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Los profesionales de la salud de las unidades de endoscopia tienen un posible riesgo de infección por SARS-CoV-2 por diferentes vías: inhalación de gotitas en el aire, aerosoles, contacto conjuntival y transmisión fecal-oral. Objetivo Describir la detección del SARS-CoV-2, en una serie de pacientes, programados para endoscopia digestiva en el Hospital Santa Caterina. Salt. (Girona). Métodos Estudio descriptivo de una serie de casos de pacientes programados para endoscopia durante el mes de mayo de 2020, en el reinicio de la actividad endoscópica después del pico pandémico, siguiendo las recomendaciones de SCD, SEED, AEG y ESGE. Examinamos muestras nasofaríngeas 48-72 horas antes de la cita, mediante RT-PCR a todos los pacientes. La extracción del ARN se hizo mediante kits: Qiagen®-adaptado, BiosSprint®96-DNA-Blood-Kit (384). Para amplificación-detección del SARS-CoV-2 se siguieron métodos recomendados por la OMS y el CDC. Resultados Se programaron 110 pacientes asintomáticos sin contacto estrecho con positivo los 14 días previos; 105 (96,4%) fueron negativos y 5 (4,5%) positivos. Dos pacientes desarrollaron clínica respiratoria después del diagnóstico (presintomáticos) y 3 continuaron asintomáticos. Los 5 pacientes eran casos autóctonos y sin antecedentes de viaje o residencia en otra ciudad o país asociado a alta prevalencia de infección. Cuatro casos fueron mujeres entre 60-81 años. El gen N fue detectado en todos los casos. Conclusiones Se detectó una alta prevalencia de infección por SARS-CoV-2 en pacientes programados por endoscopia digestiva. Dado el riesgo de transmisión a los profesionales, consideramos recomendable realizar RT-PCR del SARS-CoV-2 48-72 horas antes de la exploración en situaciones de alta incidencia poblacional.

Objectives: to conduct a systematic review to describe the epidemiological scientific evidence on gastrointestinal symptoms (GIS), enteric involvement and fecal excretion of SARS-CoV-2 viral RNA and to discuss the possible fecal-oral transmission pathway of COVID-19.Methods: We have reviewed GIS, enteric involvement, and fecal test results of SARS CoV-2 from case reports and retrospective observational studies related to the digestive system published about the outbreak.Results: The prevalence of GIS in patients infected with SARS CoV-2 ranges from 1.7% (1/56)-100% (10/10), GIS included diarrhea 1/99(1%)-8/10(80%), nausea/vomiting 1/28(3.6%)-5/10 (50%), abdominal pain 2/103(1.9%)-1/3(33.3%). A total of 3% of infected patients may experience GIS in the absence of respiratory symptoms. A pooled analysis of the results showed 16.1% GIS, 8.3% diarrhea and 12% nausea-vomiting. A higher percentage of diarrhea in patients with severe disease (5.8%) than in non-severe disease (3.5%), and a more severe course in patients with GIS (22.97%) than in those without GIS (8.12%) was found. Histological studies demonstrated the presence of ACE2 receptors and the nucleocapsid of the virus in gastrointestinal. The RNA of the virus has been detected in 27-53% of patients with COVID-19 in whom respiratory and stool samples have been analyzed, and it may persist in stool for up to an average of 11.2 days after negativization of the respiratory samples.Conclusions: GIS are common in SARS CoV-2 infection at the time of patient admission, sometimes represent the only clinical manifestation. Infection of the GI tract is possible due to the presence of ACE2 receptors, and there may be viral replication with fecal elimination.

