Dimensiones para la evaluación docente

1. Patients with secondary bacterial peritonitis as determined by clinical, microbiological and radiological findings.

2. Patients with clinical, ultrasonographic and/or histological diagnosis of primary or metastatic liver cell carcinoma who presented with ascitis

3. Patients who had antibiotics within the last one month of presentation.

4. Patients who had paracentesis before presentation

3.7.0 MATERIALS AND METHODS

Informed written consent (appendix three) was obtained from all the eligible patients.

History and physical examination was carried out on all consented patients and details recorded in a proforma (appendix 1).

3.7.1 HISTORY TAKING

Detailed history was taken including history of fever, jaundice, abdominal swelling, and abdominal pain. History of decreased urinary output was looked for as a manifestation of renal impairment. History of abnormality in mental function including changes in sleep pattern, changes in personality and alteration in level of consciousness sought as indication of hepatic encephalopathy. Positive history of haematemesis, maelena stools,

or haematochezia were sought for. Consumption of 80g of alcohol per day for 10 years and half of this amount for the same duration was taken as significant alcohol consumption for males and females respectively. Other features sought for included history of past blood transfusion, use of PPIs and propranolol.

3.7.2 PHYSICAL EXAMINATION

Detailed examination was carried out and findings recorded in the proforma. Particular signs of interest included jaundice, pyrexia and peripheral stigmata of chronic liver disease(CLD) such as sparse and silky hair, gynaecomastia and testicular atrophy in males, breast atrophy in females; leuconychia, palmer erytherma, finger clubbing, wasting of small hand muscles. Other signs examined for included examination for ascitis, peritoneal stretch tenderness and flapping tremors and Glassgow coma score.

Ascitis was graded as moderate if demonstrable by shifting dullness and severe if demonstrable by fluid thrill. Hepatic encephalopathy was graded according to West Haven criteria into mild to moderate (grade 1 or 2 and severe (grade 3 or 4)

3.7.3 PROCEDURE

Abdominal paracentesis was done on all patients under aseptic technique. Ascitic fluid was taken at Rouyon spot 2cm above and medial to the left anterior superior iliac spine or a finger breath below the umbilicus using a 21G needle attached to a 20mls syringe after cleaning with methylated spirit and then povidone iodine. About twenty (20) mls of AF was taken from each patient. AF was physically observed for colour, whether or haemorrhagic and turbidity was determined immediately by trying to read prints through

the syringe and result recorded in the questionnaire. Ascitic fluid was then distributed as follows:

 10mls into a well cocked bottle containing brain heart infusion broth for microscopy and culture.

 5mls into Ethylene Diamine Tetra-Acetate (EDTA) bottle and analysed within six hours for white cell count and differentials.

 5mls into a plane bottle for protein and glucose determination.

3.7.4.0 SAMPLE ANALYSIS

3.7.4.1 ASCITIC FLUID CULTURE

Ascitic fluid was inoculated into a bottle containing brain heart infusion broth by the bedside and taken to the microbiology laboratory and incubated aerobically by the researcher. Subsequent procedures were carried out by the resident microbiologist with assistance from qualified laboratory scientist and active participation of the researcher.

These procedures were supervised by the consultant microbiologist. Sample was incubated at 35-37°C for 18-24hours then sub-cultured on days 2, 3 and 6. Cultures that yield no growth after 7days were considered negative and discarded. Likewise five cultures that yielded multiple growth were excluded. Series of biochemical tests were carried out on the isolates to identify the bacteria to specie level. Catalase, coagulase and optocin sensitivity tests were used to identify Gram-positive isolates while triple sugar ion, citrate utilization, urease production and indole tests were used to speciate Gram-negative isolates. Antibiotic sensitivity test was carried out on the isolates using disc diffusion technique and interpreted based on the clinical and laboratory standard institute

(CLSI). Ceftriaxone, cefuroxime, amoxicillin and clavulanate, and ciprofloxacin were tested. Anaerobic culture was not carried out however, differential turbidity or colour change at the base of the culture bottle which may indicate the presence of anaerobic organisms was not observed in any of the sample. The cost of this procedure was borne by the researcher.

3.7.4.2 ASCITIC FLUID CELL COUNT AND DIFFERENTIALS

This procedure was carried out by resident microbiologist with the assistance of qualified laboratory scientist and active participation of the researcher. Ascitic fluid cell count, total and differential was carried out to determine PMN count. This was carried out using the manual counting technique. A drop of undiluted anticoagulated AF was charged into new improved Neubauer chamber. The cells was allowed to settle for about 5 minutes before counting using light microscope at ×40 magnification. The white blood cells (WBC) count was done by counting the cells in 4 big squares and multiply by 2.5 (a constant). Part of the AF was centrifuged at 2000 rpm and the mixed deposit smeared and stained with Leishman’s stain for the differential white cells count.

3.7.4.3 AF PROTEIN AND ALBUMIN

This analysis was carried out by laboratory physicians/scientist after the sample to the laboratory by the researcher. Five (5) mls of AF was submitted in plane bottle for AF protein and albumin analysis using Biuret’s methods and Bromocresol green reagent respectively in the chemical pathology laboratory.

Details of the AF analysis were recorded in the proforma.

3.7.4.4 RADIOLOGICAL INVISTIGATIONS

Abdominal ultrasound scanning was done by the radiologist looking for evidence of liver cirrhosis including shrunken-sized or normal-sized or enlarged liver with irregular edge and coarsened echotexture. Evidence of ascites and splenomegaly was looked for. Details of the ultrasound scan findings was recorded in the proforma. Chest X-ray was done where necessary to exclude other causes of ascites such as gut perforation, tuberculosis and cardiac failure

3.7.4.5 OTHER INVESTIGATIONS

Other investigations that were carried out included serum protein and albumin, serum bilirubin, serum creatinine, prothrombin time (PT), INR and hepatitis B surface antigen and anti-hepatitis C antibody. These investigations were routinely done by all patients being managed for liver cirrhosis.