Spontaneous bacterial peritonitis risk factors: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Spontaneous bacterial peritonitis}} | {{Spontaneous bacterial peritonitis}} | ||
{{CMG}} ; {{AE}} {{ | {{CMG}} ; {{AE}} {{SCh}} {{AY}} | ||
==Overview== | ==Overview== | ||
Common risk factors in | Common risk factors in cirrhotic patients with [[ascites]] include: low [[protein]] level in ascitic fluid (<1 g/dL), upper [[GI bleeding]], low [[complement]] concentration ([[C3 (complement)|complement 3]]) in ascitic fluid, [[renal failure]], elevated serum [[bilirubin]] level (>4 mg/dL), use of [[proton pump inhibitors]] ([[PPI]]) in cirrhotic patients have an increased risk, [[Child-Pugh score|Child-Pugh]] stage C, [[MELD score|Model For End-Stage Liver Disease (MELD)]] ≥ 22. | ||
==Risk Factors== | ==Risk Factors== | ||
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Risk factors include:<ref name="pmid15920324">{{cite journal| author=Sheer TA, Runyon BA| title=Spontaneous bacterial peritonitis. | journal=Dig Dis | year= 2005 | volume= 23 | issue= 1 | pages= 39-46 | pmid=15920324 | doi=10.1159/000084724 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15920324 }} </ref> | Risk factors include:<ref name="pmid15920324">{{cite journal| author=Sheer TA, Runyon BA| title=Spontaneous bacterial peritonitis. | journal=Dig Dis | year= 2005 | volume= 23 | issue= 1 | pages= 39-46 | pmid=15920324 | doi=10.1159/000084724 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15920324 }} </ref> | ||
* All cirrhotic patients with ascites | * All cirrhotic patients with ascites | ||
* Severe [[liver]] | * Severe [[liver disease]] ([[Cirrhosis]])<ref name="pmid8462803">{{cite journal| author=Andreu M, Sola R, Sitges-Serra A, Alia C, Gallen M, Vila MC et al.| title=Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites. | journal=Gastroenterology | year= 1993 | volume= 104 | issue= 4 | pages= 1133-8 | pmid=8462803 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8462803 }} </ref> | ||
* Low [[protein]] level in ascitic fluid <ref name="pmid20120777">{{cite journal| author=Mustafa MG, Al Mamun MA, Alam AK| title=Study on ascitic fluid protein level in cirrhotic patients with spontaneous bacterial peritonitis. | journal=Bangladesh Med Res Counc Bull | year= 2009 | volume= 35 | issue= 2 | pages= 41-3 | pmid=20120777 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20120777 }} </ref> | |||
* Low protein level in ascitic fluid <ref name="pmid20120777">{{cite journal |author=Mustafa MG, Al Mamun MA, Alam AK |title=Study on ascitic fluid protein level in cirrhotic patients with spontaneous bacterial peritonitis |journal=Bangladesh Med Res Counc Bull |volume=35 |issue=2 |pages= | * Upper [[GI bleeding]] poses a risk of [[bacteremia]] and SBP in a cirrhotic patient with rates of infection ranging from 17 to 21% | ||
* Upper GI bleeding poses a risk of bacteremia and SBP in a cirrhotic patient with rates of infection ranging from 17 to 21% | * Ischemia- reperfusion of the gut during variceal hemorrhage has also been proposed to interfere with the normal function of the [[reticuloendothelial system]] and to increase permeability of the [[intestinal mucosa]] | ||
* Ischemia- reperfusion of the gut during variceal hemorrhage has also been proposed to interfere with the normal function of the reticuloendothelial system and to increase permeability of the intestinal mucosa | * Survivors of a prior episode of SBP are at an increased risk of recurrence with a one-year probability of almost 70% | ||