Background Irritable bowel syndrome (IBS) is a functional disorder affecting around 11% of the world population, which diagnostic is mainly based on clinical parameters. IBS shares many symptoms with other gastrointestinal disorders such as inflammatory bowel disease (IBD), which makes positive diagnosis a difficult task. Aim This work presents the design of a new test, called RAID‐Dx, which is a mathematical algorithm based on the combination of nine faecal microbial markers capable of diagnosing IBS. Methods A cohort consisting of 165 subjects (52 IBS and 52 IBD patients, and 61 healthy controls) was recruited from the Gastroenterology Department of six hospitals. Each patient provided a stool sample from which DNA was extracted, and microbial markers composing RAID‐Dx were analysed by qPCR. The results obtained were used to define and validate the RAID‐Dx algorithm. Results The abundance of the biomarkers included in the algorithm differed according to the diagnosis. RAID‐Dx shows a high capacity to diagnose IBS with a sensitivity of 82.4% and a specificity of 85.7%. RAID‐Dx also reports higher sensitivity and specificity values than faecal calprotectin for IBS and IBD differentiation. Conclusions RAID‐Dx is a noninvasive tool aimed to diagnose IBS with high sensitivity and specificity. The use of this new tool for IBS diagnosis could significantly improve disease management, minimise its misdiagnosis and increase patients’ quality of life

Background and Aims Crohn’s disease and ulcerative colitis evolve with alternate outbreaks and remissions of variable duration in both cases. Despite the advances, about 10-30% of patients do not respond to the treatment after the induction period. Besides, between 20% to 50% further patients need an optimization of the dose to respond the treatment. Recent studies have pointed gut microbiota can play a role in the anti-TNF treatment response. This study aimed to define a bacterial signature that could be used to predict the response of patients to anti-TNF treatment. Methods There were obtained 38 stool samples from 38 IBD patients before starting anti-TNF treatments: Adalimumab, Golimumab or Infliximab. Patients were differentiated in 2 groups: responders and non-responders to biological treatment. From each sample, DNA was purified and used in a qPCR for the quantification of the 8 microbial markers. Results In this proof of concept, the predictive ability to identify anti-TNF treatment responders was analyzed. An algorithm consisting in the combination of 4 bacterial markers showed a high capacity to discriminate between responders and non- responders. The algorithm proved high sensitivity and specificity reporting values of 93.33% and 100% respectively, with a positive predictive value of 100% and a negative predictive value of 75% for predicting response to biologic treatment. Conclusions A specific bacterial signature could beneficiate patients with inflammatory bowel disease predicting the therapeutic effectiveness of an anti-TNF treatment, leading to a personalized therapy, improving the patients’ quality of life, saving costs and gaining time in patient improvement.

Healthcare professionals in endoscopy units have a possible risk of SARS-CoV-2 infection by different routes: inhalation of airborne droplets, aerosols, conjunctival contact and faecal-oral transmission. Objective To describe the detection of SARS-CoV-2 in a series of patients scheduled for digestive endoscopy at the Hospital Santa Caterina, Salt, (Girona). Methods Descriptive study of a series of cases of patients scheduled for endoscopy during the month of May 2020, when endoscopic activity was resumed after the peak of the pandemic, following SCD, SEED, AEG and ESGE recommendations. We examined nasopharyngeal samples 48−72 h before the appointment, by RT-PCR, in all patients. RNA extraction was performed using the kits: Qiagen®-adapted, BiosSprint®96-DNA-Blood-Kit (384). For amplification-detection of SARS-CoV-2, methods recommended by the WHO and the CDC were followed. Results 110 asymptomatic patients without close contact with a positive case in the previous 14 days were scheduled; 105 (96.4%) were negative and five (4.5%) were positive. Two patients developed respiratory symptoms after diagnosis (presymptomatic) and three remained asymptomatic. Allfive5 patients were autochthonous cases with no history of travel or residence in another city or country associated with high prevalence of infection. Four cases were women aged 60–81 years. The N gene was detected in all cases. Conclusions A high prevalence of SARS-CoV-2 infection was detected in patients scheduled for digestive endoscopy. Given the risk of transmission to professionals, we consider it advisable to perform SARS-CoV-2 RT-PCR 48−72 h before the examination in situations of high incidence in the population.

