原发性腹膜炎

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 occ

2、urring 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

3、（culture-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 sbp all cirrhotic patients with ascites can develop sbp it is comprising 31% of all bacterial infection it has been estimated to be between 10-30% approximately half the episodes of sbp are pres

4、ent at the 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

5、 8厌氧菌 2 0.10为界 鲎试验鲎试验 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s

6、bp：（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 cirrhotics with ascites at hospital admission whenever patients develop any of the following:* local signs of peritonitis(pain, vomiting, diarrhea, ileus)* systemic signs of infectin(fev

7、er, leukocytosis, septic shock)* hepatic encephalopathy without any clear precipitating factor* rapid renal function impairment without an apparent cause prior 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

8、菌学单个菌种常见 多种细菌secondary peritonitis unresponsive to antibiotic treatment two or more microorganisms isolated glucose 10g/l ldh upper limit of the serum level when 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 sbp third generati

9、on cephalosporin: cefotaxime 2g iv bid for 5-7 days amoxycillin-clavulanic acid is as effective as cefotaxime iv ciprofloxacin followed by oral treatment is another effective regimen these are for the initial empirical therapytreatment (continues) the antibiotic choice should be reviewed according t

10、o the results of af culture and bacterial sensitivity diuretic treatment paracentesis liver 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 group patients with bleeding:* norfloxacine 400mg bid po or n/