infections in cirrhotic patients are gram-negative bacilli arisCirrhotic patients with ascites and low ascitic fluid ing from the patient's own gastrointestinal tract flora, 13,14 total protein and/or high serum bilirubin levels are at selective intestinal decontamination (SID) has been considhigh risk to develop the first episode of spontaneous ered as a prophylactic measure. 15-17 SID consists of the inhibibacterial peritonitis during long-term follow-up. The tion of the gram-negative flora of the gut with preservation aim of the present study was to determine the efficacy of gram-positive cocci and especially anaerobic bacteria and, of continuous long-term selective intestinal decontamitherefore, prevention of intestinal colonization and translocanation with norfloxacin in the prevention of this complition by new, potentially pathogenic bacteria. 18 Previous studcation. One hundred nine cirrhotic patients with ascites ies have shown the usefulness of SID with oral norfloxacin, a and ascitic fluid total protein levels of°1 g/dL or serum poorly absorbable antibiotic, 16,19 in the prevention of bacterial bilirubin levels of ú 2.5 mg/dL without previous spontainfections during hospitalization in cirrhotic patients at high neous bacterial peritonitis were prospectively randomrisk, such as patients with ascites and low levels of total ized into two groups: group 1 (n Å 56) received norfloxaprotein in ascitic fluid 4 and patients with gastrointestinal cin, 400 mg daily administered orally, and group 2 (n Å bleeding. 20 On the other hand, long-term SID with norfloxa-53) was the long-term control group, receiving norfloxacin has been successful in the prevention of SBP recurrence cin only during hospitalization. During a mean followin patients surviving an episode of SBP. 16 Moreover, the effiup of 43 { 3 weeks, there was one spontaneous bacterial cacy of long-term prophylaxis of SBP with trimethoprimsulfaperitonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P õ methoxazole 21 or weekly ciprofloxacin 22 has recently been .01). The incidence of community-acquired spontaneous shown in patients with ascites with or without a previous bacterial peritonitis was lower in group 1 (1.8% vs. 13.2%, episode of SBP. However, in contrast with norfloxacin, these P õ .05), whereas the incidence of nosocomial spontaneantibiotics show a nonselective effect over gram-negative baous bacterial peritonitis (0% vs. 3.7%) and the incidence cilli and have a higher systemic absorption. 19,23 of extraperitoneal infections (25% vs. 24.5%) were similarIn two recent prospective studies, the 1-year probability of in both groups (P Å NS). The actuarial probability of the first episode of SBP in cirrhotic patients with ascites was survival at 18 months was 75% in group 1 and 62% in 29% 5 and 11%. 6 Moreover, in the study of Andreu et al., 5 low group 2 (P Å NS). Resistance to norfloxacin was observed total protein levels in ascitic fluid (°1 g/dL) and high serum in 9 of 10 (90%) Escherichia coli isolated in infections bilirubin levels (ú 2.5 mg/...
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 g/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 combinedtherapy 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. (HEPATOLOGY 1999;30:384-389.)Despite recent therapeutic advances, acute esophageal variceal hemorrhage is still one of the leading causes of death in patients with cirrhosis. 1 Sclerotherapy is widely used as the main emergency treatment in most institutions. Randomized, controlled trials have shown that emergency sclerotherapy (EST) is effective for the control of acute esophageal variceal bleeding, 1 and meta-analysis of comparative studies has suggested that it fares better than balloon tamponade and vasopressin. 1 It has also been suggested that EST reduces the frequency of early rebleeding, 1 which is an important indicator of death risk. 2 However, EST is not always successful, it is associated with a non-negligible rate of serious complications, and it requires a skilled endoscopist, a necessity not always available. 3 Somatostatin (SMT) was introduced for the treatment of acute variceal hemorrhage because of its capacity to decrease portal pressure and collateral splanchnic blood flow, without the adverse effects of vasopressin on the systemic circulation. 4 One placebo-controlled trial failed to show any beneficial effect with SMT, 5 although the high spontaneous success rate observed with placebo suggests that some inadvertent bias could occur in this study. 5 Furthermore, several randomized, controlled trials have shown that SMT is more effective than placebo, 6 and as effective as vasopressin, 7,8 ...
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