Aims Experience during the Covid-19 pandemic suggests that digestive endoscopy (DE) is a potential source of infection forpatients and healthcare workers (HCW). The difficult situation in Spain's hospitals forced the endoscopy units to be almostclosed for weeks. Endoscopic scientific societies, like ESGE, published strategies for their re-start;prioritization and Covid-19 screening were two essential conditions. Analyze the incidence and effects of Covid-19 transmission in patients undergoing DE and HCW during the endoscopicactivity reestablishment in 3 centers in Girona's area of health care. Methods Prospective multicentric study with consecutive collection of elective DE during the reintroduction of endoscopicactivity with previous Covid-19 PCR performed. Clinical data from patients and HCW are documented, as well as from theexamination. Telephone questionnaire is done two weeks after the DE and an interview to the HCW. Results 338 procedures were collected in 306 patients (mean age 60.63 years). Previous PCR done in 305 patients, beingnegative in 96.72 %. A total of 224 patients (73.2 %) were contacted, 34 (15.18 %) explained compatible symptoms, with fever being the mostreported (3.13 %). 4.46 % had needed medical consultation, non of them requiring admission or treatment. 18 (8.04 %)underwent another Covid-19 test, being 94.44 % negative. A questionnaire was administered to 39 HCW (mean age 41.33 years). 92.31 % used PPE and 76.92 % used a surgical mask and FFP2 simultaneously. 4 (10.26 %) reported symptoms. 92.31 % of them had previously been tested for Covid-19;serological test in 25 (69.44 %) being negative in 92 %, and in 11 the PCR test being negative in 90.91 %. Conclusions Although performing a second PCR test was extremely difficult due to low availability, our study couldsuggests that with protection measures implementation, there is a low incidence of infection and/or symptoms suggestive of covid-19 in patients who undergo DE and HCW assigned to the endoscopy area.

Background Crohn’s disease (CD) and ulcerative colitis (UC) evolve with alternate outbreaks and remissions of variable duration. Tumour necrosis factor α antagonists (anti-TNFα) have enhanced the treatment of patients with inflammatory bowel disease (IBD), improving the patient’s quality of life by reducing the number of surgeries and hospitalizations. Despite these advances, about 10–30% of patients do not respond to the treatment after the induction period. Recent studies have pointed, on one hand, gut microbiota can play a role in the anti-TNFα treatment response as gram-positive bacteria can modulate the response of NOD proteins and, on the other hand, gram-negative bacteria can stimulate TLR4 receptors causing activation of NFkß. This study aimed to define a microbial signature that could be used to predict the response of patients with CD and UC to anti-TNFα treatment. Methods This observational study consisted of obtaining a stool sample from 38 IBD patients before starting an anti-TNFα treatment. Patients were recruited at Hospital Universitari Dr. Josep Trueta (Girona) and Hospital Universitari de Bellvitge (l’Hospitalet de Llobregat). During the one-year follow-up period, disease activity levels, faecal calprotectin evolution, and anti-TNFα antibody levels were analysed to assess response to treatment, differentiating 2 groups: responders and non-responders. From each sample, DNA was purified and used in a qPCR for the quantification of the following markers: F. prausnitzii (Fpra) and its phylogroups (PHG-I and PHG-II), E. coli (Eco), A. muciniphila (Akk), Ruminococcus sp. (Rum), Bacteroidetes (Bac), M. smithii (Msm), and the total bacterial load (Eub). Results In this proof of concept, the predictive ability to identify anti-TNFα treatment responders was analysed. Individually, none of biomarkers demonstrated the ability to differentiate between groups with high sensitivity and specificity. However, an algorithm consisting of the combination of 5 microbial markers (Msm, Fpra, PHGII, Rum, and Eub) showed a high capacity to discriminate between responders and non-responders. The algorithm proved high sensitivity and specificity reporting values ​​of 93.33% and 100%, respectively, with a positive predictive value of 100% and a negative predictive value of 75% for predicting response to biologic treatment. Conclusion A specific microbial signature could beneficiate patients with IBD by predicting the therapeutic effectiveness of an anti-TNFα treatment, which could lead to a personalized therapy, improving the patients’ quality of life, saving costs, and gaining time in patient recovery.A larger prospective study will be needed to validate these results.

