- Email: [email protected]
Predictive factors of spontaneous bacterial peritonitis: univariate and multivariate analysis
Poster Sessions
54
AT1 receptor antagonists on arterial and portal pressure, kidney function and vascular contractility have never been evaluated. Methods: 40 rats with biliary cirrhosis were treated with 10 mg/KG/d Losartan (C10), 0.5 mg/KG/d Losartan (C0.5) or solvent (C) for 1 week. 10 sham operated rats served as controls (S). Hemodynamics, kidney function and aortic contractility on alpha-adrenoceptor stimulation were assessed. Results: 10 and 0.5 mg Losartan/kg/d reduced portal pressure in cirrhotic rats (C: 19.4 + 0.9; C10:15.2 + 0.3; C0.5:15.2 + 1.3 mmHg; p < 0.01). However, 10 mg Losartan/kg/d reduced arterial pressure (C: 102 + 4; C10: 64 + 3 mmHg, p < 0.01), diuresis (C: 15 + 1.6; C10:0.06 + 0.03 mud, p < 0.01), creatinine clearance (C: 1.3 + 0.1; C10:0.3 + 0.1 ml/min, p < 0.01) and sodium excretion (C: 0.8 + 0.08; C10:0.06 + 0.03 mval/d, p < 0.01). In contrast, 0.5 mg Losartan/kg/d increased diuresis (to 23 + 3.2 mud; p < 0.01) and sodium excretion (to 1.15 + 0.08 reval/d; p < 0.05) without altering arterial pressue (109 + 6 mmHg). Furthermore, 0.5 mg Losartan/kg/d significantly improved aortic contractility (Emax in g: S: 2.4 +0.3;C: 1.3 +0.1; C0.5:1.7 +0.1; p <0.05). Discussion: Low-dose Losartan reduces portal pressure and improves kidney function possibly by an improved vascular responsiveness to alphaadrenoceptor stimulation counterbalancing the hypotensive effect of Losartan, which, however is deleterious with high doses.
~-]
COMPARISON OF QUANTITATIVELIVER FUNCTION TESTS AND COMMON PROGNOSTIC SCORES IN PATIENTSWITH PRIMARY BILIARY CIRRHOSIS
Christoph Herold, Christine Deynet, Marion Ganslmayer, Eckhart G. Hahn, Detlef Schuppan. Medical Department L University of
Erlangen, Erlangen, Germany Aim: PBC, a slow progredient hepatopathy finally leads to cirrhosis. We investigated if quantitative liver function tests (QTLF) and the serum level of PIIINP provide additional informations compared to the established prognostic scores. Methods: Serum level of PIIINP and further relevant hepatic parameteres, histological staging and QTLF were assessed in 34 patients receiving ursodeoxycholic acid at timepoint 0 and after 2 years. For QTLF we performed aminopyrine breath test (ABT), galactose elimination capacity (GEC), sorbitol (SCI) - and indocyaninegreen clearance (ICG). All parameters were compared to the Christensen prognostic scores (CPS) I and II as well as to the Mayo score. 15 age-matched healthy adults served as controls. Results: Bilirbubin, IgM- and PIIINP-levels were elevated at both time poimts, while albumine and Quick's test were in normal range. Clinical parameters (ascites, cholestasis), histological staging and the CPS II worsened during the observation period, while QTLF, CPS I and the Mayo Score did not change significantly.
ABT ICG CPS I CPS lI Mayo
0 months 0.53 4- 0.28 0.17 4- 0.12 -1.14 -4- 1.55 -0.80 + 1.85 3.74 4- 1.29
24 months 0.53 -4-0.26 0.16 4. 0.12 -0.88 + 1.51 -0.46 4- 1.83 3.91 4- 1.26
Controls 0.79 + 0.09 0.19 + 0.05
Conclusion: 1) Neither QTLF nor PIIINP indicated a progression of PBC. 2) Execlusively the CPS II changed significantly. 3) QTLF cannot evaluate the prognosis of PBC sufficiently. 4) CPS II seems to be superior to CPS I and Mayo Score within an time period of two years.