* Survivors of a prior episode of SBP are at an increased risk of recurrence with a one-year probability of almost 70% | * Minimally invasive procedures such as intravenous and urinary bladder [[catheterization]] likely predisposes to bacteremia and SBP in the cirrhotics | ||
* Minimally invasive procedures such as intravenous and urinary bladder catheterization likely predisposes to bacteremia and SBP in the cirrhotics | * Low [[complement]] concentration ([[C3 (complement)|complement 3]]) in ascitic fluid <ref name="pmid20120777">{{cite journal| author=Mustafa MG, Al Mamun MA, Alam AK| title=Study on ascitic fluid protein level in cirrhotic patients with spontaneous bacterial peritonitis. | journal=Bangladesh Med Res Counc Bull | year= 2009 | volume= 35 | issue= 2 | pages= 41-3 | pmid=20120777 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20120777 }} </ref><ref name="pmid8462803">{{cite journal| author=Andreu M, Sola R, Sitges-Serra A, Alia C, Gallen M, Vila MC et al.| title=Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites. | journal=Gastroenterology | year= 1993 | volume= 104 | issue= 4 | pages= 1133-8 | pmid=8462803 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8462803 }} </ref> | ||
* Low complement concentration ([[C3 (complement)|complement 3]]) in ascitic fluid <ref name="pmid20120777">{{cite journal |author=Mustafa MG, Al Mamun MA, Alam AK |title=Study on ascitic fluid protein level in cirrhotic patients with spontaneous bacterial peritonitis |journal=Bangladesh Med Res Counc Bull |volume=35 |issue=2 |pages= | |||
* [[Renal failure]] | * [[Renal failure]] | ||
* [[Urinary tract infections]] | * [[Urinary tract infections]] | ||
* Intestinal [[bacterial overgrowth]] <ref name="pmid16782626">{{cite journal |author=van Erpecum KJ |title=Ascites and spontaneous bacterial peritonitis in patients with liver cirrhosis |journal=Scand. J. Gastroenterol. Suppl. |volume= |issue=243 |pages=79–84 |year=2006 |pmid=16782626 |doi=10.1080/00365520600664342 |url=}}</ref> | * Intestinal [[bacterial overgrowth]] <ref name="pmid16782626">{{cite journal |author=van Erpecum KJ |title=Ascites and spontaneous bacterial peritonitis in patients with liver cirrhosis |journal=Scand. J. Gastroenterol. Suppl. |volume= |issue=243 |pages=79–84 |year=2006 |pmid=16782626 |doi=10.1080/00365520600664342 |url=}}</ref> | ||
* The use of non-selective [[beta blockers]] in [[cirrhosis|cirrhotic]] patients with SBP should be discouraged since it is associated with an increased risk for [[hemodynamic compromise]], prolonged [[hospitalization]], [[hepatorenal syndrome]], and [[acute kidney injury]]<ref name="pmid24631577">{{cite journal| author=Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M et al.| title=Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. | journal=Gastroenterology | year= 2014 | volume= 146 | issue= 7 | pages= 1680-90.e1 | pmid=24631577 | doi=10.1053/j.gastro.2014.03.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24631577 }} </ref> | |||
Factors contributing to the infection include: | |||
* [[GI bleeding]] | |||
*Increased colonization of the small bowel with prominent bacterial translocation | |||
*Decreased [[Opsonin|opsonic activity]] in blood and ascitic fluid | |||
* Impaired [[complement]] | |||
* [[Leukocyte]] dysfunction | |||
*Reduced [[antibodies]] | |||
*Increased [[immunosuppressive]] [[cytokines]], endotoxin, [[TNF]] | |||
{| class="wikitable" | |||
! colspan="4" |Risk Factors for SBP | |||
|- | |||
! style="width: 25%;" |Biochemical | |||
! style="width: 25%;" |Clinical | |||
! style="width: 25%;" |Genetic | |||
! style="width: 25%;" |Pharmacological | |||
|- | |||
| valign="top" | | |||
