Mean platelet volume indicator for systemic inflammation in cirrhotic patients with spontaneous bacterial peritonitis

Introduction spontaneous bacterial peritonitis (SBP) is the most common infection in patients with cirrhosis [1] .Spontaneous bacterial peritonitis is found in patients where besides the increase of polymorphonuclear counting, they present a positive result of culture [2] . The BMN count as not always quickly available in clinical practice and the culture result usually takes 72 hours or more [3] .The use of additional markers that are rapidly and easily applicable, may add significant benefit for predicting the development of spontaneous bacterial peritonitis and achieving diagnostic accuracy [4] .Platelet size is a determinant factor of platelet proinflammatory functions. Several studies have found relationship between the mean platelet volume (MPV) and pro-inflammatory conditions, particularly acute infections [5] . Aim to identify a mean platelet volume (MPV) cutoff value which should be able to predict the presence of sponataneous bacterial peritonitis. Settings and designs a cross sectional observational study, carried out on 40 patients with AFI and 40 patients without AFI. Methods Patients were classified into two groups, group A (SBP) which included 40 patients with ascetic fluid PMN count ≤ 250 cells/mm3 and group B (non/SBP) which included another 40 patients with ascetic fluid PMN count < 250 cells/mm3. All studied patients were subjected to history taking, Clinical examination and routine laboratory investigations including: CBC including platelet number and MPV, liver function test including (ALT, AST, albumin, and direct & total bilirubin), kidney function test including (BUN &creatinine), PT, PTT, INR, ESR and CRP .Abdominal-pelvic ultrasonography was done for all patients. Aspirated ascetic fluid samples were immediately examined for bacteriological cultures. Statistical analysis used Statistical presentation and analysis of the present study was conducted, using the mean, standard deviation, independent samples t-test, Chi-square, Mann-Whitney U test and Analysis of variance [ANOVA] tests by SPSS version 22 software .Tukey test was used .Receiver operating characteristic (ROC) curve analysis was used to identify optimal cut-off values of MPV and with maximum sensitivity and specificity for differentiation of cirrhotic patients with SBP from those without SBP. Spearman’s correlation analysis was done. Results MPV was significantly higher in SBP-patients (Group A) than that of non-SBP patients (Group B) (11.6820±1.19303 fL versus 9.0325±1.12441 fL) (P-value = 0.001) .MPV has positive correlation with Ascitic sample TLC and Ascitic sample PMNC in Group A. ROC curve shows that MPV cut off value is10.25with 85% sensitivity and 75% specificity . Conclusion MPV may serve as a non-invasive, cheap and rapid test for detection and diagnosis of spontaneous bacterial peritonitis (SBP) with a sensitivity and specificity of 85% and 75% respectively.

The Diagnostic Value of CD11b Expression on Peripheral Blood Neutrophils for Detection of Spontaneous Bacterial Peritonitis

Background: Spontaneous bacterial peritonitis (SBP) is associated with the highest mortality among end-stage cirrhotic liver disease patients. Neutrophil CD11b expression increases on the neutrophil surface within 5 min of exposure to bacteria. Paracentesis remains the only accepted method for accurate evaluation of patients, with many drawbacks; hence, a diagnostic noninvasive marker with a very high sensitivity and high diagnostic accuracy is very necessary. Aim of the study: to evaluate the neutrophil CD11b as a non-invasive biomarker for the diagnosis of SBP, comparing its sensitivity and specificity to other traditional methods. Patients and Methods: 200 patients who had liver cirrhosis with ascites were recruited to the Hepatology department inpatient wards of the National Liver Institute, Menoufia University. They were divided into Group I: 100 patients with SBP and Group II: 100 patients with non SBP ascites. All studied patients were subjected to full clinical examination, abdominal ultrasound, paracentesis, and laboratory investigations including ascetic fluid (AF) examinations. The CD11b expression and its mean fluorescence intensity (MFI) were assessed on peripheral blood neutrophils by flowcytometry. Results: There was a significant increase in the MFI of CD11b in the SBP group compared to the non SBP group. At cut off >20 for MFI of CD11b with a sensitivity of 100% and specificity of 100% can discriminate between SBP and non SBP cases followed by ascetic fluid TLC examination at a cut off 0.26 (×103) with a sensitivity of 92%, and specificity of 96%, then, AF neutrophil count at cut off 0.25 (×103) with a sensitivity of 80%, specificity of 100%, and AF culture examination with a sensitivity of 56% and specificity of 100%. Conclusion: The measurement of CD11b MFI on peripheral blood neutrophils is a useful non-invasive marker with high sensitivity and specificity to predict SBP compared with other methods. Further large-scale studies are needed to study the value of CD11b MFI level in the SBP follow-up therapy.