Background: The composition of the intestinal microbiota is altered in Crohn’s disease [CD] patients. The objective of this study was to evaluate the qualitative and quantitative changes in the microbiota of CD patients in 3 months of treatment with adalimumab [ADA], and determine whether or not these changes are produced towards the recovery of the normal, healthy-like microbiota. Methods: The microbiota composition, and the Faecalibacterium prausnitzii / Escherichia coli quantitative relationship as dysbiosis indicator, were studied at baseline [T0], one month [T1], and 3 months [T3] after starting treatment using a polymerase chain reaction–denaturing gradient gel electrophoresis [PCR-DGGE] of 16S rRNA gene fragments and quantitative PCR, respectively, in rectal mucosal biopsies from 15 CD patients and four healthy subjects. Results: T0 and T3 fingerprints were different in all patients; whereas T1 and T3 presented similar patterns. Recovered phylogroups were Firmicutes \[79.1%], Bacteroides [12.5%], and Actinobacteria [6.25%]. The prevalence of E. coli decreased during treatment. Relative E. coli loads in CD samples were significantly reduced at every analysed step [T1 and T3\] \[ p < 0.005\] whereas no significant changes were observed in relative F. prausnitzii counts. Conclusion: Treatment with ADA induces short-term changes in the microbiota composition which seem to parallel the partial recovery of the gut bacterial ecology, with recovery parameters tending to eubiosis recovery. The quantitative determination of dysbiosis-representative bacteria, such as E. coli, may provide a fast and reliable indicator of the healing state of the intestinal mucosa.

Background Crohn disease (CD) and Ulcerative colitis (UC) are characterised by episodes of exacerbations and remissions. Monitoring disease activity based on intestinal lesion is mandatory prior to any change in the therapeutic strategy. Colonoscopy is the gold standard technique to monitor the disease activity in IBD patients, but it is usually discarded because of costs and risk issues. The concentration of Faecal Calprotectin (FC) is widely used as a non-invasive marker of inflammation of the intestinal mucosa, allowing the assessment of the disease activity. Recently, different studies have demonstrated that certain microbial species, part of intestinal microbiota which can be detected in stool samples, are capable of correlating with disease activity in CD and UC patients. The purpose of this study was to analyse the correlation between these microbial indicators and the FC to monitor the disease activity in CD and UC patients. Methods FC levels were used to define inflammatory disease activity, the predetermined cut-off of 250 μg/g of faeces was used, higher values indicated an active inflammation and lower values indicated disease in remission. Two cohorts consisting of 61 patients of CD (25 with active inflammation and 36 with remission) and 90 of UC (42 with active inflammation and 48 with remission) were recruited by the Gastroenterology department of 4 Catalan hospitals. A sample of faeces was collected from each patient. FC and the following markers were quantified by qPCR: Faecalibacterium prausnitzii (Fpra), Escherichia coli (Eco), Akkermansia muciniphila (Akk), Ruminococcus sp. (Rum), Bacteroidetes (Bac) and Methanobrevibacter smithii (Msm) for each sample. Results The bacterial markers presented different behaviour depending on the disease analysed. The abundances of Eco and Bac were higher in CD with active inflammation compared with CD with remission. In contrast, no significant differences were found for Fpra, Akk, Rum, and Msm. Besides, a significant positive correlation between Eco abundance and FC levels (0.280, p = 0.029) and a significant negative correlation between Msm and FC levels (−0.299, p = 0.021) were observed. According UC patients, while the abundance of Eco was higher in patients with active inflammation, the abundance of Rum was significantly less abundant. No significant differences were found for Fpra, Akk, Bac, and Msm. Moreover, we also observed a significant negative correlation between Rum and FC levels (−0.308, p = 0.003, respectively). Conclusion The abundance of Eco and Msm in CD patients and the abundance of Rum in UC patients correlate to FC in order to determine inflammatory disease activity. So, these markers can also be an accurate discriminator of active disease in CD and UC patients.

