18 patients by positive culture of ascitic fluid or positive gram stain. In 8 episodes the diagnosis was presumed on the basis of an elevated polymorphonuclear leukocyte (PMN) count in the ascitic fluid (> 250 PMN/microliters). The mean (+/- SD) age of the 11 women and 14 men was 55 +/- 14 years; 16 were attributed to Child grade C, 9 to Child grade B liver dysfunction. In 19 cases, cirrhosis was confirmed histologically. The underlying liver disease was Laennec's cirrhosis in 13 cases, hepatitis-B virus associated chronic liver disease in 7 cases and primary biliary cirrhosis in 2 cases. At the time of diagnosis, 6 of 25 patients had no fever, 13 of 25 patients had no abdominal pain, 10 of 24 patients showed no abdominal tenderness upon palpation and 5 of 26 patients had no fever or abdominal pain. 17 of 26 patients showed signs of portosystemic encephalopathy. The total white blood cell count in the ascitic fluid was 3627 +/- 3978/microliters with 71 +/- 29% polymorphonuclear cells in the group with microbiologically proven peritonitis and 5105 +/- 2860 cells/microliters (80 +/- 13%) in the group with negative ascitic fluid culture, respectively. Gram stains were positive in 8 cases and culture in 16 of 25 patients. E. coli was cultured in 8 episodes and Str. pneumoniae in two. In-hospital mortality was 61% in the group with microbiologically proven peritonitis and 14% in the group with negative ascitic fluid culture (p = 0.062); 6-month mortality rate was 78% and 86% respectively (p = 0.91). Prognosis was worse in patients Child grade C (p = 0.027), in patients lacking symptoms or signs of peritoneal irritation (p = 0.017), in patients with septic shock (p = 0.018) and in patients with elevated serum-creatinin levels at the time of diagnosis (p = 0.05). SBP is a treatable complication with high mortality of advanced liver disease. Clinical manifestations may be non-specific or absent. We recommend that diagnostic paracentesis be performed in all patients with cirrhosis and ascites if their clinical condition is rapidly worsening.
自发性细菌性腹膜炎（SBP）是肝硬化腹水患者常见的并发症。由于临床症状往往较轻或缺乏，在其他病情严重的患者中可能未被察觉。本研究聚焦于25例发生26次SBP的患者的诊断和预后情况。18例患者通过腹水培养阳性或革兰氏染色阳性确诊。8次发作是根据腹水多形核白细胞（PMN）计数升高（>250个PMN/微升）推测诊断。11名女性和14名男性的平均（±标准差）年龄为55±14岁；16例为Child C级，9例为Child B级肝功能障碍。19例经组织学证实为肝硬化。基础肝病为酒精性肝硬化13例，乙型肝炎病毒相关性慢性肝病7例，原发性胆汁性肝硬化2例。诊断时，25例患者中有6例无发热，25例患者中有13例无腹痛，24例患者中有10例触诊时无腹部压痛，26例患者中有5例无发热或腹痛。26例患者中有17例有门体性脑病的体征。腹水总白细胞计数在微生物学证实为腹膜炎的组中为3627±3978/微升，多形核细胞占71±29%，腹水培养阴性组为5105±2860个细胞/微升（80±13%）。革兰氏染色8例阳性，25例患者中16例培养阳性。8次发作培养出大肠杆菌，2次培养出肺炎链球菌。微生物学证实为腹膜炎的组院内死亡率为61%，腹水培养阴性组为14%（p = 0.062）；6个月死亡率分别为78%和86%（p = 0.91）。Child C级患者（p = 0.027）、缺乏腹膜刺激症状或体征的患者（p = 0.017）、发生感染性休克的患者（p = 0.018）以及诊断时血清肌酐水平升高的患者（p = 0.05）预后较差。SBP是晚期肝病中一种可治疗但死亡率高的并发症。临床表现可能不具特异性或不存在。我们建议，所有肝硬化腹水患者如果临床病情迅速恶化，应进行诊断性腹腔穿刺术。