''Well-established risk factors for developing an initial episode of SBP are'' : | |||
* Low ascitic fluid [[protein]] level (<1 g/dL)<ref name="pmid20120777">{{cite journal| author=Mustafa MG, Al Mamun MA, Alam AK| title=Study on ascitic fluid protein level in cirrhotic patients with spontaneous bacterial peritonitis. | journal=Bangladesh Med Res Counc Bull | year= 2009 | volume= 35 | issue= 2 | pages= 41-3 | pmid=20120777 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20120777 }} </ref> | |||
* Elevated serum [[bilirubin]] level (>4 mg/dL) | |||
* Advanced [[Cirrhosis]] | |||
* Low levels of [[25-hydroxy vitamin D]] | |||
* Serum [[Serum albumin|albumin]] level <2.85 g/dL | |||
| valign="top" | | |||
* Patients with [[Variceal bleed|variceal hemorrhage]] and [[Gastrointestinal bleeding|GI bleeding]] associated with [[cirrhosis]] are more prone to develop [[SBP]] irrespective of the presence of [[ascites]]. | |||
| valign="top" | | |||
* The [[Toll-like receptor 2|Toll-like receptor 2 (TLR2)]] proteins variants of the [[NOD2|NOD2 (nucleotide-binding oligomerisation domain)]] containing gene and [[Farnesoid X receptor|Farnesoid X]] were known to cause [[SBP]].<ref name="pmid21356257">{{cite journal| author=Nischalke HD, Berger C, Aldenhoff K, Thyssen L, Gentemann M, Grünhage F et al.| title=Toll-like receptor (TLR) 2 promoter and intron 2 polymorphisms are associated with increased risk for spontaneous bacterial peritonitis in liver cirrhosis. | journal=J Hepatol | year= 2011 | volume= 55 | issue= 5 | pages= 1010-6 | pmid=21356257 | doi=10.1016/j.jhep.2011.02.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21356257 }} </ref><ref name="pmid20087966">{{cite journal| author=Appenrodt B, Grünhage F, Gentemann MG, Thyssen L, Sauerbruch T, Lammert F| title=Nucleotide-binding oligomerization domain containing 2 (NOD2) variants are genetic risk factors for death and spontaneous bacterial peritonitis in liver cirrhosis. | journal=Hepatology | year= 2010 | volume= 51 | issue= 4 | pages= 1327-33 | pmid=20087966 | doi=10.1002/hep.23440 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20087966 }} </ref> | |||
| valign="top" | | |||
* [[Proton pump inhibitors]] (PPI) are associated with a three-fold increase in the risk and identified as an independent risk factor for [[SBP]] in patients with advanced cirrhosis. <ref name="DamVilstrup2016">{{cite journal|last1=Dam|first1=Gitte|last2=Vilstrup|first2=Hendrik|last3=Watson|first3=Hugh|last4=Jepsen|first4=Peter|title=Proton pump inhibitors as a risk factor for hepatic encephalopathy and spontaneous bacterial peritonitis in patients with cirrhosis with ascites|journal=Hepatology|volume=64|issue=4|year=2016|pages=1265–1272|issn=02709139|doi=10.1002/hep.28737}}</ref> | |||
* [[Beta-adrenergic antagonists]] namely nonselective beta-blocker (NSBB) therapy was found to be protective for SBP. | |||
|} | |||
== References == | == References == | ||
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[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Emergency mdicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | [[Category:Infectious disease]] | ||
Latest revision as of 00:15, 30 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2] Ahmed Younes M.B.B.CH [3]
Overview
Common risk factors in cirrhotic patients with ascites include: low protein level in ascitic fluid (<1 g/dL), upper GI bleeding, low complement concentration (complement 3) in ascitic fluid, renal failure, elevated serum bilirubin level (>4 mg/dL), use of proton pump inhibitors (PPI) in cirrhotic patients have an increased risk, Child-Pugh stage C, Model For End-Stage Liver Disease (MELD) ≥ 22.