Resumen Objetivo Valorar los recursos disponibles en los hospitales comarcales catalanes para la asistencia urgente de la hemorragia digestiva alta. Metodo Se analiza una encuesta enviada a 32 hospitales, sobre la existencia, composicion y recursos del turno de guardia (TDG) de endoscopia, referida al ano 2009. Resultados Respondieron 24 centros, que cubrian la asistencia de 3.954.000 habitantes. Tenian TDG 12 hospitales. No disponian de TDG en su centro de referencia 1.483.000 habitantes. Los centros con TDG tenian mas camas y cubrian mas poblacion. Los TDG estaban formados por 4,5 endoscopistas (rango 2-11), que cubrian 82,1 (33,2-182,5) guardias/ano. Diecisiete centros reportaban 1.571 episodios (51 por centro, rango 3-280, 39,68/100.000 hab.). Los centros con TDG reportaban mas casos (76 vs. 43, p = 0,047). Los que no disponen de TDG derivaron mas pacientes (147 vs . 17, p= 0,001). Los pacientes en urgencias estaban a cargo de medicina interna en 4 centros, de cirugia en 14 y repartidos entre ambos servicios en 6. Si ingresaban, quedaron a cargo de Digestivo solo en 6 hospitales. Los recursos mas utilizados eran la ligadura en la hemorragia varicosa y las terapias de inyeccion en la no varicosa. Un 21% de centros no realizaban tratamiento combinado. Conclusiones Una proporcion significativa de la poblacion no dispone de endoscopista de guardia en su centro de referencia. La constitucion de TDG en hospitales comarcales supone importantes cargas asistenciales. La coordinacion entre profesionales y centros permitiria la aplicacion eficiente de los recursos terapeuticos y el establecimiento de TDG en centros que no tienen.

Background/Aim: Cefotaxime is considered the first-choice antibiotic for empirical treatment in cirrhotic patients developing bacterial infections. It has been suggested that amoxicillin-clavulanic acid could be an alternative to cefotaxime, particularly in patients developing bacterial infections while on prophylactic norfloxacin. The aim of the present study was to compare amoxicillin-clavulanic acid with cefotaxime in the treatment of bacterial infections in cirrhosis. Methods: Ninety-six hospitalized cirrhotic patients with suspicion of bacterial infection were prospectively included and randomized into two groups: one group ( n =48) received amoxicillin-clavulanic acid, first intravenously 1 g-0.2 g every 8 h, and then orally 500 mg-125 mg every 8 h, and the other group ( n =48) received intravenous cefotaxime 1 g every 6 h. Patients were stratified for previous prophylaxis with norfloxacin and ascitic fluid infection. Results: Sixteen patients were excluded from the analysis because bacterial infection was not demonstrated or because of secondary peritonitis. Therefore, 38 patients from the amoxicillin-clavulanic acid group and 42 from the cefotaxime group were finally analyzed. There were 24 ascitic fluid infections in each group. Infection resolution (86.8% vs 88%, 95% CI: −0.15 to 0.13, p NS), spontaneous bacterial peritonitis resolution (87.5% vs 83.3%, 95% CI: −0.15 to 0.24, p NS), duration of treatment, incidence of complications, time of hospitalization and hospital mortality were similar in both groups. Considering patients on prophylactic norfloxacin, infection resolution was also similar (100% vs 83.3%, 95% CI: −0.04 to 0.37, p NS). No adverse events were observed in either of the two groups. The cost of antibiotics was statistically lower in the amoxicillin-clavulanic acid group ( p Conclusions: Amoxicillin-clavulanic acid is as effective as cefotaxime in the treatment of bacterial infections in cirrhotic patients, but is less expensive and can be administered orally. These results suggest that amoxicillin-clavulanic acid is an effective alternative to cefotaxime for the empirical treatment of bacterial infections in cirrhosis.

