Original article
Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax

https://doi.org/10.1016/j.ajg.2017.05.010Get rights and content

Abstract

Background and study aims: Spontaneous bacterial empyema (SBEM) is an underestimated condition in patients with ascites and hepatic hydrothorax with a high mortality. This study aimed to find whether spontaneous bacterial peritonitis (SBP) is a prerequisite for SBEM. Patients and methods: 3000 HCV-related cirrhotic patients with ascites and hydrothorax were screened for the presence of SBP (ascitic fluid neutrophils >250/mm3) and SBEM (positive pleural fluid culture and neutrophils >250/mm3 or negative pleural fluid culture and neutrophils >500/mm3 with no evidence of pneumonia/parapneumonic effusion on chest radiograph or CT). Results: The prevalence of SBEM in cirrhotic patients was 1.2% (36/3000) unlike SBP (1.6%; 48/3000). SBEM was detected in 51.4% of the patients with hepatic hydrothorax (36/70). A total of 70 patients had concomitant ascites and hydrothorax, namely SBP (n = 17), SBEM (n = 5), and dual SBP and SBEM (n = 31), whereas 17 patients had sterile concomitant ascites and hydrothorax. Age, sex, liver function, kidney function tests, complete blood count, INR, MELD, MELD-Na, blood chemistry, and culture/sensitivity for ascitic and pleural fluid were statistically not different (p > 0.05) between SBP and dual SBP and SBEM patients. Escherichia coli and Klebsiella pneumoniae were detected in the culture. From univariate analysis, no predictors of dual SBP and SBEM were detected. Conclusion: SBEM is a part of SBP in cirrhotic patients with ascites and hydrothorax.

Introduction

Liver cirrhosis is usually associated with increased mortality and morbidity as it may be complicated by ascites, portal hypertension (PH) and fatal hepatocellular carcinoma [1]. There are various pulmonary diseases which develop as a consequence of cirrhosis and PH, namely hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax [2].

Hepatic hydrothorax is a transudative pleural effusion in patients with cirrhosis/PH without evidence of cardiopulmonary aetiology. It is usually seen in patients with ascites with an incidence of 6–15%. In 79.5% of the cases, it is usually right sided, however, may be left sided in 17.5% and as bilateral effusion in 3% of the cases. It may be asymptomatic or associated with dyspnoea and respiratory distress [3].

Spontaneous bacterial empyema (SBEM) is simply an infection of pre-existing hepatic hydrothorax. It usually occurs in association with spontaneous bacterial peritonitis (SBP), although it may also occur independent of it [4]. It is reported to be associated with 20% mortality [5]. In fact, the name empyema is a misnomer because it is completely different from pneumonia-related empyema in its aetiology and physical and chemical criteria of the effusion fluid. Moreover, indwelling chest tube should not be used in patients with SBEM [6].

This study aimed to find if SBP is a prerequisite for SBEM.

Section snippets

Patients and methods

After institutional review board approval, this study was conducted in National Liver Institute hospitals, Menoufia University, Egypt. Informed consent was obtained from all enrolled patients.

A total of 3000 patients with HCV-related liver cirrhosis who were admitted to the Hepatology department, National Liver Institute hospitals, Menoufia University, Egypt, were enrolled. Diagnosis of cirrhosis was based on clinical, laboratory, and ultrasonographic findings with or without liver biopsy [7].

Statistical analysis

Data were statistically analyzed using IBM® SPSS® Statistics® version 21 for Windows. Data were expressed as mean ± standard deviation. All p-values are two-tailed, with values < 0.05 considered statistically significant. Comparisons between two groups were performed using the Student’s t-test. Chi-squared test (χ2) and Fisher’s exact test were used for categorical data analysis. Univariate logistic regression analysis was used to detect the predictors of dual SBP and SBEM.

Results

In total, 3000 HCV-related liver cirrhosis patients were screened for concomitant ascites and hydrothorax. Only 70 patients had concomitant ascites and hydrothorax: SBP (n = 17; 24.3%), SBEM (n = 5; 7.1%), and dual SBP and SBEM (n = 31; 44.3%), whereas 17 (24.3%) patients had sterile concomitant ascites and hydrothorax. The prevalence of SBEM in cirrhotic patients was 1.2% (36/3000) unlike SBP (1.6%; 48/3000). SBEM was detected in 51.4% (36/70) of the patients with hepatic hydrothorax as shown in

Discussion

Progressive liver disease may finally lead to cirrhosis, which may be complicated by ascites, PH, varices, and hepatorenal syndrome [1]. Liver cirrhosis may be associated with various lung diseases such as hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax [15]. Hepatic hydrothorax is reported to occur in up to 10% of the patients with ascites, causing dyspnea and respiratory infection with bad prognosis [14]. It usually develops as a result of passage of the ascitic

Conflict of interest

None.

References (27)

  • Y.K. Lai et al.

    POINT: does spontaneous bacterial empyema occur? Yes

    Chest

    (2015)
  • T.A. Nguyen et al.

    COUNTERPOINT: does spontaneous bacterial empyema occur? No

    Chest

    (2015)
  • K.L. Krok et al.

    Hepatic hydrothorax

    Semin Respir Crit Care Med

    (2012)
  • View full text