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PubMed2005

[Diagnosis of spontaneous ascites infection in patients with cirrhosis: reagent strips].

AIM: To evaluate the sensitivity, specificity, and predictive values of dipstick testing (DT) for detecting spontaneous bacterial peritonitis (SBP), defined by an ascites neutrophil polymorphonuclear cell count > or = 250/mm3, in patients with cirrhosis. METHODS: The study includes all patients with cirrhosis and ascites admitted to our general hospital on the southern outskirts of the Paris metropolitan area (France) from June 2003 to May 2004 (n = 47:27 men and 20 women). Diagnostic abdominal paracentesis was performed on admission, and a Multistix SG (Bayer Pharma) reagent strip was immersed in one ascitic sample from each patient. Readings after 120 s were either negative (DT-) or positive (DT+, with 4 levels of positivity: trace, +, ++, or +++). In case of cytologically-proven SBP, patients were treated with cefotaxime, and subsequent paracentesis with DT and cytologic testing took place every 48 hours, until recovery. RESULTS: Six of the 47 patients had proven SBP, all with clinical signs of SBP (fever and/or abdominal pain); five of these patients were DT+ and one was DT-. In the five patients initially DT+, the DT became negative at the same time as the cytologic criteria for SBP disappeared. Forty-one patients did not meet the cytologic criteria for SBP: 34 were DT- and 7 were DT+ (traces: 4, ++: 2, +++:1); two of these had clinical signs suggestive of SBP. CONCLUSION: Although the sensitivity (83%), specificity (83%) and negative predictive value (97%) of DTwere satisfactory, its positive predictive value (42%) was low. Dipstick testing of ascitic fluid is easy to perform and inexpensive and may be recommended for diagnosis and follow-up of SBP, especially in emergency settings.

Aged↗
PubMed2005

Case report: delirium associated with ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome (OHSS) is one of the most important complications of assisted reproductive technologies. Mild OHSS is characterized by ovarian enlargement and abdominal discomfort. In severe cases anasarca, hepatic dysfunction, reduced blood volume, electrolyte imbalance, organ failure and thromboembolic phenomena may be observed. Delirium is a syndrome, not a disease, and has many causes, all of which result in a similar pattern of signs and symptoms relating to a patient's level of consciousness and cognitive impairment. Delirium remains an under-recognized and under-diagnosed clinical disorder. The case is presented of a 30-year-old woman with OHSS and delirium. She underwent intracytoplasmic sperm injection (ICSI) for severe male factor infertility. Five days after oocyte retrieval, ascite formation was observed in ultrasonographic evaluation, and embryo transfer was cancelled. Twelve days after retrieval she came to the emergency clinic with abdominal distension and pain. She was hospitalized and paracentesis was performed every other day three times. She had altered consciousness and psychomotor hypoactivity 1 h after the last paracentesis. Psychiatric consultation revealed that she was in a state of delirium, and haloperidol was administered for treatment. Her symptoms disappeared within a week. Her medication was stopped when symptoms resolved and she was still asymptomatic in psychiatric evaluation 1 week later.

Adult↗
PubMed2002

Management of refractory ascites and hepatorenal syndrome.

Refractory ascites and hepatorenal syndrome (HRS) are the late complications of the terminal stages of cirrhosis. The definitions of refractory ascites and HRS proposed by the International Ascites Club in 1996 are now widely accepted, and are useful in diagnosis, treatment and research in this field. In both conditions, the only treatment of proven value for improved survival is liver transplantation. However, because of better understanding about the pathophysiology of HRS, including the roles of portal hypertension, ascites formation and hemodynamic derangements, treatments such as transjugular intrahepatic portasystemic shunt (TIPS) and new pharmacological agents may be considered to alleviate the problem prior to transplantation. Symptomatic treatment of refractory ascites includes TIPS and repeated large volume paracentesis. Transjugular intrahepatic portasystemic shunt can improve survival while waiting for liver transplantation. Practical management guidelines for TIPS and large volume paracentesis, including the prevention and management of further complications, are considered in this review.

Ascites↗
PubMed2000

[Minimally invasive therapy for clinically complete central retinal artery occlusion--results and meta-analysis of literature].

