Biomedical subjects

B A Runyon

Publications and source records attributed to B A Runyon.

At least 55 records · Page 3Linked to original sources

PubMed1990

Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis.

To prospectively assess the value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis, we performed serial paracenteses in 43 episodes of ascitic fluid infection (28 spontaneous and 15 secondary) in 40 patients. The algorithm involved identification of (a) secondary peritonitis associated with gut perforation, based on previously proposed criteria in patients with neutrocytic ascites (ascitic fluid total protein greater than 1 g/dl, glucose less than 50 mg/dl, and lactate dehydrogenase greater than the upper limit of normal for serum) and (b) separation of spontaneous from secondary peritonitis (unassociated with perforation) based on the response of the ascitic fluid cell count to antibiotic therapy. The perforation criteria had 100% sensitivity in detecting episodes of actual gut perforation; their specificity, however, was low (45%). After 48 h of treatment the concentration of ascitic fluid neutrophils was below the baseline pretreatment value in all episodes of spontaneous peritonitis but in only two thirds of the patients with secondary peritonitis. This algorithm is useful in (a) identifying patients who have infected ascites associated with perforation of an intraabdominal viscus, and (b) differentiating spontaneous from nonperforation secondary peritonitis on the basis of the response of the ascitic fluid cell count to appropriate antibiotic therapy. The optimal time for repeat paracentesis in patients with infected ascites appears to be 48 h after initiation of treatment.

Algorithms↗

PubMed1990

Spontaneous Salmonella infection of high-protein noncirrhotic ascites.

Spontaneous bacterial peritonitis rarely complicates high-protein (greater than 2.5 g/dl) ascites. The relatively high endogenous antimicrobial (opsonic) activity of the ascitic fluid in this setting appears to protect the patient from infection. We report two patients with high-protein, noncirrhotic ascites complicated by spontaneous peritonitis due to Salmonella species. One patient had ascites due to heart failure, whereas the other patient's ascites was due to peritoneal carcinomatosis. The ascitic fluid total protein concentrations were 3.1 and 3.3 g/dl, respectively, and the opsonic activity of the ascitic fluid specimens were 2.03 and 2.00 log kill, respectively, indicating a high degree of bacterial killing. We hypothesize that the virulence of the Salmonella species was able to overcome the high opsonic activity in the ascitic fluid, resulting in infection in these two patients. Fever, abdominal pain, or encephalopathy in a patient with high-protein ascites may suggest the presence of an unusual organism causing spontaneous bacterial peritonitis.

Ascites↗

PubMed1990

Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis.

Ascitic fluids from patients suspected of having spontaneous bacterial peritonitis were inoculated into blood culture bottles (i) at the bedside and (ii) in the laboratory after a delay. In 29 episodes in which the bedside bottles were culture positive, only 22 (75.9%) of the laboratory-inoculated sets demonstrated growth; this difference was statistically significant (P less than 0.02).

Ascitic Fluid↗

PubMed1989

Polymorphonuclear cell count response and duration of antibiotic therapy in spontaneous bacterial peritonitis.

The purposes of this study were (a) to measure serially ascitic fluid polymorphonuclear cell response in treated spontaneous bacterial peritonitis and (b) to determine whether an ascitic fluid polymorphonuclear cell count of less than 250 per mm3 on serial paracenteses was a satisfactory endpoint for antibiotic therapy. Thirty of 33 patients showed an exponential fall in ascitic fluid polymorphonuclear cell count after 48 hr of antibiotic therapy; the magnitude of decrease correlated with survival (p less than 0.01). Among the patients whose antibiotic therapy was discontinued when the ascitic fluid polymorphonuclear cell count reached 250 per mm3 or less, the duration of therapy was considerably shorter than for the patients who received "conventional" therapy (p less than 0.01). Recurrence of spontaneous bacterial peritonitis was similar in the two groups. Mortality correlated with the severity of underlying liver disease but not with duration of antibiotic therapy.