Risk Factors
Risk factors include:[1]
- All cirrhotic patients with ascites
- Severe liver disease (Cirrhosis)[2]
- Low protein level in ascitic fluid [3]
- Upper GI bleeding poses a risk of bacteremia and SBP in a cirrhotic patient with rates of infection ranging from 17 to 21%
- Ischemia- reperfusion of the gut during variceal hemorrhage has also been proposed to interfere with the normal function of the reticuloendothelial system and to increase permeability of the intestinal mucosa
- Survivors of a prior episode of SBP are at an increased risk of recurrence with a one-year probability of almost 70%
- Minimally invasive procedures such as intravenous and urinary bladder catheterization likely predisposes to bacteremia and SBP in the cirrhotics
- Low complement concentration (complement 3) in ascitic fluid [3][2]
- Renal failure
- Urinary tract infections
- Intestinal bacterial overgrowth [4]
- The use of non-selective beta blockers in cirrhotic patients with SBP should be discouraged since it is associated with an increased risk for hemodynamic compromise, prolonged hospitalization, hepatorenal syndrome, and acute kidney injury[5]
Factors contributing to the infection include:
- GI bleeding
- Increased colonization of the small bowel with prominent bacterial translocation
- Decreased opsonic activity in blood and ascitic fluid
- Impaired complement
- Leukocyte dysfunction
- Reduced antibodies
- Increased immunosuppressive cytokines, endotoxin, TNF
| Risk Factors for SBP | |||
|---|---|---|---|
| Biochemical | Clinical | Genetic | Pharmacological |
|
Well-established risk factors for developing an initial episode of SBP are : |
|
|
|
References
- ↑ Sheer TA, Runyon BA (2005). "Spontaneous bacterial peritonitis". Dig Dis. 23 (1): 39–46. doi:10.1159/000084724. PMID 15920324.
- ↑ 2.0 2.1 Andreu M, Sola R, Sitges-Serra A, Alia C, Gallen M, Vila MC; et al. (1993). "Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites". Gastroenterology. 104 (4): 1133–8. PMID 8462803.
- ↑ 3.0 3.1 3.2 Mustafa MG, Al Mamun MA, Alam AK (2009). "Study on ascitic fluid protein level in cirrhotic patients with spontaneous bacterial peritonitis". Bangladesh Med Res Counc Bull. 35 (2): 41–3. PMID 20120777.
- ↑ van Erpecum KJ (2006). "Ascites and spontaneous bacterial peritonitis in patients with liver cirrhosis". Scand. J. Gastroenterol. Suppl. (243): 79–84. doi:10.1080/00365520600664342. PMID 16782626.
- ↑ Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M; et al. (2014). "Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis". Gastroenterology. 146 (7): 1680–90.e1. doi:10.1053/j.gastro.2014.03.005. PMID 24631577.
- ↑ Nischalke HD, Berger C, Aldenhoff K, Thyssen L, Gentemann M, Grünhage F; et al. (2011). "Toll-like receptor (TLR) 2 promoter and intron 2 polymorphisms are associated with increased risk for spontaneous bacterial peritonitis in liver cirrhosis". J Hepatol. 55 (5): 1010–6. doi:10.1016/j.jhep.2011.02.022. PMID 21356257.
- ↑ Appenrodt B, Grünhage F, Gentemann MG, Thyssen L, Sauerbruch T, Lammert F (2010). "Nucleotide-binding oligomerization domain containing 2 (NOD2) variants are genetic risk factors for death and spontaneous bacterial peritonitis in liver cirrhosis". Hepatology. 51 (4): 1327–33. doi:10.1002/hep.23440. PMID 20087966.
- ↑ Dam, Gitte; Vilstrup, Hendrik; Watson, Hugh; Jepsen, Peter (2016). "Proton pump inhibitors as a risk factor for hepatic encephalopathy and spontaneous bacterial peritonitis in patients with cirrhosis with ascites". Hepatology. 64 (4): 1265–1272. doi:10.1002/hep.28737. ISSN 0270-9139.