Background: Spontaneous bacterial peritonitis (SBP) is a serious complication of liver cirrhosis. It contributes to high morbidity and mortality in this population. In-hospital mortality of SBP ranges between 20% and 40%, suggesting that further refinements are essential in managing SBP. Early recognition of high-risk patients would enable us to reduce the short-term mortality. Objective: The current study aimed to evaluate the value of clinical, biochemical and inflammatory markers in the prediction of 1-month and 3-month cumulative mortality in patients with SBP. Patients and methods: Two hundred patients with a confirmed diagnosis of SBP were enrolled. They were admitted and received the proper treatment at the National Liver Institute Hospital-Menoufia University, Egypt. Patients were prospectively followed up for mortality over a period of three months. Predictors of mortality were assessed and analyzed. Results: Mortality rates were 20% and 41% at 1 month and 3 month respectively. Our findings showed that low blood pressure, abdominal pain, fever, higher Child-Pugh score, MELD score, serum bilirubin, INR, serum creatinine, Creactive protein to albumin (CRP/Albumin) ratio, neutrophil-lymphocyte ratio (NLR), massive splenomegaly and large ascites have been demonstrated as risk factors associated with short-term mortality. Conclusion: SBP carries a high risk of mortality among cirrhotic patients. Clinical parameters (low blood pressure, abdominal pain, fever, massive splenomegaly and large ascites), prognostic scores (Child-Pugh and MELD) and inflammatory markers (CRP, CRP/albumin ratio, and NLR) seem to be accurate and reliable tools that could independently predict short-term mortality in patients with SBP.

Background: Several precipitating factors of hepatic encephalopathy have been recognized and studied. Hepatic encephalopathy which is a frequent and grave complication of liver failure, is associated with multiple biochemical changes like high serum ammonia, mercaptan and phenol levels, low albumin levels and derangements in electrolytes. It is characterized by a range of neuronal and psychological aberrations mainly due to the inability of liver to metabolize different neurotoxic chemicals produced in the body. Hypokalemia is one of the most important findings in hepatic encephalopathy and postulated as a precipitating factor of the condition. The authors aimed to know the frequency of hypokalemia and its relation to the severity of hepatic encephalopathy. Methods: After taking approval from the hospital ethical review committee, a total of 5000 patients with hepatic encephalopathy were recruited by consecutive sampling. They were interviewed, examined and investigated for serum potassium levels and other precipitating factors of hepatic encephalopathy. Results: Total of 5000 patients including 3070 (61.4%) males and 1930 (38.6%) females, aging 13 years and above were studied. The frequency of hypokalemia was 78% (3900 patients). Relating the serum potassium level with the severity of hepatic encephalopathy, 1200 (60%) out of 2000 patients with serum potassium below 2.5 mEq/l were in grade 4 (40%) and 800 out of 2000 were in grade 3 encephalopathy. On the other hand, only 700 patients (6.4%) out 1100 with serum potassium above 3.4 mEq/l were in grade 4 encephalopathy. Conclusion: Hypokalemia is a frequent finding in patients with hepatic encephalopathy and found to be directly related to its severity.

SummaryThe Lancetleld group G streptococcus is known to be a cause of serious infective illness. However, few cases of septic arthritis are recorded. Only one report of this infection, following total joint replacement, has appeared in the orthopaedic literature.1 Here we describe a further case of infection in a previously normal joint that presented with unusual clinical findings and radiographic changes. We stress the importance of accurate bacteriological investigation and aggressive treatment.

BACKGROUND Choledocholithiasis develops in up to 20% of patients with gall bladder stones. The challenge in diagnosis usually occurs with small stones that may be missed by magnetic resonance cholangiopancreatography (MRCP). Endoscopic ultrasound (EUS) is accurate in detecting common bile duct (CBD) stones missed by MRCP, especially the small ones or those impacted at the distal CBD or the papillary region. AIM To evaluate the accuracy of EUS in detecting CBD stones missed by MRCP. METHODS Patients with an intermediate likelihood of choledocholithiasis according to ESGE guidelines and those with acute pancreatitis of undetermined cause were included. The presence of choledocholithiasis was evaluated by MRCP and EUS, and then results were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The sensitivity and specificity of EUS and MRCP were compared regarding the presence of stones, the size, and the number of detected stones. RESULTS Ninety out of 100 involved patients had choledocholithiasis, while ten patients were excluded as they had pancreatic or gall bladder masses during EUS examination. In choledocholithiasis patients, the mean age was 52.37 ± 14.64 years, and 52.2% were males. Most patients had biliary obstruction (74.4%), while only 23 (25.6%) patients had unexplained pancreatitis. The overall prevalence of choledocholithiasis was 83.3% by EUS, 41.1% by MRCP, and 74.4% by ERCP. Also, the number and size of CBD stones could be detected accurately in 78.2% and 75.6% by EUS and 41.1% and 70.3% by MRCP, respectively. The sensitivity of EUS was higher than that of MRCP (98.51% vs 55.22%), and their predictive value was statistically different ( P < 0.001). Combination of both tools raised the sensitivity to 97.22% and specificity to 100%. CONCLUSION EUS could be a useful tool in assessing patients with suspected choledocholithiasis especially if combined with MRCP. However, its usefulness depends on its availability and the experience of the local centers.