自發性細菌性腹膜炎
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自發性細菌性腹膜炎 | |
---|---|
分類和外部資源 | |
醫學專科 | 胃腸學 |
ICD-11 | DC50.00 |
ICD-10 | K65.2 |
eMedicine | 789105 |
自發性細菌性腹膜炎(英語:Spontaneous bacterial peritonitis,SBP)是指在腹膜中發生的細菌感染,但沒有明顯的感染源。[1]具體是腹水(即體積過度增加的腹膜液)受到感染。[2]腹水是肝硬化最常見的併發症。[1]SBP也可能發生在腎病綜合症患者中。[3][4]SBP的死亡率很高。[5]
SBP的診斷需要腹腔穿刺術,即從腹膜腔中抽取腹膜液樣本。[6]如果液體中含有大量中性粒細胞(>250個細胞/µL),則可以確認感染並給予抗生素,而無需等待培養結果。[7]除抗生素外,通常還輸注白蛋白。[7]
自發性細菌性腹膜炎可能引發其他危及生命的併發症,例如腎功能不全和肝功能不全增加。[8][9]30%的SBP患者出現腎功能不全,這是與死亡率關聯性最強的預測因素之一。如果有這種發展跡象,也將給予白蛋白輸注。[10]
自發性真菌性腹膜炎(英語:Spontaneous fungal peritonitis,SFP)也可能發生,這有時會伴隨細菌感染。[11]
徵狀
自發性細菌性腹膜炎的徵狀包括發燒、寒戰、噁心、嘔吐、腹痛和壓痛、全身不適、精神狀態改變和腹水惡化。[1]13%的患者沒有任何徵狀。[12]在急性或慢性肝功能衰竭的情況下,SBP是肝性腦病的主要誘因之一,如果沒有其他明確的因果指征,則可能懷疑SBP。[10]
自發性真菌性腹膜炎的徵狀也可能與細菌性腹膜炎相同,導致難以區分。延誤診斷會延誤抗真菌治療並導致更高的死亡率。[11]
病因
SBP最常由革蘭氏陰性大腸桿菌引起,其次是克雷伯氏菌。鑑定出的常見革蘭氏陽性菌包括鏈球菌、葡萄球菌和腸球菌。[13]由革蘭氏陽性菌引起的SBP的百分比一直在增加。[7][13]
當自發性細菌性腹膜炎被抗生素治療治好後,有時會緊接着出現自發性真菌性腹膜炎。[11]這是因為抗生素的使用會導致腸道菌群中的真菌過度生長,而真菌或會轉移到腹膜腔中。[11][14]儘管真菌比細菌大,晚期肝硬化導致腸道通透性增加,使它們更容易轉移。[11]SFP主要由念珠菌引起,最常見的是白色念珠菌。[14]
病理生理學
H2拮抗劑和質子泵抑制劑是減少或抑制胃酸分泌的藥物。它們在治療肝硬化中的應用與SBP的發展有關。[15][16][17]細菌易位被認為是SBP發生的關鍵機制。[1][18]在大部分肝硬化患者中發現可能與這種易位有關的小腸細菌過度生長。[19]對於受損的宿主防禦,患有嚴重急性或慢性肝病的患者通常缺乏補體,也可能存在中性粒細胞和網狀內皮系統功能障礙。[20]
研究表明,腹水蛋白濃度低於1 g/dL的肝硬化患者發生SBP的可能性是濃度較高的個體的10倍。[21]學界認為腹水的抗菌或調理活性與蛋白質濃度密切相關。[22]其他研究證實了腹水蛋白濃度作為SBP首次發作的最佳預測指標的有效性。[20]
在腎病綜合症患者當中,SBP常影響兒童,很少影響成人。[23]
診斷
腹膜感染引起炎症反應,隨後腹水中的中性粒細胞數量增加。[5]診斷SBP需要通過腹腔穿刺術(吸取腹水);如果液體中含有超過250個細胞/mm3(等於細胞計數250x106/L)液體的中性粒細胞,且沒有其他原因(例如內臟器官的炎症或穿孔),則診斷為SBP。[1][10]
此外,亦會對腹水進行培養,以識別細菌。如果將樣品放在普通的無菌容器中,40%的樣品會識別出微生物,而如果將樣品放在裝有培養基的瓶子中,靈敏度會提高到72-90%。[10]
預防
抗生素(口服氟喹諾酮諾氟沙星)可能對符合以下情況的肝硬化患者有幫助:
- 腹水蛋白<1.0 g/dL。[21]體液蛋白<15 g/L且Child-Pugh評分至少為9或腎功能受損的患者也可能受益。[24]
- 既往患過SBP[25]
在以下情況下,入院的肝硬化患者應接受預防性抗生素治療:
對肝硬化患者使用利福昔明的研究表明,其使用可能有效預防自發性細菌性腹膜炎。[9][27]
治療
抗生素
儘管沒有高質量的證據,但第三代頭孢菌素被認為是肝硬化患者自發性細菌性腹膜炎的標準經驗性治療。[28]
在實驗中,頭孢噻肟是治療SBP的首選藥物。[29]在確診SBP後,通常建議住院觀察和靜脈抗生素治療。
在肝腎綜合症中存在腎功能障礙風險的情況下,通常也給予靜脈內白蛋白。48小時後可重複穿刺以確保控制感染。從單次SBP發作恢復後,建議無限期預防性使用抗生素。[10]
促動力劑
在抗生素方案中添加促動力藥物可能通過減少小腸細菌過度生長來降低自發性細菌性腹膜炎的發生率。[30]
靜脈注射白蛋白
一項隨機對照試驗發現,在入院當天和住院第3天靜脈注射白蛋白可以減少腎功能損害。[31]
流行病學
腹水患者接受常規腹腔穿刺術,入院時活躍SBP的發生率為10%至27%。[32]
歷史
SBP於1964年由哈羅德·康涅狄格首次描述。[33]
參考文獻
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外部連結
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