Long-term primary antibiotic prophylaxis of spontaneous bacterial peritonitis has been suggested to be useful in cirrhotic patients with low ascitic fluid protein levels. However, it is unlikely that all such patients need prophylactic treatment. The aim of this study was to identify the group of cirrhotic patients with low ascitic fluid protein levels at high risk of developing a first episode of spontaneous bacterial peritonitis during outpatient follow-up.One hundred nine cirrhotic patients with low ascitic fluid protein levels and without previous episodes of spontaneous bacterial peritonitis were followed up in an outpatient clinic.Twenty-eight patients developed a first spontaneous bacterial peritonitis episode. In the multivariate analysis, serum bilirubin level (3.2 mg /dL) and platelet count (98.000/mm(3)) independently correlated with the risk of developing the first spontaneous bacterial peritonitis (P0.01 and P0.05, respectively). According to the median relative risk coefficient, a low-risk group (relative risk1.09) and a high-risk group (relative risk1.09) were established. The probability of developing a first spontaneous bacterial peritonitis episode at 1-year follow-up was significantly higher in the high risk-group (low-risk group, 23.6%; high-risk group, 55%; P0.01) as a consequence of a higher probability of the first community-acquired episode (13.7% vs. 47.6%, respectively, P0.01). One-year probability of survival was significantly lower in the high-risk group (low-risk group, 57.6%; high-risk group, 38%, P0.05).Cirrhotic patients with low ascitic fluid protein levels (/=1 g /dL) and high bilirubin level and/or low platelet count are at high risk of developing a first episode of spontaneous bacterial peritonitis during long-term follow-up.

Recent trials have shown that somatostatin (SMT) is as effective as sclerotherapy in the treatment of acute variceal bleeding and that the combination of both treatments is more effective than sclerotherapy alone. To assess whether the addition of sclerotherapy improves the efficacy of SMT alone, all patients admitted to our unit with gastrointestinal bleeding and with suspected cirrhosis received a continuous infusion of SMT (250 micrograms/h). Endoscopy was performed between 1 and 5 hours later, and patients with esophageal variceal bleeding were randomized to receive or not to receive sclerotherapy. In both groups, SMT infusion was continued for 5 days. Fifty patient admissions were allocated to each group. Therapeutic failure occurred in 21 cases of the SMT group and in 7 cases of the combined-therapy group (P =.002). Failure to control the acute episode occurred in 24% vs. 8% (P =.03) and early rebleeding in 24% vs. 7% (P =.03), respectively. Transfusional requirements were significantly higher in the SMT group, while the incidence of complications was lower (8% vs. 24%; P =.029). In the multivariate analysis, the presence of shock at admission and active bleeding during endoscopy were the variables that better predicted the failure of therapy with SMT alone. Mortality at 6 weeks was similar. These data demonstrate that the addition of sclerotherapy significantly improves the efficacy of SMT alone for the treatment of acute variceal bleeding, although it also increases the rate of complications. Patients with shock and those with active bleeding are more likely to benefit from this combined therapy.

Selective intestinal decontamination with norfloxacin is useful to prevent bacterial infections in several groups of cirrhotic patients at high risk of infection. However, the emergence of infections caused by Escherichia coli resistant to quinolones has recently been observed in cirrhotic patients undergoing prophylactic norfloxacin. Our aim is to determine the characteristics of the infections caused by E. coli resistant to norfloxacin in hospitalized cirrhotic patients. One hundred and six infections caused by E. coli in 99 hospitalized cirrhotic patients were analyzed and distributed into two groups: group I (n = 67), infections caused by E. coli sensitive to norfloxacin, and group II (n = 39), infections caused by E. coli resistant to norfloxacin. The clinical and analytical characteristics at diagnosis of the infection were similar in both groups. Previous prophylaxis with norfloxacin was more frequent in group II (15/67, 22.4% vs. 32/39, 82%, P < .0001), as a result of a higher number of patients submitted to continuous long-term prophylaxis in this group, whereas previous short-term prophylaxis was similar in both groups. Infections were more frequently nosocomial-acquired in group II than in group I (17/67, 25.3% vs. 20/39, 51.2%, P = .01). The type of infections was similar in both groups: urinary tract infections 38 in group I and 24 in group II, spontaneous bacterial peritonitis 8 and 2, spontaneous bacteremia 4 and 4, and bacterascites 1 and 0, respectively (pNS). Mortality during hospitalization was similar in the two groups (4/67, 5.9% vs. 5/39, 12.8%, pNS). None of the E. coli resistant to norfloxacin were also resistant to cefotaxime and only one of them was resistant to amoxicillin-clavulanic acid. Prophylaxis with norfloxacin, usually continuous long-term prophylaxis, favors the development of infections caused by norfloxacin-resistant E. coli. Long-term antibiotic prophylaxis should therefore be restricted to highly selected groups of cirrhotic patients at high-risk of infection. Infections caused by E. coli resistant to norfloxacin show a severity similar to those caused by sensitive E. coli. No significant associated resistance between norfloxacin and the antibiotics most frequently used in the treatment of bacterial infections in cirrhotic patients has been observed.

