BackgroundKnowledge about bacterascites is limited and management guidelines are based on small patient series. The purpose of this study was to add further insight into the clinical characteristics, microbiological findings, and prognosis of patients diagnosed with bacterascites.MethodsRetrospective analysis of patients with advanced chronic liver disease diagnosed with bacterascites and SBP between January 2003 and August 2016.ResultsIn this study, 123 patients were included with 142 episodes of bacterascites. The median MELD score was 20 and clinical symptoms of infection were present in 78%. Empiric antibiotic treatment was initiated in 68%. In 26 untreated patients undergoing repeated paracentesis, 42% were diagnosed with either ongoing bacterascites or SBP. The presence of signs or symptoms of infection was not an independent predictor for mortality or spontaneous resolution of infection. The 1‐month and 1‐year mortality rates of the 123 patients studied, were 32% and 60%, respectively; these results were in line with data pertaining to the prognosis of SBP.ConclusionsPatients with bacterascites and SBP are highly comparable with respect to severity of liver disease and overall prognosis. If left untreated, bacterascites is likely to persist or to evolve to SBP in a significant proportion of patients. The results of this study support current guidelines regarding the treatment of ascitic fluid infection, but could not confirm the prognostic relevance of symptomatic disease at the time of diagnosis. We suggest that the threshold to initiate antibiotic treatment, in particular in cases with severely advanced liver disease, should be low.

SummaryBackgroundEvidence for the efficacy of TIPSS in ectopic variceal bleeding (EctVB) is largely based on relatively small series.AimTo define the efficacy of TIPSS in EctVB.MethodsRetrospective analysis of consecutive patients with chronic liver disease who presented with EctVB and received TIPSS in three tertiary centres in 1992‐2016.ResultsThe study included 53 patients (70% male, median age 61 years, median model for end‐stage liver disease (MELD) score 11). The ectopic varices were located around the insertion of stomas (40%), duodenum (23%), rectum (17%) and at other sites (20%). Three‐quarters of the patients had previously received unsuccessful medical, endoscopic or surgical therapy. The median follow‐up was 14.0 months. Following TIPSS, bleeding recurred in 12 patients: 6 of 12 (50%) with duodenal varices, 2 of 9 (22%) with rectal varices and one each with stomal (1/21), intraperitoneal (1/3), hepaticojejunostomy (1/2) and ascending colon varices (1/2). The risk factors for re‐bleeding were MELD score at TIPSS placement (HR: 1.081 per point; 95% confidence interval (CI): 1.012‐1.153; P = 0.034), varices located at site other than an enterostomy (HR: 9.770; 95%CI: 1.241‐76.917; P = 0.030) and previous local therapy (HR: 5.710; 95%CI: 1.211‐26.922; P = 0.028). The estimated cumulative re‐bleeding rate was 23% at 1 year, 26% at 3 years and 32% at 5 years. Post‐TIPSS hepatic encephalopathy manifested or worsened in 16 of 53 patients (30%).Conclusion TIPSS provides long‐term control of bleeding in most cirrhotic patients with EctVB. TIPSS is particularly effective in stomal EctVB, the most frequent cause of EctVB, but might not be as effective in duodenal EctVB.

BackgroundRecent investigations suggest an increasing prevalence of Gram-positive and antibiotic-resistant bacteria causing spontaneous bacterial peritonitis (SBP), probably related to changes in antibiotic prescription patterns, in particular more widespread and long-term use of antibiotic prophylaxis with quinolones.ObjectiveThe primary objective of this study was to assess potential changes in the microbiology of SBP in two patient cohorts studied at a 10-year interval. Further aims were to study prognostic factors and outcome of SBP.MethodsA retrospective double-cohort study, including all ascitic cultures from patients with cirrhosis obtained 2003–2005 and 2013–2014, was conducted.ResultsIn total 312 patients were included, 125 patients in the first and 187 patients in the second cohort. SBP was diagnosed in 132 of 840 analyzed ascitic fluid samples; 62 samples were culture positive. An increase of Gram-positive bacterial isolates was noted from 26% to 46% between cohorts (p = 0.122). The prevalence of multidrug-antibiotic–resistant pathogens increased from 25% to 32% (p = 0.350). Survival after SBP among the two cohorts was comparable.ConclusionThis single-center study in the Netherlands found a modest but nonsignificant increase in the proportion of patients with SBP caused by Gram-positive bacteria and multidrug-antibiotic–resistant bacteria over a 10-year period. Our findings differ from reported data in other countries and suggest empiric antibiotic prophylaxis and treatment of SBP should be based on national and regional microbiological findings and resistance patterns.