~
PROSPECTIVE RANDOMIZED TRIAL OF INTRAVENOUS CIPROFLOXACIN FOR PREVENTION OF BACTERIAL INFECTION IN CIRRHOTIC PATIENTSWITH VARICEAL BLEEDING
Sung Noh Hong, Min Kyu Rhyu, Jun Hyuk Lee, Moon Suk Choi, Kwang Chul Koh, Young Ho Kim, Jae J. Kim, Sung Woon Paik, Jong Chul Lee, Kwu Wan Choi. Division of Gastroenterology,
Department of lnternal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Object: In cirrhotic patients with variceal bleeding, bacterial infections are frequent. Previously we found that majority of bacterial infections occurred within 72 hours after bleeding. Up to date, the trials of oral antibiotic prophylaxis for bacterial infection of bleeding cirrhotic patients are focused on selective intestinal decontamination. However, immediate administration of antibiotics via oral route or naso-gastric tube may be difficult in some cirrhotic patients with active bleeding. Intravenous antibiotics could be administrated easily despite of the cirrhotic patients with active bleeding. The aims of the study were to assess the efficacy of short-term use (for 3 days) of prophylactic intravenous ciprofloxacin for bacterial infection prospectively in cirrhotic patients with variceal bleeding. Method: 36 cirrhotic patients with esophageal variceal bleeding were randomized into 2 group: Treatment groups (n = 16) received the intravenous ciprofloxacin 200 mg iv q 12 hours for 3 days and control groups (n = 20) didn't. Parameters of outcome are incidence of bacterial infection in 7 days, hospital stay and cost. Result: Incidence of bacterial infections was significantly higher in patients from control group than in patients from treatment group (45% vs 13%; p value was 0.039). Also, the hospital stay and cost were significantly higher in patients from control group than in patients from treatment group (14.2 vs 20.4, 26575 vs 39385; p value were less than 0.001 respectively) Conclusion: Use of intravenous ciprofloxacin for 3 days was not only effective in prevention of bacterial infection but also cost-effective in cirrhotic patients with variceal bleeding.
[-~]
PREDICTIVE FACTORS OF SPONTANEOUS BACTERIAL PERITONITIS: UNIVARIATEAND MULTIVARIATEANALYSIS
Razvan Iacob, Speranta Iacob, Mircea Diculescu. Fundeni
Gastroenterology and Hepatology Center, Bucharest, Romania Aim: To establish the importance of predictive factors of spontaneous bacterial peritonitis (SBP) occurrence and its prophylactic means, because SBP is a frequent and severe complication of cirrhosis (mortality rate 20-40%). Methods: A case-control study, which included 277 cirrhotic patients diagnosed and treated in Fundeni Gastroenterology and Hepatology Center was performed. 136 patients had SBP and variants (bacterascites and neutrocitic culture-negative ascites) and 141 had uncomplicated ascites. The association between the analysed predictive factors and occurrence of SBP was assessed based on the odds ratio (OR) and the level of statistical significance based on the confidence interval for OR and the p value (<0.05) associated to the chi-squared test in contingency tables. Multivariate analysis was performed by logistic regression using NCSS 2000. Results: As predictive factors statistically significant associated with the occurrence of SBP were detected: Child-Pugh C class (OR = 3.83, p < 0.001), the presence of gastrointestinal bleeding on admittence (OR = 2.39, p = 0.003), denutrition (OR = 1.89, p = 0.014), trombocytes < 98000/mm 3 (OR = 2.18, p = 0.001), protrombinic activity < 50% (OR = 3.32, p < 0.001), low serum cholesterol levels (< 130 mg/dl) (OR = 2.54, p < 0.001), serum albumin < 3 g/dl (OR = 2.40, p < 0.001), ascitic fluid albumin < 1 g/dl (OR = 3.96, p < 0.001), ascitic fluid total protein < 1 g/dl (OR = 5.72, p < 0.001), portal vein diameter > 10 mm (OR = 3.83, p < 0.001), esophageal varices grade 4 (OR = 2.57, p = 0.006). The protective factors for the occurrence of SBP were: paracentesis > 51 and plasma volume expansion with albumin or dextran 70 (OR = 0.45, p = 0.008), selective
Category 2: Cirrhosis and its complications, pathophysiology and clinical aspects bowel decontamination with norfloxacin (OR = 0.27, p = 0.002). Multivariate analysis suggests that the following factors have the most important role in the occurrence or non-occurrence of SBP: Child-Pugh class, ascitic fluid albumin, ascitic fluid total protein, portal vein diameter, protrombinic activity and plasma volume expansion with albumin or dextran 70. Conclusions: Cirrhotic patients in Child-Pugh C class and with low ascitic fluid total protein have the highest risk to develop SBP. Our data have shown that the most important predictive factors for occurrence of SBP belong to the hepatocellular failure and the portal hypertension has only an adjacent role.