Objective: Selective intestinal decontamination with norfloxacin is useful in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding. However, bleeding cirrhotic patients with ascites, encephalopathy, or shock are at high risk to develop bacterial infections in spite of prophylactic norfloxacin. The aim of this study was to assess whether the addition of intravenous ceftriaxone could improve the efficacy of prophylaxis with norfloxacin in these patients. Methods: Fifty-six cirrhotic patients with gastrointestinal hemorrhage and ascites, encephalopathy, or shock were randomized into two groups: Group 1 (n = 28) received oral norfloxacin 400 mg/12 h for 7 days, and group 2 (n = 28) received norfloxacin plus intravenous ceftriaxone 2 g daily during the first 3 days of admission. Results: Ten patients were excluded because of community-acquired infection, surgery, or death within the first 24 h. The incidence of bacterial infections during hospitalization was 18.1% in group 1 and 12.5% in group 2 (p = NS). The incidence of severe infections (spontaneous bacterial peritonitis, bacteremia, or pneumonia) was also similar in both groups: 9% in group 1 versus 8.3% in group 2 (p = NS). There were no statistical differences between the two groups with respect to duration of hospitalization or mortality. The cost of antibiotic therapy (including prophylaxis and treatment of infections) was significantly higher in group 2. Conclusion: These results suggest that the addition of intravenous ceftriaxone during the first 3 days of hospitalization does not improve the cost-efficacy of oral norfloxacin in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding and high risk of infection.

Splanchnic and systemic arteriolar vasodilationplays an important role in ascites formation incirrhosis. Octreotide produces splanchnicvasoconstriction, but the effects on systemichemodynamics and renal function are controversial. This studyevaluated the effect of subcutaneous octreotideadministration on systemic hemodynamics, endogenousvasoactive systems, and renal function in cirrhoticpatients with ascites. Twenty patients were included: 10received octreotide 250 μg/12 hr subcutaneously (forfive days), and 10 did not. No statistically significantchanges were found in mean arterial pressure and cardiac rate. Octreotide induced astatistically significant decrease in plasma reninactivity (P < 0.01), plasma aldosterone (P = 0.01)and plasma glucagon (P < 0.05). No significantvariations were observed in other systemic vasoactivesubstances (nitric oxide and prostacyclin). Renalfunction was not modified in either group. Inconclusion, in cirrhotic patients with ascites,subcutaneous octreotide administration decreases plasma glucagon, reninactivity, and aldosterone without changing in systemichemodynamics or renal function.

