Background/Aims
Large volume paracentesis (LVP) associated with plasma volume expansion is known to be an effective and safe therapy for tense or refractory ascites in cirrhosis. Spontaneous bacterial peritonitis (SBP) is one of the frequent infections in patients with cirrhosis. We conducted a study to assess the efficacy and safety of large volume paracentesis in cirrhotic patients with SBP. Methods: We randomly assigned 40 patients with cirrhosis and SBP to either treatment with LVP (21 patients) or general management (19 patients). LVP was defined as drainage of ascitic fluid of more than 4 liters in a single tap or loss of shifting dullness after paracentesis. LVP was performed within 48 hours after the diagnosis of SBP in the LVP group. Cefotaxime was given daily in doses that varied according to the serum creatinine level in both groups. Albumin was given at a dose of 6-8 g per 1 liter of removed ascites in the LVP group. Results: After seven days of treatments, the blood chemistry test, and WBC (PMN) counts and protein concentration in the ascitic fluid were not different between the two groups. Among them, the WBC (PMN) counts were decreased significantly in both groups and protein concentrations tended to increase. Durations of abdominal tenderness and pain were shorter in the LVP group but the differences were statistically not significant. Admission periods, resolution rates of SBP after seven days of treatment, complication rates and in-hospital mortality rates were not different between the two groups. Conclusions: The two treatment methods demonstrated almost the same effectiveness and safety. The symptoms were improved slightly faster in the LVP group. We concluded that large volume paracentesis is not an absolute contraindication and can be a tolerable and safe therapy in some selected cirrhotic patients with tense ascites and SBP.(Korean J Hepatol 2002;8:52-60)

Backgrounds/Aims
Recently, treatment failure with the third generation of cephalosporin was increasingly noted in patients with spontaneous bacterial peritonitis (SBP). We therefore were to evaluate the pattern of antibiotic resistance and its clinical significance. Methods: We retrospectively analyzed 580 episodes of SBP occurring between 1995 and 1999. There were 87 episodes of SBP in 1995, 222 in 1998, and 271 in 1999. The pattern of isolated organisms and antibiotic resistance, and prognostic factors for survival, were analyzed. Results: Microorganisms were isolated in 41% of total episodes. The three most frequently isolated organisms were E. coli (48%), K. pneumoniae (15%), and Aeromonas (8%). The percentage of resistant strains to cefotaxime (9%, 14%, 32%) and ciprofloxacin (13%, 21%, 32%) significantly increased. The proportion of E. coli producing extended spectrum β-lactamase (ESBL) also increased significantly (0%, 16%, 33%). The need of secondary antibiotics such as imipenem due to treatment failure was significantly increased from 0% in 1995 to 33% in 1999. Overall in-hospital mortality, however, was not changed (20%, 20%, 24%, respectively). The factor affecting early mortality was renal failure at diagnosis. Prognostic factors for long-term survival were the presence of associated malignancy and ESBL-producing microorganisms. Conclusion: Microorgansims resistant to third generation cephalosporin and quinolone were increasingly isolated over the 5 years in patients with SBP. Measures to prevent in-hospital spread of resistant strains and indiscreet use of antibiotics should therefore be instituted.(Korean J Hepatol 2002;8:61-70)

Background/Aims
Spontaneous bacterial peritonitis (SBP) is a major problem associated with liver cirrhosis which has high mortality. Increased production of inflammatory mediators, such as tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) may be associated with development of renal impairment, one of the most important prognostic parameters in SBP. The aim of this study is to investigate the changes of these cytokines in ascitic fluid and plasma in patients with SBP and the relationship between these cytokines and development of renal impairment. Methods: Forty patients with liver cirrhosis and ascites were studied 21 with SBP and 19 with sterile ascites. TNF-α and IL-6 levels in ascitic fluid and plasma were determined by ELISA at the time of diagnosis in both groups and 48 hours after antibiotics treatment in SBP patients. Results: TNF- and IL-6 levels in ascitic fluid and plasma were significantly higher in patients with SBP than those without SBP (ascitic fluid TNF-α: 2.5±0.5 vs. 1.6±0.2; plasma TNF-α: 2.3±0.5 vs. 1.5±0.2; ascitic fluid IL-6: 3.8±0.5 vs. 3.0±0.4; plasma IL-6: 3.4±0.5 vs. 2.3±0.3, log pg/mL) (p<0.001). In patients with SBP, levels of TNF-α and IL-6 in ascitic fluid and plasma decreased 48 hours after antibiotics treatment. Eleven patients with SBP (11/21, 52%) developed renal impairment. Patients with renal impairment had significantly higher ascitic fluid and plasma TNF-α levels than those without renal impairment (median 2.5 vs. 2.1 for ascitic fluid, p=0.006; median 2.4 vs. 2.0, log pg/mL for plasma, p=0.04). Although four out of eleven (36%) patients who developed renal impairment died during hospitalization, all the patients without renal impairment survived (p=0.09). Conclusion: Our results suggest that the levels of TNF-α and IL-6 in ascitic fluid and plasma are increased in SBP and elevated levels of TNF-α in ascitic fluid and plasma may be associated with development of renal impairment, thus indicating poor prognosis in patients with SBP. (Korean J Hepatol 1999;5:314－321)