I-~
COMPLIANCE OF CIRRHOTIC PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS TO PROPHYLACYIC ANTIBIOTIC THERAPY: INFLUENCE ON RECURRENCE
Iulia Simionov, Liana Gheorghe, Cristian Gheorghe, Roxana Vadan.
Results: TIPSS insertion reduced portal pressure (p < 0.05) and resulted in a significant increase in CBF: 53.9 (4-3.4) to 68.3 (4-3.5) ml/100 g/min (p < 0.05) and cardiac output and a reduction in systemic vascular resistance (p < 0.05 for both). There was no significant change in whole body production of arginine and citrulline: 701 (4-100) to 740 (4-117) and 209 (-I-18) to 195 (4-15) nmol/kg bw/min) respectively. TIPSS insertion resulted in a significant increase in whole body NO production: 40.6 (4-11.2) to 71.2 (4-15.7) nmol/kg bw/min) (p < 0.05). Conclusion: This is first study that quantitates the rate of NO production in patients with cirrhosis and clearly shows that TIPSS insertion results in peripheral and cerebral vasodilation, and increased whole body production of NO. The cause of this increase in NO production is unknown but is likely to be responsible for the haemodynamic disturbances that follow TIPSS insertion.
~-']
Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania Background: Spontaneous bacterial peritonitis (SBP) represents, an important cause of morbidity and mortality in patients with hepatic cirrhosis (HC). It has been established that prophylactic antibiotic therapy significantly reduces the development of SBP in patients with HC and prior SBP episode. Aim: This study was design to evaluate the compliance of SBP patients to profilactic antimicrobial therapy and the efficacy of this regimen on the PBS recurrence. Methods: 106 patients diagnosed in our unit with HC and SBP, who received an indication for prophylactic antibiotic therapy according to conventional guidelines, had been followed at 3 month interval for 18 months. Patients who didn't complete 2 consecutive examinations were excluded, so 84 patients were enrolled in the study. Results: 59 out of 84 patients (58 males and 26 females mean age 55 years, range 16 to 76; Child Pugh classification A:B:C = 1:34:49; etiology: viral 37 pts., alcoholic 19 pts., and mixed 28 pts.) were compliant to prophylactic antimicrobial therapy (compliance 70.2%). At subsequent examinations only 10 (16.95%) compliant patients presented SBP (6 neutrocytic ascites and 4 positive cultures); out of 25 noncompliant pts., 17 (68%) presented SBP (15 neutrocytic ascites and 2 with positive cultures); p = 0.00001 (Fisher Exact Test, Yates Corrected). Conclusion: Patients compliance with prophylactic therapy plays a major role in the recurrence of subsequent SBP episodes.