BACKGROUND: Goal of our study was the comparison of the efficacy of various minimal invasive therapeutic regimens for clinically complete central retinal artery occlusion (CRAO) and the comparison with the literature. PATIENTS AND METHODS: In a retrospective study 93 patients treated for CRAO during the period 1994-1998 were identified. 65 of these patients with clinically complete occlusion without a cilioretinal artery were included in the study. Analysis focused on the results of different therapies and the duration of visual impairment till starting treatment. RESULTS: The following therapies were used: acetazolamide (65%), aspirin (60%), bulbus massage (45%), hemodilution (34%), oral pentoxifylline (28%), topical beta blockers (9%), paracentesis (8%), heparin (6%). In 15% of all cases an improvement of at least 3 visual acuity gradations was achieved. No significant positive influence of any treatment method could be identified. Also, a correlation between duration of visual impairment and final visual acuity could not be shown. In the literature very different criteria for inclusion of patients to the studies and for visual acuity improvement are found. When applying comparable criteria to ours most studies show similar results for the therapies listed above as well as for paracentesis and the use of carbogen (95% O2 and 5% CO2). CONCLUSION: The minimal invasive treatments given above do only improve natural course of CRAO in occasional cases. Thus a therapy (-combination) should be chosen, which is adapted to the individual risk factors and is exposing the patient to a low risk by therapy itself.

Acetazolamide↗
PubMed2004

[Spontaneous bacterial peritonitis (SBP). Retrospective and prospective data from a multicenter study on prevalence, diagnosis and therapy in Germany].

BACKGROUND: Data regarding the prevalence of SBP in patients with ascites or the diagnostic and therapeutic management of SBP in Germany are lacking. PATIENTS AND METHODS: In a multicenter study (40 hospitals), retrospective, then prospective data were collected investigating the prevalence of SBP in patients with ascites and the pertinent diagnostic and therapeutic management. In 272 prospectively entered patients with ascites (cirrhosis/malignant ascites/other: n = 227/42/3) a diagnostic paracentesis was performed and SBP diagnosed using the ascitic neutrophil count. History, clinical symptoms and laboratory findings were recorded and potential risk factors analysed by univariate analysis and stepwise logistic regression. SBP was treated with a standard dose of a third-generation cephalosporin. RESULTS: In the retrospective study, SBP was diagnosed in 648 of 4,697 patients with ascites (14 %). Employed diagnostic and therapeutic pathways were not effective in several hospital departments. In the prospective trial, SBP was found in 134 of 272 patients with ascites (49,3 %). Frequency of symptoms was significantly different in patients either with or without SBP, as were macroscopic aspect of ascites, urine excretion and several biochemical parameters. However, their diagnostic precision was unsatisfactory. Predictive factors for SBP were previous paracentesis, endoscopic procedures and a history of abdominal pain. Treatment was effective in 83,5 % of cases. Inhospital mortality was 10 %. CONCLUSION: The prevalence of SBP in hospitalised patients with ascites in Germany is similar to that in southern Europe and USA. Symptoms alone lack sufficient diagnostic accuracy. Third-generation cephalosporin is an effective antibiotic in SBP. Pertinent diagnostic and therapeutic management calls for improvement.

Analysis of Variance↗
PubMed1997

A novel approach to the treatment of ascites associated with ovarian hyperstimulation syndrome.

Ascites is a clinical manifestation of severe ovarian hyperstimulation syndrome (OHSS) which may complicate the induction of ovulation using exogenous gonadotrophins. In severe OHSS severe ascites may occur and can lead to dyspnoea, abdominal discomfort and oliguria. To relieve ascites paracentesis is performed two to three times weekly as needed. We report three cases where an indwelling peritoneal catheter was used to decrease the need for repeated paracentesis. Under ultrasound guidance a closed system Dawson-Mueller catheter with 'simp-loc' locking design was inserted to allow continuous drainage of the ascitic fluid. A total of 23 l of the ascitic fluid were drained from the first, 20 l from the second and 28 l from the third patient with significant decrease in abdominal discomfort and improvement in the urine output. No complications or adverse reactions were noted. Continuous drainage of the ascitic fluid is efficient. It quickly decreases the abdominal discomfort, improves the urine output and prevents the need for multiple abdominal paracenteses which some patients may require.