Amyloid A in Serum and Ascitic Fluid as a Novel Diagnostic Marker of Spontaneous Bacterial Peritonitis

Background: Diagnosis of Spontaneous Bacterial Peritonitis (SBP) depends mainly on ascetic fluid culture which may be negative in spite of the clinical suggestion of SBP and high ascetic fluid neutrophilic count. Aim: This study aimed to evaluate the biological importance of amyloid A biomarker in both serum and ascetic fluid to diagnose SBP as early as possible and to compare it to other markers (C-reactive protein (CRP), and the neutrophil-to-lymphocyte ratio (NLR)). Methods: This study included 37 patients with hepatic ascites; twenty-two of them had SBP, and 15 patients did not have SBP. Serum and ascetic fluid amyloid A, ascetic fluid neutrophil, C-reactive protein, and neutrophil-to-lymphocyte ratio were measured in all subjects before the start of antimicrobial chemotherapy to the infected ones. Results: Both the serum and ascetic fluid amyloid and also, CRP were significantly higher in patients infected with ascetic fluid than others. The cut-off point of serum amyloid A for early detection of SBP was 9.25ug/ml with the high sensitivity and specificity. For ascetic amyloid A, the sensitivity and specificity were 90.09% and 60% at cut-off point 2.85ug/ml, respectively. Conclusion: Amyloid A in serum and ascitic fluid can be considered as a good biomarker for early diagnosis of SBP.

An unusual presentation of ACE inhibitor-induced visceral angioedema

ACE inhibitors (ACEi) are common anti-hypertensive drugs that can cause angioedema. Though classic, or facial angioedema is rare, visceral angioedema is even less common. When angioedema occurs, it typically presents early, within 30 days of initiating therapy. Visceral angioedema most commonly presents with nausea, emesis, abdominal pain and diarrhoea, and thus is often mistaken for an episode of gastroenteritis. When a CT scan is obtained, it typically shows characteristic findings, including ascetic fluid, mild mesenteric oedema and thickening of the small bowel. In this case report, we present a patient who did not experience her first episode of visceral angioedema until after she had been on ACEi therapy for 5–7 years. In addition, she experienced recurrent episodes of visceral angioedema that were separated by approximately 4 years at a time. Both of these features make for a particularly unique presentation.

Investigation in liver disease

This chapter discusses investigations in liver disease, including blood tests (liver chemistry and liver function tests, alpha-fetoprotein, viral serology, antibodies and immunoglobulins), ascetic fluid analysis, imaging (hepatobiliary ultrasound, CT, MRI, endoscopic ultrasound), and liver biopsy.

A Case Study on Ascites of Hepatic Origin and Their Proper Management in a Male German Shepherd Dog

A male German shepherd dog of 11 months was presented to HART Clinic, Pokhara with the history of abdominal swelling, respiratory distress, lethargy, anorexia and weakness. Physical examination revealed dyspnea, pale mucous membrane, and undulating movement (thrills) of fluid on tapping the abdomen. Fecal sample collected for assessing the severity of endoparasites which was found negative. The hematological study showed an increase in numbers of neutrophils, while there were decreased erythrocytes and hemoglobin concentration. The biochemical analysis resulted in an elevated SGOT, SGPT level but decrease in total protein level. Ascitic fluid collected from abdominal paracentesis on examination revealed transudate fluid with serum-albumin ascetic gradient (SAAG) >1.1 gm/dl suggesting ascites due to portal hypertension (96% accuracy) caused by Liver cirrhosis. The dog was diagnosed as ascites of hepatic origin resulting portal hypertension and hypoproteinemia. The abdominocentesis was performed to drain the ascetic fluid followed by albumin and normal saline administration. The dog was further treated with antibiotic, diuretic, amino acid and liver tonics along with protein rich but salt free diet. The dog showed remarkable improvement with gradual reduced in abdominal distention and normalization of the appetite after 7 days of treatment.Int. J. Appl. Sci. Biotechnol. Vol 5(4): 555-558