~ 7 8 7 INCREASED CEREBRAL AND PERIPHERAL VASODILATION, AND WHOLE BODY NITRIC OXIDE (NO) PRODUCTION AFTER INSERTION OF A TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT-SHUNT (TIPSS) IN PATIENTS WITH CIRRHOSIS Raiiv Jalan 1, Steven Olde Damink 2, Nicholaas Deutz 2, Doris Redhead 3, Alistair Lee 3. l lnstitute of Hepatology, UCL, London; SRoyal Infirmary,
Edinburgh, UK,"2Dept. Surgery, Academic Hospital, Maastricht, Netherlands Background and Hypothesis: This study tests the hypothesis that the increase in CBF observed after TIPSS insertion is the result of increased whole body NO production. Methods: 9 patients (Pugh score: 10.2 (4-1.0) undergoing emergency TIPSS placement for control of variceal bleeding were studied. CBF and cardiovascular haemodynamics were measured before and after TIPSS insertion. Whole body NO production was measured using infusion of the stable isotopes L-[guanidine-15N2] arginine and L-[ureido-13C; 5,52H2] citrulline. Enrichments were measured using an LC-MS system. The whole-body rate of production of arginine, citrulline and NO were calculated (PNAS 1996, 93:11460--5).
55
USEFULLNESS OF ROUTINE ANALYSIS OF ASCITES FLUID AT THE TIME OF THERAPEUTIC PARACENTESIS IN ASYMPTOMATIC CIRRHOTIC OUT PATIENTS
Jean Francois Cadranel I , Remy Romney 1, Philippe Mathurin 2, Nathalie Ganne-Carrie 3, Chantai Halimi 4, Abdel Medini 5, Jean Claude Chaput 2, P. Cruand 3, Arnaud Panwels s , Patrice Lemaitre I .
1Hospital Laennec, Creil; 2Hospital Antoine Beclere, Clamart; 3Hospital Jean Verdier, Bondy; 4Hospital Senlis, Senlis; 5Hospital Gonesse, Gonesse, France It is recommanded to perform exploratory paracenteses in cirrhotic patient because of frequency and severity of spontaneous bacterial peritonitis (SBP) and culture negative neutrocytic ascites (CNNA). The aims of this prospective study were 1) to evaluate the prevalence of SBP, CNNA and bacterascites (B) in asymptomatic cirrhotic ascitic outpatients 2) to determine if, in these patients, suppression of EP could be safe and cost effective. Methods: during a 12 months period, 270 consecutive therapeutic paracenteses (P) were performed in 67 consecutive patients. Child-Pugh class were B in 60% and C in 33%. A medical history and exam was obtained at each P and subjects with suspicion of infection were excluded from the study. Ascites fluid protein concentration (APC), ascites fluid cell count (AFC) and bedside inoculation into blood culture bottles were performed at time of E Results: Mean age was 59 + 9 years, 59 (88%) had alcoholic cirrhosis, 52 (77.6%) received diuretics, 25 (37.3%) received norfloxacine. The number and volume of P were 5 -4- 4 and 5.5 4- 3 liters; P were compensated with albumin in 59.6%. APC was 17.5 4- 8.6 g/l, AFC and polynuclear percent were 127.7 4- 155/mm 3 and 4.7 4- 11%. B were observed in 10 (3.7%) P with commensal germs. No patient had SBP nor CNNA. Conclusions: 1) the prevalence of SBP and CNNA in asymptomatic cirrhotic outpatients with ascites is near 0%. 2) Suppression of EP, based on careful clinical and biological exam could be safe and led to a 5300 euros economy per 100 LVP.