Anti-Bacterial Agents↗

PubMed1989

Effect of diuresis versus therapeutic paracentesis on ascitic fluid opsonic activity and serum complement.

Therapeutic paracentesis has recently been reported to eliminate ascites in patients with cirrhosis more rapidly than diuresis. However, diuresis has been shown to increase ascitic fluid opsonic activity. Patients with adequate ascitic fluid opsonic activity have been reported to be protected from spontaneous bacterial peritonitis. In this randomized controlled trial, 19 patients with cirrhotic ascites were treated with diuresis versus daily therapeutic paracenteses during 20 hospitalizations. Serum and ascitic fluid complement concentrations and ascitic fluid opsonic activity were measured at the beginning and end of treatment. Although opsonic activity increased significantly (p less than 0.01) in patients treated with diuresis, this parameter was stable in the paracentesis group. The stability of the ascitic fluid opsonic activity and complement concentration in the paracentesis group were maintained at the expense of a decrease in serum complement, whereas serum and ascitic fluid complement increased in the diuresis group. Diuresis may have the advantage over therapeutic paracentesis of providing better protection from spontaneous bacterial peritonitis. Study of larger numbers of patients will determine if these changes in complement concentrations and opsonic activity translate into an increased risk of spontaneous bacterial peritonitis in vivo.

Ascites↗

PubMed1988

Optimization of ascitic fluid culture technique.

The conventional method of ascitic fluid culture detects bacteria in only 42%-65% of patients who have neutrocytic ascites and suspected spontaneous bacterial peritonitis. In this study ascitic fluid was cultured by the conventional method as well as by a new method consisting of bedside inoculation of blood culture bottles with ascites. The conventional cultures grew bacteria in only 13 (43%) of 30 episodes of neutrocytic ascites, whereas the blood culture bottles grew bacteria in 28 (93%); this difference was significant (p less than 0.0001). The blood culture bottle method also resulted in more rapid detection of bacterial growth. The median concentration of bacteria in infected ascites was one organism per milliliter. Bedside inoculation of blood culture bottles with ascitic fluid is more sensitive than the conventional method in detecting bacterial peritonitis. The insensitivity of the conventional method is probably due to the low concentration of bacteria in infected ascites and the small volume of ascites cultured by this method.

Ascitic Fluid↗

PubMed1988

Cardiac ascites: a characterization.

In a prospective study, there were 13 patients with cardiac ascites among a group of 262 ascites patients (5% of the total). I compared the characteristics of 20 ascitic fluid samples from these patients with heart failure to those of 20 patients with cirrhotic ascites. The serum-ascites albumin concentration gradient was greater than or equal to 1.1 g/dl in all patients in both groups. The ascitic fluid total protein concentration was greater than or equal to 2.5 g/dl in all patients with cardiac ascites whereas only 10% of patients with cirrhotic ascites had such high values. The ascitic fluid lactate dehydrogenase and red cell counts were significantly higher in cardiac ascites than in cirrhotic ascites--although cardiac ascites was not visibly bloody. The peripheral hematocrit of patients with cardiac ascites was also significantly higher than that of patients with cirrhotic ascites. The ascitic fluid analysis in patients with cardiac ascites is characteristic and may assist in the differential diagnosis of ascites.

Ascites↗

PubMed1987

Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy.

Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.

Aged↗

PubMed1987

Amylase levels in ascitic fluid.

The amylase concentration of ascitic fluid and serum were measured in patients with various types of ascites to determine their normal range. The mean (+/- SD) nonpancreatic ascites amylase concentration was 42 +/- 44 IU/L (range 4-234) and the mean ascitic fluid/serum amylase concentration ratio was 0.44 +/- 0.33 (range 0.10-1.55). Of the various types of non-pancreatic ascites (sterile cirrhotic, infected, malignant, etc.), no group had a significantly different ascitic fluid amylase concentration or concentration ratio than any other group. Two patients with pancreatic ascites had a mean ascitic fluid amylase concentration of 1,957 +/- 1,093 IU/L and a mean amylase concentration ratio of 5.59 +/- 0.02--both significantly (p less than 0.001) greater than those of nonpancreatic ascites.

