Spontan-bakterielle und sekundäre Peritonitis bei Patienten mit Leberzirrhose und Aszites

Zusammenfassung

Die Peritonitis stellt eine der häufigsten infektiösen Komplikationen beim Patienten mit Leberzirrhose und Aszites dar. In mehr als 95 % der Fälle tritt sie als spontan-bakterielle Peritonitis (SBP) als Folge der Translokation von Bakterien aus dem Darmlumen in die mesenterialen Lymphknoten mit nachfolgender systemischer Zirkulation auf. Identifizierte Risikofaktoren, die eine antibiotische Prophylaxe der SBP rechtfertigen, stellen eine vorausgegangene Episode einer SBP, das Auftreten einer gastrointestinalen Blutung und ein erniedrigtes Aszitesprotein in Verbindung mit Nieren- oder fortgeschrittener Leberinsuffizienz dar. Die Therapie der SBP ist ausschließlich konservativ und sollte unter Berücksichtigung individueller und nosokomialer Risikofaktoren für antimikrobielle Resistenzen empirisch mit Cephalosporinen der 3. Generation unter zusätz-licher Gabe von Albumin durchgeführt werden. Im Gegensatz zur SBP ist die sekundäre bakterielle Peritonitis ein deutlich selteneres ( < 5 % aller Fälle) und prognostisch ungünstigeres Krankheitsbild, das als Folge einer Hohlorganperforation oder eines entzündlichen oder ischämischen intraabdominellen Prozesses entsteht. Die Höhe der Neutrophilenkonzentration im Aszites sowie klinisch-chemische und mikrobiologische Untersuchungen im Aszites sind geeignet, den Verdacht auf eine sekundäre Peritonitis zu erhärten und sollten eine sofortige sorgfältige Abklärung inklusive abdomineller Computertomografie nach sich ziehen. Aufgrund der hohen Mortalität von 60 – 80 % sind bei der sekundär-bakteriellen Peritonitis ein Anaerobier-wirksames antibiotisches Therapieregime, eine zeitnahe chirurgische Versorgung und eine interdisziplinäre postoperative Betreuung der Patienten indiziert.

Abstract

Peritonitis is one of the most frequent infectious complications in patients with liver cirrhosis and ascites. In more than 95 % it occurs as spontaneous bacterial peritonitis (SBP) as a result of bacterial translocation from intestinal bacteria and bacterial products into mesenteric lymph nodes and subsequent systemic circulation. Identified risk factors that justify antibiotic prophylaxis for SBP include a prior episode of SBP, gastrointestinal haemorrhage and low ascitic fluid protein in combination with renal or advanced liver failure. SBP requires conservative therapy, which should be empirically performed using third-generation cephalosporins and adjunctive albumin therapy under consideration of individual and nosocomial risk factors for antimicrobial resistance. In contrast to SBP, secondary bacterial peritonitis is a rare ( < 5 % of all cases of peritonitis) and more unfavourable disease. It occurs as a result of hollow organ perforation or intra-abdominal inflammatory or ischaemic processes. Analysis of ascitic fluid may help substantiating the suspicion of secondary peritonitis and should entail a meticulous diagnostic work-up including abdominal computed tomography. Because of the high mortality rate (60 – 80 %) of secondary peritonitis antibiotic regimens with anti-anaerobic activity, prompt surgical treatment and interdisciplinary postoperative care are necessary to improve patient outcomes.

Schlüsselwörter

Peritonitis - Infektion - Leberversagen

Key words

peritonitis - infection - liver failure

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