I-~
OLFACTORY FUNCTIONS IN PATIENTS WITH HEPATIC CIRRHOSIS AND WITHOUT OVERT HEPATIC ENCEPHALOPATHY
Jasna Jovic l, Nebojsa Jovic 1,2. 1 Clinicfor Gastroenterology, Military Medical Academy, Belgrade; 2 Department of Neurology and Psychiatry for Children and Youth, Medical School Belgrade, Yugoslavia Olfaction play a significant if often subtle role in nutrition not only, but in human beha-viour and ability for interaction with environment. Liver diseases are important aetiology among conditions associated with chemosensory disturbances. Olfactory functions were assessed in a group of 28 patients aged 37 to 70 years (mean 52.1) with proven hepatic cirrhosis. Alcoholic cirrhosis was noted in 16, till non-alcoholic (after hepatitis B, PBC) aetiology was diagnosed in remaining 12 patients. Modified Child's
54
AT1 receptor antagonists on arterial and portal pressure, kidney function and vascular contractility have never been evaluated. Methods: 40 rats with biliary cirrhosis were treated with 10 mg/KG/d Losartan (C10), 0.5 mg/KG/d Losartan (C0.5) or solvent (C) for 1 week. 10 sham operated rats served as controls (S). Hemodynamics, kidney function and aortic contractility on alpha-adrenoceptor stimulation were assessed. Results: 10 and 0.5 mg Losartan/kg/d reduced portal pressure in cirrhotic rats (C: 19.4 + 0.9; C10:15.2 + 0.3; C0.5:15.2 + 1.3 mmHg; p < 0.01). However, 10 mg Losartan/kg/d reduced arterial pressure (C: 102 + 4; C10: 64 + 3 mmHg, p < 0.01), diuresis (C: 15 + 1.6; C10:0.06 + 0.03 mud, p < 0.01), creatinine clearance (C: 1.3 + 0.1; C10:0.3 + 0.1 ml/min, p < 0.01) and sodium excretion (C: 0.8 + 0.08; C10:0.06 + 0.03 mval/d, p < 0.01). In contrast, 0.5 mg Losartan/kg/d increased diuresis (to 23 + 3.2 mud; p < 0.01) and sodium excretion (to 1.15 + 0.08 reval/d; p < 0.05) without altering arterial pressue (109 + 6 mmHg). Furthermore, 0.5 mg Losartan/kg/d significantly improved aortic contractility (Emax in g: S: 2.4 +0.3;C: 1.3 +0.1; C0.5:1.7 +0.1; p <0.05). Discussion: Low-dose Losartan reduces portal pressure and improves kidney function possibly by an improved vascular responsiveness to alphaadrenoceptor stimulation counterbalancing the hypotensive effect of Losartan, which, however is deleterious with high doses.
~-]
COMPARISON OF QUANTITATIVELIVER FUNCTION TESTS AND COMMON PROGNOSTIC SCORES IN PATIENTSWITH PRIMARY BILIARY CIRRHOSIS
Christoph Herold, Christine Deynet, Marion Ganslmayer, Eckhart G. Hahn, Detlef Schuppan. Medical Department L University of
Erlangen, Erlangen, Germany Aim: PBC, a slow progredient hepatopathy finally leads to cirrhosis. We investigated if quantitative liver function tests (QTLF) and the serum level of PIIINP provide additional informations compared to the established prognostic scores. Methods: Serum level of PIIINP and further relevant hepatic parameteres, histological staging and QTLF were assessed in 34 patients receiving ursodeoxycholic acid at timepoint 0 and after 2 years. For QTLF we performed aminopyrine breath test (ABT), galactose elimination capacity (GEC), sorbitol (SCI) - and indocyaninegreen clearance (ICG). All parameters were compared to the Christensen prognostic scores (CPS) I and II as well as to the Mayo score. 15 age-matched healthy adults served as controls. Results: Bilirbubin, IgM- and PIIINP-levels were elevated at both time poimts, while albumine and Quick's test were in normal range. Clinical parameters (ascites, cholestasis), histological staging and the CPS II worsened during the observation period, while QTLF, CPS I and the Mayo Score did not change significantly.
ABT ICG CPS I CPS lI Mayo
0 months 0.53 4- 0.28 0.17 4- 0.12 -1.14 -4- 1.55 -0.80 + 1.85 3.74 4- 1.29
24 months 0.53 -4-0.26 0.16 4. 0.12 -0.88 + 1.51 -0.46 4- 1.83 3.91 4- 1.26
Controls 0.79 + 0.09 0.19 + 0.05
Conclusion: 1) Neither QTLF nor PIIINP indicated a progression of PBC. 2) Execlusively the CPS II changed significantly. 3) QTLF cannot evaluate the prognosis of PBC sufficiently. 4) CPS II seems to be superior to CPS I and Mayo Score within an time period of two years.