Amylases↗

PubMed1987

Exquisite sensitivity to small decrements in corticosteroid dose in autoimmune chronic active hepatitis.

Symptomatic relapses of autoimmune chronic active hepatitis during steroid withdrawal are well known. However, the exquisite sensitivity of some patients to very small decrements in steroid dose has not been emphasized. Reported here are two patients who developed, during steroid withdrawal, eight relapses of their disease; symptomatic and biochemical relapses occurred within 3 weeks after prednisone had been reduced from 2.5 mg every other day to 1.75 mg every other day in one patient and from 2.5 mg per day to zero in the other. "Physiologic" doses of prednisone may be therapeutic in some patients with autoimmune chronic active hepatitis.

Adolescent↗

PubMed1987

Ascitic fluid bilirubin concentration as a key to choleperitoneum.

Total bilirubin concentration was measured in the ascitic fluid and serum of 65 patients with various types of ascites to determine the normal range of these parameters. The mean (+/- SD) ascitic fluid bilirubin was 0.7 +/- 0.8 mg/dl, and the mean ascitic fluid/serum bilirubin ratio was 0.38 +/- 0.44. Subsequently, I recognized choleperitoneum in a patient with bile-stained ascites preoperatively, because the ascitic fluid bilirubin was 18.5 mg/dl and the ratio was 7.1. Laparotomy documented a ruptured gallbladder. An ascitic fluid bilirubin concentration greater than 6 mg/dl with an ascitic fluid/serum bilirubin ratio greater than 1.0 appears to be characteristic of choleperitoneum.

Aged↗

PubMed1987

Inoculation of blood culture bottles with ascitic fluid. Improved detection of spontaneous bacterial peritonitis.

The observation that only 42% of the cases of suspected spontaneous bacterial peritonitis at the University of New Mexico, Albuquerque, had positive cultures prompted a change in ascitic fluid culture technique such that a large volume (10 mL in toto) of ascitic fluid was inoculated into blood culture bottles at the bedside. This new method of culture increased the percentage of cases with positive cultures to 91% and decreased the interval between inoculation of the culture and detection of bacterial growth. This is a more sensitive method of culture than the conventional method in detecting spontaneous bacterial peritonitis.

Ascitic Fluid↗

PubMed1986

Polymicrobial bacterascites. A unique entity in the spectrum of infected ascitic fluid.

A retrospective analysis of 1578 abdominal paracenteses revealed ten cases of polymicrobial bacterascites, ie, growth of multiple organisms in ascitic fluid with a neutrophil count less than 250 cells/cu mm. Six of the ten paracenteses that documented this condition were traumatic (bloody or producing feculent material). Clinical peritonitis developed in only one patient. No one died as a result of the infection. Polymicrobial bacterascites is rare (0.6% of paracenteses). It is frequently due to a traumatic paracentesis (bowel entry by the paracentesis needle), and is associated with low morbidity.

Ascitic Fluid↗

PubMed1986

Spontaneous vs secondary bacterial peritonitis. Differentiation by response of ascitic fluid neutrophil count to antimicrobial therapy.

A retrospective chart review revealed 24 patients who had at least one subsequent ascitic fluid neutrophil count within 14 days of the ascitic fluid analysis that was diagnostic of spontaneous bacterial peritonitis. The neutrophil count decreased (after antibiotic therapy was started) at an exponential rate, with a half-life of 34 +/- 35 hours. In none of four episodes of secondary bacterial peritonitis was there an exponential decline in neutrophil count after antimicrobial therapy was initiated. In fact, the first follow-up neutrophil count was greater than the baseline value in all four episodes. The response pattern of the ascitic fluid neutrophil count to antimicrobial therapy is helpful in differentiating spontaneous from secondary bacterial peritonitis.

