الفهرس 
CHRONIIC LIIVER DIISEASE
Primary sclerosing cholangitisOnly 14 pages are availabe for public view
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Abstract
The current study was designed to evaluate the validity
of (TREM-1) in diagnosis of Spontaneous Bacterial
Peritonitis in cirrhotic patients and follow up after treatment
for cirrhotic patients admitted to Tropical Medicine
department at Ain Shams University hospitals during the six
months period starting from August 2017 to February 2018.
Sixty patients were enrolled in this study. All of them
were subjected to Complete history taking, thorough clinical
examination, laboratory investigations including (complete
blood picture, C reactive protein, liver and renal profiles,
abdominal ultrasonography, ascitic fluid sampling for ascitic
cell count, biochemical assay (ascitic fluid albumin, LDH,
glucose and total proteins levels), ascitic fluid culture and
sensitivity and measurement of TREM-1.
The studied patients were classified into two groups:
1. group 1 (control): includes 30 patients had ascites due to
various liver diseases but did not have any evidence of
infected ascites, bacterascites or spontaneous bacterial
peritonitis.
2. group 2 (SBP): included 30 patients diagnosed with
spontaneous bacterial peritonitis based on fever,
abdominal tenderness, leukocytosis, elevated CRP, ascitic cell count > 250 cells and ascitic culture and sensitivity.
Ascitic TREM-1 was measured before treatment, Then
those patients received empirical antibiotics in the form of
third generation cephalosporins for 5 days or until the
results of ascitic culture and sensitivity become available
then the patients received the antibiotics according to
cultures. Followed second ascitic sample for measurement
of TREM-1 was taken after treatment. Monitoring of the
response was guided by improvement of clinical signs
(fever and abdominal tenderness) and improvement of
ascitic cell count taken after 48 hours from the start of
antibiotic treatment.
Among the 30 patients with SBP, 20 patients were
males (66.7%) and 10 patients were females (33.3%). The
mean and SD of age among the studied patients in SBP group
was 53.9±8.5 years. Hepatitis C virus was the most common
etiology of chronic liver disease in patients of SBP group
(83%).
In the current study (in SBP group), the main
presenting symptoms among the patients with SBP were
abdominal pain which was presented in (93%) and fever in
(60%) of patients. The most common clinical sign was lower
limb edema which was presented in all patients on general
examination. While on abdominal examination, 60% of
patients had tense ascites and 56.7% of patients had
abdominal tenderness. Additionally, jaundice, enlarged spleen, enlarged liver and hepatic encephalopathy were noted
in patients with SBP at a frequency of 60%, 70%, 86.7% and
30% respectively, 40% of patients had history of
hematemesis. Abdominal pain, tenderness and fever were
found to have significant statistical difference when
compared with patients with non-infected ascites.
All cases of chronic liver disease were diagnosed
according to clinical, biochemical, and/or imaging findings.
The severity of cirrhosis was categorized by Child-Pugh’s
classification where Child class B and Child class C were
represented in 26.7% and 73.3% of patients with SBP
respectively. Moreover, the mean of MELD score between
SBP group was 18.8 (±7.2).
As regard the laboratory findings, the total leucocytic
count was significantly higher in patients with SBP than in
patients with non-SBP. The level of AFP and INR were
significantly higher in patients with SBP than in patients
with non-SBP. The serum albumin was significant lower in
SBP patient than in control. Serum CRP and ESR were
significantly higher in patients with SBP (44.7±35 and
33.1±19.6 respectively) than in patients with non-SBP
(14.8±17.8 and 18.4±15.3 respectively). No difference
between the two group in AST, ALT, Bilirubin and renal
functions tests.
In the current study ascitic fluid samples were obtained
under complete aseptic conditions for ascitic fluid analysis which include routine appearance, biochemical tests, cell
count, culture and the level of TREM-1.
As regards ascitic fluid chemistry, all ascitic samples
were transudate. In SBP group, the mean of ascitic fluid cell
count and LDH level were significantly higher in comparison
to the control group.
The present study showed that the mean of ascitic fluid
ascitic fluid albumin was significant lower in SBP patients.
In our study, A high statistical significant difference
was observed in ascitic fluid LDH and cell count in the SBP
group patients before and after the treatment, ascitic fluid
LDH and cell count levels were significantly higher before
treatment than after treatment.
The current study showed that there was high
statistical significant difference between the two group in the
base level of TREM-1 in which the mean was 1280 (1136.9)
with level range between (580 - 4500) in SBP versus mean
129.9 (51.9) with level range between (60 - 250) in the
control group, this result support the validity of TREM-1 in
diagnosis of SBP.
Also this study showed a statistical significant
difference in the level of TREM-1 before and after treatment
in the SBP patients in which the mean of TREM-1 before
treatment was 1280.6 (1136.9) with level range between (580 - 4500) versus mean 376.2 (78.4) and level range between
(260 - 560) after the treatment, this result support the
prognostic value of TREM-1 in follow up the SBP patient.
The ascitic culture and sensitivity taken from the
studied patients was negative in all patient in control group
with ascitic cell count less than 250 cells/mm3, while in SBP
group showed that 18 patients had culture negative
neutrocytic ascites (60%) and 12 patients had monomicrobial
bacterascites (40%). The most frequently isolated microorganism
was E. coli that was detected in three patients
(10%) followed by Klebsiella, Staph coagulase negative,
Acintobacter spp., Streptococcus Viridans, where each of
them was isolated in two patients (6.7%).
Our study on the 30 patients with ascitic SBP showed
significant improvement in ascitic fluid TREM-1, cell count
and culture 5 days after starting antibiotic treatment
(cefotaxime 2gm every 8 hours). There was 12 patients
(40%) with positive ascitic culture where ceftriaxone,
imipenem, meropenem and cefotaxime were sensitive in
54.6% of patients while tazocin and gentamicin were
sensitive in 45.5% and 36.4% of patients respectively,
vancomycin, levofloxacin and ciprofloxacin were sensitive in
27.3% of patients. Although the third generation
cephalosporins are still effective as first-line therapy as it was
effective in treatment of infected ascites in our study with
culture sensitivity about 55%.So, third-generation cephalosporins, especially
Cefotaxime that can present at good concentration in the
peritoneal fluid, continue to be the gold-standard antibiotic
treatment for patients with infected ascites especially in
community-acquired infections.