MINISTRY OF EDUCATION
AND TRAINING
DEPARTMENT OF DEFENSE
THE CLINICAL RESEARCH INSTITUTE OF MEDICINE SCIENCE 108
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VU THANH TRUNG
THE CLINICAL, LABORATORIAL FEATURES AND
TREATMENT OF SPONTANEOUS BACTERIAL
PERITONITIS IN CIRRHOSIS
Subject: Gastroenterology
Code: 62.72.01.43
SUMMARY OF THE THESIS
HANOI - 2019
THIS STUDY IS COMPLETED
CLINICAL RESEARCH INSTITUTE OF MEDICINE SCIENCE 108
Science instructors:
1. Prof.Dr. MAI HONG BANG
2. Assoc. PHAN QUOC HOAN
Reviewer 1:
Reviewer 2:
Reviewer 3:
The thesis has been defended before the Institute of Dissertation thesis
at the Institute: 14 hours on September 11, 2018
The thesis can be found at:
1. National library
2. Library of the Clinical Medicine Research Institute 108
1
INTRODUCTION AND AIMS
Cirrhosis is the common end-stage disease of a variety of chronic
hepatitis. Worldwide, cirrhosis is thought to be the leading cause of
death in the 14th. There are many types of infections that occur in
cirrhosis and spontaneous bacterial peritonitis (SBP) is a severe and
frequent complication. The incidence of SBP in cirrhotic patients with
ascites is hospitalized from 10% -30%. The main causes of viral
hepatitis are Gram-negative bacteria, commonly known as E. coli,
Klebsiella sp., Enterobacter sp., And some Gram-positive bacteria:
Streptococci, Enterococci. Ascites analysis plays an important role,
determining the diagnosis and direction for treatment of SBP. The
diagnosis of SBP is based on the number of neutrophil counts (> 250
cells / mm3) or / and positive bacteriuria. However, the pathogenic
strains of bacterial pathogens are frequently altered, with increasing
antibiotic resistance of bacterial strains, which makes treatment of SBP
more difficult in patients with cirrhosis. In Vietnam, there are not many
studies on SBP.
Targets:
+ Description of clinical characteristics, subclinical disease
Peritonitis infections spontaneously.
+ Results of identification of bacteria and antibiotics on the
isolates of bacteria.
+ Evaluation of the results of treatment of peritonitis infection
spontaneously in patients with cirrhosis.
NEW CONTRIBUTION OF THE THESIS
The thesis has scientific and practical implications, which are
related to many disciplines such as intestinal digestion, infectivity and
microbiology. In clinical practice, the topic describes the main features
of spontaneous abdominal infections in patients with cirrhosis of the
ascites, the pathogenic strains, the antibiotic sensitivity assessment
Bacteria isolates and evaluated the efficacy of the regimen starting with
two antibiotics: Cefotaxime 4g / day + Ciprofloxacin 1g / day, effective
treatment with antibiotics and experience.
STRUCTURE OF THE THESIS
The dissertation has 121 pages, including: research introduction
and objectives (2 pages), overview (36 pages), subjects and methods
(25 pages), research results (27 pages) Comment (29 pages), conclusion
(2 pages). The thesis has 32 tables, 12 charts, 15 images, 189 references
including 9 Vietnamese documents and 180 English documents.
2
Chapter I
OVERVIEW DOCUMENT
1.1. History
Spontaneous peritonitis was first described in German medical
journals in 1907 by Krencker E. Subsequently, the findings on SBP
were described in France by: Brule M 1939), Cachin M (1955) and
Calori J (1958). However, in 1964, Harold O. Conn introduced the term:
spontaneous bacterial peritonitis (SBP), and this term has been used so
far. The concept of spontaneous peritonitis (SBP) refers to the bacterial
ascites infection, but does not detect the pathway of bacteria and is
capable of medical treatment.
1.2. Epidemiology
In patients with cirrhosis, the mortality rate is related to bacterial
complications of 30-50%. Frequency of infection is 5-7% for external
patients and accounts for 32-34% for internal patients and even up to 45%
for patients with complications of gastrointestinal bleeding. Common
infections in patients with cirrhosis are: Peritonitis, autoimmune
peritonitis - SBP (25% -31%), urinary tract infections - UTI (20% -
25%), pneumonia (15% -21% %) sepsis- SEPSIS (12%), soft tissue
infections (11%) ...
About 75% of cases of cirrhosis in cirrhotic patients are Gram-
negative bacteria, such as Escherichia coli, Klebsiellaspp,
Enterobacterspp, P. aeruginosa, Vibrio spp, Aeromonas spp. While
Gram positive accounts for 20.2% and anaerobic species accounts for
3.2%. Recently, the prevalence of gram-positive bacterial infections has
been on the rise, according to a study by Marco Fiore et al.
1.3.The pathogenesis of SBP
Conn H.O's BT (bacterial translocation) approach in the 1960s was
the basis for the pathogenesis of SBP.
Today, the mechanism of pathogenesis of SBP is better understood
with the participation of many factors:
Form Factors:
+ Changes in anatomic structure and portal vein pressure.
+ Immune disorders: site and system.
_ Excessive growth of bacteria.
+ Movement path of bacteria:
+ Lymphatic drainage.
+ Blood sugar.
3
+ The way of smuggling.
Factors supporting the movement of bacteria:
Environment, nutrition, metabolism, stress, drug use PPIs ...
1.4. Clinical presentations
The main clinical symptoms of SBP include:
- Symptoms of total or local peritonitis.
- infection syndrome.
- Impaired liver function syndrome.
- Hepatic encephalopathy (HE).
- Kidney
- Hepatic renal syndrome (HRS).
- Shock
- Gastrointestinal bleeding.
In particular, asymptomatic SBP, about 1.5% -3.5%.
1.5. Diagnostic tests for SBP
1.5.1. Microbiologic testings
Today, screening facilities use aseptic culture in blood culture
bottles on bacterial culture systems and automatic bacteriostatic
identification. This method has been shown to have a higher positive
rate of implantation than conventional implantation.
1.5.2. Methods of counting the polymorphonuclearneutrophilic
leukocyte (PMN)
The method of counting PMN cells in ascites is crucial to the
diagnosis of SBP. Multi-core counting methods used include:
The classic method of counting white blood cells by Giemsa
staining and microscopic counts is subjective and time consuming.
The automatic / semi-automatic hematopoieticcounting
method has the advantage of fast and accurate and indicates the
percentage of white blood cells in ascites, which makes it easy to
calculate the white blood cell count accurately. PMN = total white
blood cell x% Neutrophil. The SBP is diagnosed valid when the
number of PMN cells> 250 / μL. Automatic blood counting methods
have been shown to have a sensitivity and specificity of 94% and 100%,
respectively. Negative predictive value is 99.1%, positive predictive
value is 100%.
Urine reagent strip testings (Multistix 8SG urine test). The scientific
basis of this method is to detect indirectly leukocyte esterase-leukocyte
esterase cells secreted by these cells. Enzyme esterase activates the color
indicator on the test and performs colorimetry on the machine. This