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Arch Hellen Med, 35(1), January-February 2018, 7-28


Bacterial infection in cirrhosis of the liver: New aspects

I. Mani, L. Vasilieva, S.P. Dourakis
Second Department of Internal Medicine, "Hippokration" General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

Infections, which are a common complication of cirrhosis of the liver, result from an insufficient systemic immune response, which becomes more prominent as the liver disease progresses. The risk of infection is further increased by the phenomenon of bacterial translocation, a unique characteristic of cirrhosis that occurs as a consequence of inefficient local intestinal mucosal defense and subsequent bacterial overgrowth. Infection leads to an exaggerated inflammatory response via induction of excessive secretion of proinflammatory cytokines. Cytokines trigger a wide variety of receptor and signaling molecules, leading to aggravation of the hyperdynamic circulation and deterioration of the hemodynamic balance, organ failure and coagulation abnormalities. Clinical manifestations of this process include deterioration of liver function, which may meet the criteria for acute on chronic liver failure, complications of cirrhosis, such as variceal bleeding, encephalopathy and hepatorenal syndrome, and systemic inflammatory response syndrome, sepsis and septic shock. Despite the variety of treatment options, the incidence of unfavorable outcomes is high, as infection is associated with a fourfold increase in mortality in these patients. This is partially explained by the fact that diagnosis of infection is particularly challenging, as most of the conventional clinical and laboratory markers are not accurate in patients with cirrhosis. Hypersplenism leads to leukopenia and portal hypertension, and hyperdynamic circulation causes low blood pressure and increased heart rate. Hepatic encephalopathy is often accompanied by hyperventilation, and fever may be absent. Blood culture may be positive in only 40% of cases. Prophylactic antibiotic therapy is recommended for patients with a history of spontaneous bacterial peritonitis, those with ascites or specific risk factors, and those with variceal bleeding. Studies in large series of patients are needed to determine the best preventive measures and treatment options for infection in patients with cirrhosis.

Key words: Bacterial infections, Bacterial translocation, Cirrhosis, Sepsis.

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