~
PROSPECTIVE RANDOMIZED TRIAL OF INTRAVENOUS CIPROFLOXACIN FOR PREVENTION OF BACTERIAL INFECTION IN CIRRHOTIC PATIENTSWITH VARICEAL BLEEDING
Sung Noh Hong, Min Kyu Rhyu, Jun Hyuk Lee, Moon Suk Choi, Kwang Chul Koh, Young Ho Kim, Jae J. Kim, Sung Woon Paik, Jong Chul Lee, Kwu Wan Choi. Division of Gastroenterology,
Department of lnternal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Object: In cirrhotic patients with variceal bleeding, bacterial infections are frequent. Previously we found that majority of bacterial infections occurred within 72 hours after bleeding. Up to date, the trials of oral antibiotic prophylaxis for bacterial infection of bleeding cirrhotic patients are focused on selective intestinal decontamination. However, immediate administration of antibiotics via oral route or naso-gastric tube may be difficult in some cirrhotic patients with active bleeding. Intravenous antibiotics could be administrated easily despite of the cirrhotic patients with active bleeding. The aims of the study were to assess the efficacy of short-term use (for 3 days) of prophylactic intravenous ciprofloxacin for bacterial infection prospectively in cirrhotic patients with variceal bleeding. Method: 36 cirrhotic patients with esophageal variceal bleeding were randomized into 2 group: Treatment groups (n = 16) received the intravenous ciprofloxacin 200 mg iv q 12 hours for 3 days and control groups (n = 20) didn't. Parameters of outcome are incidence of bacterial infection in 7 days, hospital stay and cost. Result: Incidence of bacterial infections was significantly higher in patients from control group than in patients from treatment group (45% vs 13%; p value was 0.039). Also, the hospital stay and cost were significantly higher in patients from control group than in patients from treatment group (14.2 vs 20.4, 26575 vs 39385; p value were less than 0.001 respectively) Conclusion: Use of intravenous ciprofloxacin for 3 days was not only effective in prevention of bacterial infection but also cost-effective in cirrhotic patients with variceal bleeding.
[-~]
PREDICTIVE FACTORS OF SPONTANEOUS BACTERIAL PERITONITIS: UNIVARIATEAND MULTIVARIATEANALYSIS
Razvan Iacob, Speranta Iacob, Mircea Diculescu. Fundeni
Gastroenterology and Hepatology Center, Bucharest, Romania Aim: To establish the importance of predictive factors of spontaneous bacterial peritonitis (SBP) occurrence and its prophylactic means, because SBP is a frequent and severe complication of cirrhosis (mortality rate 20-40%). Methods: A case-control study, which included 277 cirrhotic patients diagnosed and treated in Fundeni Gastroenterology and Hepatology Center was performed. 136 patients had SBP and variants (bacterascites and neutrocitic culture-negative ascites) and 141 had uncomplicated ascites. The association between the analysed predictive factors and occurrence of SBP was assessed based on the odds ratio (OR) and the level of statistical significance based on the confidence interval for OR and the p value (<0.05) associated to the chi-squared test in contingency tables. Multivariate analysis was performed by logistic regression using NCSS 2000. Results: As predictive factors statistically significant associated with the occurrence of SBP were detected: Child-Pugh C class (OR = 3.83, p < 0.001), the presence of gastrointestinal bleeding on admittence (OR = 2.39, p = 0.003), denutrition (OR = 1.89, p = 0.014), trombocytes < 98000/mm 3 (OR = 2.18, p = 0.001), protrombinic activity < 50% (OR = 3.32, p < 0.001), low serum cholesterol levels (< 130 mg/dl) (OR = 2.54, p < 0.001), serum albumin < 3 g/dl (OR = 2.40, p < 0.001), ascitic fluid albumin < 1 g/dl (OR = 3.96, p < 0.001), ascitic fluid total protein < 1 g/dl (OR = 5.72, p < 0.001), portal vein diameter > 10 mm (OR = 3.83, p < 0.001), esophageal varices grade 4 (OR = 2.57, p = 0.006). The protective factors for the occurrence of SBP were: paracentesis > 51 and plasma volume expansion with albumin or dextran 70 (OR = 0.45, p = 0.008), selective
Category 2: Cirrhosis and its complications, pathophysiology and clinical aspects bowel decontamination with norfloxacin (OR = 0.27, p = 0.002). Multivariate analysis suggests that the following factors have the most important role in the occurrence or non-occurrence of SBP: Child-Pugh class, ascitic fluid albumin, ascitic fluid total protein, portal vein diameter, protrombinic activity and plasma volume expansion with albumin or dextran 70. Conclusions: Cirrhotic patients in Child-Pugh C class and with low ascitic fluid total protein have the highest risk to develop SBP. Our data have shown that the most important predictive factors for occurrence of SBP belong to the hepatocellular failure and the portal hypertension has only an adjacent role.