Background: After 5  years since the registration of rifaximin-α as a secondary prophylaxis for overt hepatic encephalopathy (HE) in the Netherlands, we aimed to evaluate the use of hospital resources and safety of rifaximin-α treatment in a real-world setting. Methods: We carried out prospective identification of all patients using rifaximin-α for overt HE. We assessed hospital resource use, bacterial infections, and adverse events during 6-month episodes before and after rifaximin-α initiation. Results: During 26 months we included 127 patients [71.7% male; median age 60.8 years (interquartile range: 56.2–66.1); median model for end-stage liver disease (MELD) score 15.0 (interquartile range: 12.1–20.4); 98% using lactulose treatment]. When comparing the first 6 months after rifaximin-α initiation with the prior 6 months, HE-related hospital admissions decreased (0.86 to 0.41 admissions/patient; p < 0.001), as well as the mean length of stay (8.85 to 3.79 bed days/admission; p < 0.001). No significant differences were found regarding HE-related intensive care unit admissions (0.09 to 0.06 admission/patient; p = 0.253), stay on the intensive care unit (0.43 to 0.57 bed days/admission; p = 0.661), emergency department visits (0.66 to 0.51 visits/patient; p = 0.220), outpatient clinic visits (2.49 to 3.30 bed visits/patient; p = 0.240), or bacterial infections (0.41 to 0.35 infections/patient; p = 0.523). Adverse events were recorded in 2.4% of patients. Conclusions: The addition of rifaximin-α to lactulose treatment was associated with a significant reduction in the number and length of HE-related hospitalizations for overt HE. Rifaximin-α treatment was well tolerated.

Colorectal cancer (CRC) screening with colonoscopy is commonly used in patients who are candidates for liver transplantation. We initiated this study to define the risk‐benefit ratio of performing screening colonoscopy in this population. A retrospective observational study of all consecutive patients undergoing colonoscopy during pre–liver transplantation screening between 2004 and 2017 was conducted. Endoscopic and pathological findings and clinical events potentially related to the colonoscopy in the 30 days after the procedure were registered and compared with a 30‐day inpatient control time frame. A total of 858 colonoscopies were performed in 808 patients (65% male; median age, 55 years [interquartile range (IQR), 47‐62]; median model for end‐stage liver disease (MELD) score, 15 [IQR, 11‐18]). CRC was found in 2 patients (0.2%), and advanced adenomas were found in 44 patients (5.4%). The only independent risk factor for an advanced neoplasm was age (odds ratio, 1.072 per year; 95% confidence interval, 1.031‐1.115; P < 0.001). During the 30‐day postprocedure period, 178 clinical events occurred in 128 patients compared with 101 clinical events in 72 patients in the control time frames ( P < 0.001). After colonoscopy, there was a significantly increased risk for renal failure ( P = 0.001) and gastrointestinal (GI) bleeding ( P = 0.023). Presence of ascites and MELD score were identified as independent risk factors for acute renal failure and GI bleeding. During the study observation period, 53.5% of the screened population actually underwent liver transplantation. Conclusion : CRC screening in pre–liver transplantation patients is associated with a relatively low prevalence of CRC and an increased risk of postcolonoscopy complications such as acute renal failure and GI bleeding, especially in patients with advanced liver disease. Because the risk‐benefit ratio of standard performance of a screening colonoscopy in this population appears questionable, alternative screening strategies should be considered.