Background/Aims
: The standard regimen of SBP is cefotaxime 2 g IV, every 8 hours for 10 days, and the success rate is approximately 90%. It was reported that 5-day therapy was as effective as 10-day therapy, but, generally, the 5-day therapy has not been accepted in practice. This study was done to confirm whether the short-term therapy is as effective as long-term therapy, and additionally whether the opsonin capacity influences the final output of antibiotic therapy. Methods : Of the 27 patients who met strict criteria for SBP or culture negative neutrocytic ascites, 14 were randomized to a group receiving 5 days and 13 to a group receiving 10 days of single agent cefotaxime 2g IV every 8 hours. Many variables (clinical data, standard liver and kidney function results, ascitic fluid data, complement proteins) were obtained at admission, the 2nd day, and the last day(the 5th or 10th day) of the study. Results : Hospitalization mortality(7% vs 15%), recurrence rate(21% vs 0%), infection related mortality(7% vs 0%) and therapeutic response(86% vs 92%) were not significantly different between the 5- and 10-day treatment groups. The opsonic activity was not significantly different between the recurrence(n=3) group and non-recurrence group(n=26), but the indices of opsonic activity in recurrence group showed lower tendency than those in non-recurrence group. Early response rate was significantly different between the high and low protein concentration in ascitic fluid. Conclusions : Short course treatment of SBP is as effective as long-course therapy and significantly less expensive. (Korean J Hepatol 2000;6:102－110)

Background/Aims
Nitricoxide (NO) is a molecule involved in vascular dilatation and pathogen suppression. It also has immunologic and regulatory functions. Liver cirrhosis is characterized by an increased risk for bacterial infections, including spontaneous bacterial peritonitis (SBP). The role of NO in SBP which develops in cirrhosis has not been clearly established. The aim of this study was to investigate the role of NO in the pathogenesis of SBP and its clinical usefulness for prediction of disease prognosis. Methods: This study was designed to investigate the changes of ascites NO in the course of treatment. Nitricoxide metabolite (nitrites+nitrates [NO x]) was measured by chemilum inescence in 84 ascites samples obtained from 84 cirrhotic patients. Among them , the 38 patients with SBP were treated with cefotaxim e 2.0 g, q 12hr for 7 days. In 24 of SBP patients, ascites was obtained consecutively before treatment (day 0),during treatment (day 2),and after treatment (day 7). Results: Ascites NO levels in the patients w ith SBP (n=38; 82.3 14.4 μM ) were not different from those in patients with sterile ascites (n=46; 54.6 13.0 μM ). There was no significant change of NO levels in sequential ascites samples during antibiotic treatment. A scites NO level before treatment was significantly higher in SBP patients who responded to antibiotics (n=26; 101.86 μM/L) than that in SBP patients who did not respond to antibiotics (n=12; 40.03 μM/L, P =0.044). A significant direct correlation was found between ascites and serum NO levels before treatment (Pearson correlation,r²=0.86,P =0.001). Among the SBP patients, treatment response rate to antibiotics were significantly higher in those patients with pretreatment NO level≥80 μM/L in multivariate analysis. Conclusions: Ascites NO level was not different between ascites from SBP patients and ascites from cirrhotic patients with sterile ascites. There were no changes of ascites NO in SBP patients during treatment. Therefore ascites NO was not useful to predict the progress of SBP. Ascites NO levels reflect serum NO levels, and the patients with higher NO level may have better response to antibiotics. (Korean J Hepatol 2004;10:207-215)