I-~
COMPLIANCE OF CIRRHOTIC PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS TO PROPHYLACYIC ANTIBIOTIC THERAPY: INFLUENCE ON RECURRENCE
Iulia Simionov, Liana Gheorghe, Cristian Gheorghe, Roxana Vadan.
Results: TIPSS insertion reduced portal pressure (p < 0.05) and resulted in a significant increase in CBF: 53.9 (4-3.4) to 68.3 (4-3.5) ml/100 g/min (p < 0.05) and cardiac output and a reduction in systemic vascular resistance (p < 0.05 for both). There was no significant change in whole body production of arginine and citrulline: 701 (4-100) to 740 (4-117) and 209 (-I-18) to 195 (4-15) nmol/kg bw/min) respectively. TIPSS insertion resulted in a significant increase in whole body NO production: 40.6 (4-11.2) to 71.2 (4-15.7) nmol/kg bw/min) (p < 0.05). Conclusion: This is first study that quantitates the rate of NO production in patients with cirrhosis and clearly shows that TIPSS insertion results in peripheral and cerebral vasodilation, and increased whole body production of NO. The cause of this increase in NO production is unknown but is likely to be responsible for the haemodynamic disturbances that follow TIPSS insertion.
~-']
Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania Background: Spontaneous bacterial peritonitis (SBP) represents, an important cause of morbidity and mortality in patients with hepatic cirrhosis (HC). It has been established that prophylactic antibiotic therapy significantly reduces the development of SBP in patients with HC and prior SBP episode. Aim: This study was design to evaluate the compliance of SBP patients to profilactic antimicrobial therapy and the efficacy of this regimen on the PBS recurrence. Methods: 106 patients diagnosed in our unit with HC and SBP, who received an indication for prophylactic antibiotic therapy according to conventional guidelines, had been followed at 3 month interval for 18 months. Patients who didn't complete 2 consecutive examinations were excluded, so 84 patients were enrolled in the study. Results: 59 out of 84 patients (58 males and 26 females mean age 55 years, range 16 to 76; Child Pugh classification A:B:C = 1:34:49; etiology: viral 37 pts., alcoholic 19 pts., and mixed 28 pts.) were compliant to prophylactic antimicrobial therapy (compliance 70.2%). At subsequent examinations only 10 (16.95%) compliant patients presented SBP (6 neutrocytic ascites and 4 positive cultures); out of 25 noncompliant pts., 17 (68%) presented SBP (15 neutrocytic ascites and 2 with positive cultures); p = 0.00001 (Fisher Exact Test, Yates Corrected). Conclusion: Patients compliance with prophylactic therapy plays a major role in the recurrence of subsequent SBP episodes.
