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1 Journal Reading R 巫怡潁 V S 余文良 F E B. 1 7 T H, 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權

3 Background & purpose Infection in cirrhotic patient with UGIB Higher mortality AASLD (American Association for the Study of Liver Disease) guidelines Antibiotic (Abx) prophylaxis Oral norfloxacin IV ciprofloxacin IV ceftriaxone

4 Background & purpose (cont.) Research deficiencies No study for the effect Abx prophylaxis in cirrhotic patient with peptic ulcers bleeding alone 30-40%: nonvariceal UGIB

5 Materials & methods Patients Jan Sep Cross-sectional, retrospective chart view Kaohsiung Change Gung Memorial Hospital 250 cirrhotic patients Peptic ulcer hemorrhage underwent endoscopy 148 cases met criteria M/F=109/39; mean age: 60.8±12.9 y Group A: n=38 received antibiotic prophylaxis Group B: n=110 not received

6 Materials & methods Exclusion criteria Existing sings of infection on admission BT> 38 C, WBC> 10 3 /µl Received oral/parenteral Abx in week prior procedure Other source for UGIB Died within 1 st day after admission Not complete the in hospital follow-up period

7 GU or DU dx Clinical signs of hematemesis, coffee ground vomitus, hematochezia, melena Endoscopic signs of high-risk ulcers (Forrest classification) Time from admission to endoscopic Rx Rockall classification All received endoscopy in 24 hours after arriving ER Other registered variables

8 End point Signs of infection Experienced rebleeding Length of hospital stay death

9 Definitions Cirrhosis Severity- Pugh s modification of Child s classification Alcohol-related liver Consumption>80 g/d in M >40g/g in F At least 10 years (-) viral, metabolic, autoimmune markers HBsAg(HBV), anti-hcv(hcv)

10 Definitions Treatment Pantoprazole High dose-80mg st + 200mg continue for 3 days 40mg q12h Rebleeding After intervention successfully at least 24-h period of stable vital signs hematemesis, melena Signs of hypovolemic shock Hb >2g/dl

11 Definitions Infectious episode Bacteremia Spontaneous bacterial peritonitis Pneumonia UTI

12 Statistical analysis Continuous variables means± standard deviations Distributions of continuous variables Chi-square test Compare differences Kaplan-Meier analysis Log-rank test SPSS v17.0

13 Results

14 Demographic & clinical characteristics

16 Endoscopic findings & Rockall score Mean time for endoscopic intervention 7.1±6.3h Source GU: 58.8%; DU: 34.4% Combined: 6.8% 96% found active ulcers with stigmata 68.2% with EV or GV, none of them with SRH Mean value in Rockall score (no different in 2 groups) 6.5±1.3 at admission 91.2%>=5

17 Rockall score

18 Bacterial infections 84.8%

19 Group A(n=4) Bacteremia x2 SBP x1 UTI x1 Group B(n=29) Bacteremia x13 K. p x6; E. coli x4; GPC x5 Pneumonia x4 SBP x4 UTI x8

20 Risk factors for infection

22 Rebleeding & death 22.3% 12.8% 47.4% 31.6%

24 Independent risk factors for rebleeding

26 Independent risk factors for death

28 Discussions Difference from cirrhosis & non-cirrhosis Non-cirrhosis Advanced age Chronic use NSAIDs Cirrhosis Alcohol Portal hypertension Coagulopathy & thrombocytopenia

29 No study clarifying the prophylactic antibiotic in cirrhotic with peptic ulcers alone incidence of rebleeding Not all-cause mortality

30 Risk factors Recurrent bleeding Male Advanced stage of cirrhosis(c-p class C) No antibiotic prophylaxis Relevant factors for all-cause mortality C-P C liver cirrhosis Hemodynamic instability on admission Bacterial infection Alcohol consumption total bilirubin level

31 Probable mechanism? Bacterial translocation Intestinal bacterial overgrowth Intestinal dysmotility intestinal permeability Bacterial byproduct portal pressure Impair liver function & coagulation

32 Rebleeding rate 22.3% vs. 3.2%(non-cirrhotic) High stigmata in this study 68.2% found varices 62.8% with advanced stage of cirrhosis In-hospital death in two group is similar Same to Gonzalez-Gonzalez et al. Concomitant comorbidities linked to death

33 Strong recommend the routine prophylaxis antibiotic in cirrhotic pt with UGIB In-hospital mortality and risk factors High dose of PPI? Limitation in cirrhotic pt

34 Limitations Single center report Retrospective chart review Small sample size

35 Conclusion Antibiotic prophylaxis in cirrhotic pt with peptic ulcer bleeding Reduced infection and rebleeding Independent predictors of recurrent bleeding Male Cirrhosis C-P class C No antibiotic prophylaxis

36 Thanks a lot!

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$(Microsoft PowerPoint ppt [\254\333\256e\274\322\246\241])$ 報告者 : 2014.02.10 陳經國 R1 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權 Introduction Multiple clinical trials have shown Cirrhotic patients with GI bleeding receiving prophylactic antibiotics reduce infectious