Anti-Bacterial Agents↗

PubMed1986

Bacterial peritonitis secondary to a perinephric abscess. Case report and differentiation from spontaneous bacterial peritonitis.

A cirrhotic patient is described who presented with Escherichia coli septic arthritis as the first manifestation of a perinephric abscess. Results of baseline abdominal paracentesis were unremarkable. After 10 days of antibiotics, abdominal paracentesis was repeated because of recurrence of fever; E. coli peritonitis was confirmed. Subsequent autopsy revealed a perinephric abscess. Development of bacterial peritonitis during antibiotic treatment is distinctly unusual in the "spontaneous" form of peritonitis and should raise suspicion of secondary bacterial peritonitis.

Abscess↗

PubMed1986

Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis.

To assess the risk of development of spontaneous bacterial peritonitis in relation to the ascitic fluid total protein concentration, routine admission abdominal paracentesis was performed on a group of 107 patients during 125 hospitalizations. The paracentesis was repeated if evidence of peritonitis developed during hospitalization. Twenty-one episodes of spontaneous peritonitis (or its culture-negative variant) were documented in 17 patients. The ascitic fluid protein concentration in the spontaneous peritonitis group (0.72 +/- 0.53 g/dl) was significantly lower (p less than 0.001) than that in the group of patients with sterile portal hypertension-related ascites (1.36 +/- 0.89 g/dl) and was significantly lower than that of patients with ascites due to miscellaneous causes. Of the patients whose initial sterile ascitic fluid protein concentration was less than or equal to 1.0 g/dl, 7 of 47 (15%) developed spontaneous peritonitis during their hospitalization; whereas only 1 of 65 (1.5%) patients who had an initial sterile ascitic fluid protein concentration greater than 1.0 g/dl developed spontaneous peritonitis. This difference in risk of development of peritonitis in relation to initial ascitic fluid protein concentration was also significant (p less than 0.01). Low-protein-concentration ascitic fluid predisposes to spontaneous bacterial peritonitis.

Ascitic Fluid↗

PubMed1986

Elevated ascitic fluid fibronectin concentration. A non-specific finding.

Ascitic fluid fibronectin concentration was measured in 111 specimens by laser nephelometry. Sterile, portal hypertension-related fluid fibronectin concentration (24 +/- 14 micrograms/ml) was significantly lower than the concentration in infected, portal hypertension-related ascites (49 +/- 44 micrograms/ml, P less than 0.001), peritoneal carcinomatosis (123 +/- 45 micrograms/ml, P less than 0.001), massive liver metastases-related ascites (55 +/- 21 micrograms/ml, P less than 0.001), as well as in ascites of other types (94 +/- 42 micrograms/ml, P less than 0.001). The percentage of samples with fibronectin concentration, greater than 75 micrograms/ml, was 0% for sterile, portal hypertension-related ascites, 28% for infected, portal hypertension-related ascites, 89% for peritoneal carcinomatosis, 20% for massive liver metastases-related ascites, and 72% for ascites of other types. Ascitic fluid fibronectin concentration correlated in a linear fashion with ascitic fluid total protein (r = 0.81, P less than 0.001). Fibronectin concentration in ascites appears to be elevated under a variety of conditions and does not appear to be a specific marker for cancer.

Ascites↗

PubMed1986

Ascitic fluid and serum C-reactive protein concentrations in patients with and without peritonitis.

Seventy-five paired ascitic fluid and serum specimens were tested for C-reactive protein (CRP) concentrations with the use of laser nephelometry. There was no clear separation of the ascitic fluid or serum values of the 19 paired specimens obtained from patients with peritonitis from the 37 paired sterile portal-hypertension-related samples or from the 19 paired miscellaneous specimens. The ascitic fluid CRP concentrations of patients with sterile portal-hypertension-related ascites were not significantly different from those of infected specimens. However, the serum CRP values were significantly higher in patients with peritonitis than in patients with sterile portal-hypertension-related ascites. Ascitic fluid CRP does not appear to be a useful indicator of ascitic fluid infection.

Ascitic Fluid↗