~ 7 8 7 INCREASED CEREBRAL AND PERIPHERAL VASODILATION, AND WHOLE BODY NITRIC OXIDE (NO) PRODUCTION AFTER INSERTION OF A TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT-SHUNT (TIPSS) IN PATIENTS WITH CIRRHOSIS Raiiv Jalan 1, Steven Olde Damink 2, Nicholaas Deutz 2, Doris Redhead 3, Alistair Lee 3. l lnstitute of Hepatology, UCL, London; SRoyal Infirmary,
Edinburgh, UK,"2Dept. Surgery, Academic Hospital, Maastricht, Netherlands Background and Hypothesis: This study tests the hypothesis that the increase in CBF observed after TIPSS insertion is the result of increased whole body NO production. Methods: 9 patients (Pugh score: 10.2 (4-1.0) undergoing emergency TIPSS placement for control of variceal bleeding were studied. CBF and cardiovascular haemodynamics were measured before and after TIPSS insertion. Whole body NO production was measured using infusion of the stable isotopes L-[guanidine-15N2] arginine and L-[ureido-13C; 5,52H2] citrulline. Enrichments were measured using an LC-MS system. The whole-body rate of production of arginine, citrulline and NO were calculated (PNAS 1996, 93:11460--5).
55
USEFULLNESS OF ROUTINE ANALYSIS OF ASCITES FLUID AT THE TIME OF THERAPEUTIC PARACENTESIS IN ASYMPTOMATIC CIRRHOTIC OUT PATIENTS
Jean Francois Cadranel I , Remy Romney 1, Philippe Mathurin 2, Nathalie Ganne-Carrie 3, Chantai Halimi 4, Abdel Medini 5, Jean Claude Chaput 2, P. Cruand 3, Arnaud Panwels s , Patrice Lemaitre I .
1Hospital Laennec, Creil; 2Hospital Antoine Beclere, Clamart; 3Hospital Jean Verdier, Bondy; 4Hospital Senlis, Senlis; 5Hospital Gonesse, Gonesse, France It is recommanded to perform exploratory paracenteses in cirrhotic patient because of frequency and severity of spontaneous bacterial peritonitis (SBP) and culture negative neutrocytic ascites (CNNA). The aims of this prospective study were 1) to evaluate the prevalence of SBP, CNNA and bacterascites (B) in asymptomatic cirrhotic ascitic outpatients 2) to determine if, in these patients, suppression of EP could be safe and cost effective. Methods: during a 12 months period, 270 consecutive therapeutic paracenteses (P) were performed in 67 consecutive patients. Child-Pugh class were B in 60% and C in 33%. A medical history and exam was obtained at each P and subjects with suspicion of infection were excluded from the study. Ascites fluid protein concentration (APC), ascites fluid cell count (AFC) and bedside inoculation into blood culture bottles were performed at time of E Results: Mean age was 59 + 9 years, 59 (88%) had alcoholic cirrhosis, 52 (77.6%) received diuretics, 25 (37.3%) received norfloxacine. The number and volume of P were 5 -4- 4 and 5.5 4- 3 liters; P were compensated with albumin in 59.6%. APC was 17.5 4- 8.6 g/l, AFC and polynuclear percent were 127.7 4- 155/mm 3 and 4.7 4- 11%. B were observed in 10 (3.7%) P with commensal germs. No patient had SBP nor CNNA. Conclusions: 1) the prevalence of SBP and CNNA in asymptomatic cirrhotic outpatients with ascites is near 0%. 2) Suppression of EP, based on careful clinical and biological exam could be safe and led to a 5300 euros economy per 100 LVP.
I-~
OLFACTORY FUNCTIONS IN PATIENTS WITH HEPATIC CIRRHOSIS AND WITHOUT OVERT HEPATIC ENCEPHALOPATHY
Jasna Jovic l, Nebojsa Jovic 1,2. 1 Clinicfor Gastroenterology, Military Medical Academy, Belgrade; 2 Department of Neurology and Psychiatry for Children and Youth, Medical School Belgrade, Yugoslavia Olfaction play a significant if often subtle role in nutrition not only, but in human beha-viour and ability for interaction with environment. Liver diseases are important aetiology among conditions associated with chemosensory disturbances. Olfactory functions were assessed in a group of 28 patients aged 37 to 70 years (mean 52.1) with proven hepatic cirrhosis. Alcoholic cirrhosis was noted in 16, till non-alcoholic (after hepatitis B, PBC) aetiology was diagnosed in remaining 12 patients. Modified Child's