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1、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 occurring in d
2、ifferent 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（culture-negative
3、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 SBP,All 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 the time of hospit
4、al admission and the remainder are acquired during hospitalization,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,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 1其他 15 6,Although the flora
5、of the large intestine is most frequently anaerobic,their isolation as a causative bacteria of SBP is an infrequent event.WHY?Inability of anaerobes to translocate across the intestinal mucosaThe high O2 content of the intestinal wall,发病机理,SBP患者腹水中分离出来的细菌多为胃肠道细菌，表明细菌来自胃肠道，但细菌经过什么途径进入腹水目前尚不清楚。可能的途径如下
6、：,一，胃肠道细菌迁移细菌通过肠壁直接到达腹腔肝硬化时胃肠道内菌群失调，菌群上移。回肠末端、空回肠均有大肠杆菌生长。酒精性肝硬化 30.3%有小肠细菌过度生长，健康者无有腹水者 37.1%有小肠细菌过度生长，无腹水者 5.3%小肠细菌过度生长者 30.7%发生SBP，高于不伴者（9.09%）。但SBP大多为单一细菌感染，提示这一途径仅是SBP形成的可能原因之一。,淋巴液引流异常肝硬化动物模型中肠系膜淋巴结细菌迁移（Bacterial translocation,BT）发生率达69%，合并营养不良者达95%，有SBP者达100%，而无SBP者仅为57%。肠系膜淋巴结培养与SBP腹水中的致病菌是一
7、致的。肠系膜缺血；出血性休克；肠道细菌过度生长及内毒素血症均可促进BT的发生。,侧枝循环开放肝脏对清除门静脉血中的细菌起着十分重要的作用，侧枝循环可使门脉中细菌直接进入体循环形成菌血症。菌血症是SBP发生的一个重要环节。SBP时至少约50%患者，可在血液中分离出与腹水相同的致病菌，约1/3 SBP为非肠源性。,Pathogenesis of SBP,Bacterialovergrowth,Portal hypertension,Translocation tolymph node,Motility decreases,Congestionedema,Increases thepermeabil
8、ity andfacilitates translocation,Translocation,Submucosa,Bloodstream,Lymph node,Translocation has been observed inhealthy individuals at the time oflaparatomy.In cirrhosis,several formsof immunedeficiency favor the spread of bacteria to the blood stream,二，免疫缺陷机体防御功能低下是SBP发生的促进因素肝内单核巨噬细胞系统，特别是Kuffer细
9、胞功能低下免疫系统功能低下营养不良腹水抗菌活力低下,三，易患因素严重肝功能不全腹水低蛋白消化道出血SBP存活者侵袭性操作内窥镜、硬化剂、腹穿、导管、导尿等其他,Patients recovering from the first episode are at high risk of recurrence:At 6 months 43%At 1 year 69%At 2 years 72%,临床表现,压痛、反跳痛和肠鸣音减弱。可有休克和肝昏迷。腹痛、发热为最常SBP临床表现差异很大，典型者为畏寒发热、腹痛、腹部见的症状。,普通型最常见，急性起病。腹痛，继而发热、腹膜刺激症、腹水迅速增加、血WB
10、C升高，核左移、腹水为急性炎症。休克型腹痛或急性发热后几小时或一天内迅速出现周围循环衰竭，占SBP8%。,肝昏迷型常无发热或腹痛，早期出现神经精神症状，迅速进入昏迷顽固性腹水型腹水进行性增多，利尿剂治疗无效无症状型,DiagnosisSuspicion of SBP is based on clinical PictureThe diagnosis must be based on AF analysis,诊断,腹水细菌培养和WBC计数是最重要和最有意义的检查细菌培养 阳性率2760腹水白细胞和PMN计数是诊断SBP最快捷、最可靠的指标腹水WBC0.5 x 109/L,PMN0.25 x 10
11、9/L为标准。培养阴性白细胞性腹水（CNNA）为SBP的一种亚型。,诊断标准如下腹水PMN0.5 x 109/L(血腹1/250RBC)腹水培养阴性腹腔内无感染源30天内未使用抗生素排除其他原因造成腹水PMN升高腹水糖/血糖比值由1.300.20降至0.960.24,腹水LDHSBP时腹水LDH明显升高，以120u/L为标准，诊断SBP的敏感性为63%，特异性97%。腹水乳酸盐（LA）腹水PH常降至7.327.35之间 血与腹水PH梯度亦可用作诊断SBP指标以 0.10为界鲎试验多项指标联合检测,1988年我国腹水会议制定的肝硬化腹水合并SBP诊断参考标准：1.出现发热、腹痛及腹部压痛、反跳痛
12、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 cirrhot
13、ics with ascites,At hospital admissionWhenever patients develop any of the following:Local signs of peritonitis(pain,vomiting,diarrhea,ileus)Systemic signs of infectin(fever,leukocytosis,septic shock)Hepatic encephalopathy without any clear precipitating factorRapid renal function impairment without
14、 an apparent causePrior to antibiotic prophylaxis,if gastrointestinal bleeding,鉴别诊断,1.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,Secondary PeritonitisUnresponsive to antibiotic treatmentTwo or more microorganisms isolatedGlucose 10g/lLDH upper limit of the serum
15、levelWhen suspected:Radiologic investigationUse antibiotic against anaerobe,2.结核性腹膜炎3.其他感染所致的发热,Treatment of SBP,Third generation cephalosporin:cefotaxime 2g IV bid for 5-7 daysAmoxycillin-clavulanic acid is as effective as cefotaximeIV ciprofloxacin followed by oral treatment is another effective r
16、egimenThese are for the initial empirical therapy,Treatment(continues),The antibiotic choice should be reviewed according to the results of AF culture and bacterial sensitivityDiuretic treatmentParacentesisLiver transplation,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
17、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。,SBP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 group,Patients with bleeding:Norfloxacine 400mg bid PO or N/G tube(7 days)Patients with ascites and protein1g/dl400mg norfloxacine PO during hospitalizationAf
18、ter first episode of SBP:Norfloxacine 400mg indefinitely,reduce SBP from 68%to20%,Conclusion,Bacterial translocation has been reduced by PO norfloxacineThe use of empirical Ab should be started in all those with 250/mm3 PMNAnaerobic bacteria are rarely foundOpportunistic organisms are isolated in immunesuppressed patients,