Inoculation of ascitic fluid into conventional blood culture bottles is more sensitive than conventional culture in the diagnosis of spontaneous bacterial peritonitis. BacT/ALERT is an automated colorimetric microbial detection system that has been shown to be faster than conventional blood culture bottles in the diagnosis of bacteremia. The aim of the study was to compare the BacT/ALERT system with the conventional culture and the conventional blood culture bottles method in the diagnosis of spontaneous bacterial peritonitis.All the ascitic fluid samples from patients with cirrhosis hospitalized in our Department between September 1992 and May 1994 (n=1032) were prospectively evaluated. In all cases, an aliquot of ascitic fluid was sent for Gram's stain and conventional culture, and 20 ml were inoculated at the bedside into blood culture bottles: 10 ml into conventional blood culture bottles and 10 ml into BacT/ALERT.Thirty ascitic fluid infections (23 spontaneous bacterial peritonitis and 7 neutrocytic ascites) and 20 bacterascites were diagnosed. Conventional culture was positive in 10/30 ascitic fluid infections (33.3%), conventional blood culture bottles in 22/30 (73.3%) (p0.01 compared to conventional culture) and BacT/ALERT in 20/30 (66.6%) (p0.05 compared to conventional culture, pNS compared to conventional blood culture bottles). The time elapsed for culture positivity was 43.4+/-34.2 h for conventional blood culture bottles and 13.3+/-9.2 h for BacT/ALERT (p0.001). Thirteen of the 23 cases of spontaneous bacterial peritonitis (56.5%) were detected within the first 12 h with BacT/ALERT, as compared to only three (13%) with conventional blood culture bottles (p0.03).The automated system BacT/ALERT provides an earlier microbiologic diagnosis of spontaneous bacterial peritonitis than conventional blood culture bottles with similar sensitivity.

During acute variceal bleeding, several factors may lead to elevations of hepatic venous pressure gradient (HVPG), which may precipitate further hemorrhage. Whether somatostatin can suppress these increments is unknown. This study monitored somatostatin effects on HVPG during acute bleeding and assessed whether the changes affect outcome.In 40 patients with acute variceal bleeding treated with sclerotherapy, a catheter was placed into a main hepatic vein for 24-hour serial measurements of HVPG. After baseline measurements, patients received somatostatin (N = 25) or placebo (N = 15) under double blind conditions.Somatostatin but not placebo produced a sustained decrease in HVPG (from 20.7 +/- 3.7 mm Hg to 17.7 +/- 2.7, P0.01). In patients receiving placebo, HVPG increased after a test meal (P = 0.018) and after blood transfusion (P = 0.034). Somatostatin completely prevented these increments. HVPG decreased significantly only in patients without further bleeding. One of 27 patients with HVPG20 mm Hg at baseline or decreased10% rebled vs. 9 of 13 who had neither of these 2 criteria (P0.0001). Both criteria had independent prognostic value for further bleeding.During acute variceal bleeding, somatostatin produces a significant and sustained decrease in HVPG and prevents secondary elevations. Monitoring HVPG may stratify further bleeding risk and discriminate treatment response.

Cirrhotic patients with ascites and low ascitic fluid total protein and/or high serum bilirubin levels are at high risk to develop the first episode of spontaneous bacterial peritonitis during long-term follow-up. The aim of the present study was to determine the efficacy of continuous long-term selective intestinal decontamination with norfloxacin in the prevention of this complication. One hundred nine cirrhotic patients with ascites and ascitic fluid total protein levels ofor = 1 g/dL or serum bilirubin levels of2.5 mg/dL without previous spontaneous bacterial peritonitis were prospectively randomized into two groups: group 1 (n = 56) received norfloxacin, 400 mg daily administered orally, and group 2 (n = 53) was the long-term control group, receiving norfloxacin only during hospitalization. During a mean follow-up of 43 +/- 3 weeks, there was one spontaneous bacterial peritonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P.01). The incidence of community-acquired spontaneous bacterial peritonitis was lower in group 1 (1.8% vs. 13.2%, P.05), whereas the incidence of nosocomial spontaneous bacterial peritonitis (0% vs. 3.7%) and the incidence of extraperitoneal infections (25% vs. 24.5%) were similar in both groups (P = NS). The actuarial probability of survival at 18 months was 75% in group 1 and 62% in group 2 (P = NS). Resistance to norfloxacin was observed in 9 of 10 (90%) Escherichia coli isolated in infections from group 1 and in 4 of 11 (36.3%) from group 2 (P.05). The overall incidence of infections caused by norfloxacin-resistant bacteria was higher in group 1 (19.6% vs. 15%), but it did not reach statistical significance. Continuous long-term selective intestinal decontamination with norfloxacin is effective in preventing the first spontaneous bacterial peritonitis in cirrhotic patients at high risk. However, the emergence of infections caused by norfloxacin-resistant bacteria must be weighed carefully against the benefits of continuous long-term prophylaxis.