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1、自发性细菌性腹膜炎自发性细菌性腹膜炎民勤县人民医院赵伯元定义自发性细菌性腹膜炎（Spontaneous Bacterial Peritonitis , SBP）指无腹腔脏器穿孔，炎症而发生的腹膜急性细菌性感染，是肝硬化门脉高压的常见并发症之一。典型临床表现为发热、腹痛和腹部压痛，血白细胞增高。Spontaneous bacterial peritonitis(SBP) is a frequent and severe complication of cirrhotic patients with ascites.Although SBP has been described as occurr
2、ing in different settings, such as nephrotic syndrome, heart failure; most SBP episodes develop in patients with end stage liver disease as a manifestation of liver failure.Ascitic fluid infection is blood-borne and in 90% of cases is monomicrobial.SBP分三个亚型：1. 细菌培养阳性+腹水多形核白细胞增加；2. 细菌培养阴性的白细胞性腹水（cult
3、ure-negative neutrocytic ascites , CNNA）；3. 细菌性腹水（bacterial ascites, BA）指腹水培养阳性而PMN不升高。Prevalence of SBPAll cirrhotic patients with ascites can develop SBPIt is comprising 31% of all bacterial infectionIt has been estimated to be between 10-30%Approximately half the episodes of SBP are present at th
4、e time of hospital admission and the remainder are acquired during hospitalization发生率发生率SBP最常发生于失代偿期肝硬化患者，也可见于其他腹水患者。占住院肝硬化患者的10%30%无腹水者约10%有腹水者20%合并肝性脑病者高达36%。病原学病原学腹水感染细菌主要来自胃肠道90%以上为单一菌种感染主要为需氧G杆菌大肠杆菌所致的SBP约占40%50%。SBP的病原学（n=263）致病菌 病例数 %大肠杆菌 121 46链球菌属 80 30肺炎克雷伯菌 24 9G需氧阴性菌 22 8厌氧菌 2 0.10为界鲎试验鲎
5、试验多项指标联合检测多项指标联合检测19881988年我国腹水会议制定的肝硬化腹年我国腹水会议制定的肝硬化腹水合并水合并SBPSBP诊断参考标准诊断参考标准：1. 出现发热、腹痛及腹部压痛、反跳痛等腹膜刺激症。2. 腹水WBC0.3 x 109/L,PMN50%，腹水培养有致病菌生长或涂片阳性者可确诊为SBP。 3.凡腹水WBC0.3 x 109/L,PMN50%， 结合临床可诊断为SBP。4.凡腹水WBC0.3 x 109/L,PMN25%，即使无临床表现，应高度怀疑SBP，并按SBP治疗。 5. 如腹水检查不能达到上述标准，下列试验阳性者也可诊断为SBP：（1）腹水PH0.10(注不得超过
6、30min)；（2）腹水乳酸盐0.63mmol/l， 但 需 排 除 恶 性 腹 水 。（3）腹水 试验阳性，腹水ADA6ku/L、排除结核如恶性肿瘤。Diagnostic paracentesis in cirrhotics with ascitesAt hospital admissionWhenever patients develop any of the following:*Local signs of peritonitis(pain, vomiting, diarrhea, ileus)*Systemic signs of infectin(fever, leukocytosi
7、s, septic shock)*Hepatic encephalopathy without any clear precipitating factor*Rapid renal function impairment without an apparent causePrior to antibiotic prophylaxis, if gastrointestinal bleeding鉴别诊断鉴别诊断1.1.继发性腹膜炎继发性腹膜炎 指标 SBP 继发性腹膜炎发生率 1-15% 0.4-2.3%WBC10 x 109/L 少见 常见气腹症 少见 常见细菌学单个菌种常见 多种细菌Secon
8、dary PeritonitisUnresponsive to antibiotic treatmentTwo or more microorganisms isolatedGlucose 10g/lLDH upper limit of the serum levelWhen suspected:*Radiologic investigation*Use antibiotic against anaerobe2.2.结核性腹膜炎结核性腹膜炎3.3.其他感染所致的发热其他感染所致的发热Treatment of SBPThird generation cephalosporin: cefotaxi
9、me 2g IV bid for 5-7 daysAmoxycillin-clavulanic acid is as effective as cefotaximeIV ciprofloxacin followed by oral treatment is another effective regimenThese are for the initial empirical therapyTreatment (continues)The antibiotic choice should be reviewed according to the results of AF culture an
10、d bacterial sensitivityDiuretic treatmentParacentesisLiver transplation预后预后住院病死率原为50%-90%，现约40%。与预后有关的因素。（1）肝肾功能；（2）腹水蛋白含量；（3）腹水PH；（4）腹水LDH；（5）WBC计数；（6）48小时内对治疗反应SBP易复发，6个月为43%，1年为69%，2年为74%。1年生存率为38%，死亡原因31%为SBP复发。SBPSBP预防预防积极治疗基础疾病避免各种创伤性检查和侵入性治疗积极治疗腹水预防性应用抗生素其他药物Prophylaxis at high risk groupPatients with bleeding:*Norfloxacine 400mg bid PO or N/G tube (7 days)Patients with ascites and protein250/mm3 PMNAnaerobic bacteria are rarely foundOpportunistic organisms are isolated in immunesuppressed patients
