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Abstract
Spontaneous bacterial peritonitis develops in about 10-27% of cirrhotic patients with ascites. It is one of the most frequent complications in severely decompensated cirrhotic patients. Spontaneous bacterial peritonitis patients are more likely to have functional renal failure which is a frequent event in the course of SBP and constitutes the most important predictor of hospital mortality in those patients.
Tumor necrosis factor-a is probably the most important inflammatory mediator of SBP patients, TNF-a induces the synthesis and release of inducible nitric oxide synthetase (INOS). TNF-a and NO have been implicated in splanchnic vasodilatation and hyperdynamic circulation ending in hepatorenal syndrome.
The aim of this study is to assess the role of TNF-a and NO in development of hepatorenal syndrome in cirrhotic ascitic patients complicated with SBP.
This study was carried out on 60 patients, suffering from cirrhotic ascites with and without SBP in addition to 10 healthy control.
All subjects were divided into four groups;
Group (I): This group involved 20 cirrhotic ascitic patients complicated with SBP and hepatorenal syndrome.
Group (II): It comprised 20 cirrhotic ascitic patients complicated with SBP, without hepatorenal syndrome.
Group (III): It included 20 patients with sterile cirrhotic ascites not complicated with hepatorenal syndrome.
Group (IV): It involved 10 healthy control subjects.
Diagnosis of SBP was based on ascitic fluid polymorphonuclear cell count (PMN) ³ 250 cells/mm3 with a compatible clinical picture or PMN ³ 500 cells/mm3 with or without a compatible clinical picture.
All patients were subjected to careful history taking, thorough clinical examination, abdominal ultra-sonography, complete urine analysis, complete blood picture, liver and kidney functions tests, virological markers (HCVAb, HBsAg), blood culture, ascitic fluid analysis, and determination of both serum & ascitic TNF-a and NO using ELISA technique. In addition to previous investigations, assessment of ascitic fluid PMN, blood picture, liver & kidney functions, ascitic & serum TNF-a and NO level were done for group I and II after 48 hours of treatment with 3rd generations cephalosporines.
The following results were obtained.
· Abdominal pain, fever, encephalopathy, jaundice and GIT bleeding were the most frequent presentations respectively.
· 22 patients (55%) out of total 40 SBP cases were culture positive, where E. coli followed by Streptococcus, Klebsiella and Staphylococcus were the causative pathogens of ascitic fluid infection (50%, 22.72%, 18.1% and 9.1% respectively).
· Total serum and ascitic TNF-a and NO levels were significantly higher in SBP patients than cirrhotic patients with sterile ascites.
· Moreover, total serum and ascitic TNF-a and NO levels were higher in SBP patients complicated with hepatorenal syndrome than SBP patients without hepatorenal syndrome.
· Correlation studies showed significant positive correlation between serum levels of both TNF-a and NO among studied groups. Moreover, there was direct correlation between serum and ascitic levels of both TNF-a and NO.
· Also, total serum TNF-a and NO levels were increased in patients with fever, abdominal pain, jaundice and encephalopathy.
· Serum TNF-a and NO levels were elevated in patients with hepatitis B among group I (SBP with hepatorenal syndrome) with no significant difference between TNF-a and NO levels and etiology of cirrhosis among other groups.
· Also, there was significant correlation between serum TNF-a and NO level and bilirubin, prothrombin time and total leucocytic count among studied groups.