Adult↗
PubMed1998

Treatment options for cirrhotic ascites.

Ascites due to cirrhosis can usually be managed successfully by dietary sodium restriction and carefully monitored diuretic therapy. However, paracentesis with an albumin infusion is a relatively safe alternative that has gained widespread acceptance. Other plasma expanders offer a cheaper alternative to albumin. Other recently developed techniques include peritoneovenous shunt and transjugular intrahepatic portosystemic stent shunt. Each of these is associated with an operative mortality and substantial complications, but for diuretic-resistant ascites a peritoneovenous shunt has comparable results to paracentesis/albumin. For patients with spontaneously occurring renal failure the prognosis is poor. None of the above treatments improves renal function. Management should therefore be symptomatic with paracentesis as necessary.

Ascites↗
PubMed2002

A severe case of ovarian hyperstimulation syndrome with liver dysfunction and malnutrition.

Ovarian hyperstimulation syndrome (OHSS) is a potentially fatal condition associated with the use of ovulation-inducing drugs. We describe a 28-year-old woman who presented with ascites, oliguria and vomiting. Over 2 weeks, the combination of intractable vomiting, intravenous rehydration, paracentesis, hypercatabolism and proteinuria led to severe hypoalbuminaemia with gross oedema and progressively worsening liver function. The patient's albumin dropped to 9 g/l with liver function abnormalities peaking at: alanine aminotransferase, 462 IU/l; alkaline phosphatase, 706 IU/l; bilirubin, 26 micromol/l; and prothrombin time, 19 s. The judicious use of paracentesis and commencement of total parenteral nutrition coincided with a rapid clinical improvement. One month after discharge, the patient was asymptomatic with normal liver function. This case demonstrates the severity of malnutrition and liver dysfunction that can occur with severe OHSS. Increasing use of in-vitro fertilization techniques makes it mandatory for clinicians to be aware of the clinical features, complications and treatment of this condition, and we would suggest that patients with severe OHSS should be jointly managed by physicians and obstetricians.

Adult↗
PubMed2004

Comparison of percutaneous management techniques for recurrent malignant ascites.

The Pleurx subcutaneous tunneled catheter is approved for repeated, long-term drainage of malignant pleural effusions; however, there is limited literature describing its use in malignant ascites. The authors compared the safety and efficacy of two percutaneous drainage methods: large volume paracentesis and Pleurx catheter placement over a 41-month period. The Pleurx catheter provided effective palliation with a complication rate similar to that for large volume paracentesis, while preventing the need for frequent trips to the hospital for repeated percutaneous drainage.

Adult↗
PubMed1998

Correlation between anterior chamber IgG/albumin concentrations and laser flare photometry in eyes with endogenous uveitis.

PURPOSE: To assess the correlation between laser flare measurements and anterior chamber IgG/albumin concentrations in eyes with mild to severe inflammation. MATERIALS AND METHODS: Seventeen eyes of 17 patients with endogenous uveitis underwent diagnostic paracentesis. IgG and albumin concentrations were determined from the samples of aqueous humor. Laser flare measurements were performed 1 h prior to paracentesis. The relationship between flare measurements and IgG/albumin concentrations was studied be plotting the data on a logarithmic scale. RESULTS: The flare measurement was 97.5+/-150.0 photons ms (mean +/- SD; range 4.3-528.7). The IgG concentration was 41.0+/-51.4 mg/dl mean +/- SD; range 0.2-200). The albumin concentration was 184.6+/-196.2 mg/dl (mean +/- SD; range 4-535). When plotted on a logarithmic scale, there was a statistically significant linear relationship between the flare measurements and the anterior chamber IgG or albumin concentrations (y = 1.14x-0.64, r= 0.87, p<0.001 for IgG; y = 1.39x-0.1, r= 0.94, p<0.001 for albumin). CONCLUSION: Laser flare photometry is an accurate technique for assessing anterior chamber inflammation. Flare measurements strongly correlate with blood-aqueous barrier breakdown.

Adolescent↗
PubMed2005

Spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid in patients with decompensated cirrhosis. The modifier 'spontaneous' distinguishes this from surgical peritonitis. The infecting organisms are usually enteric gram-negatives which have translocated from the bowel. Symptoms of infection occur in most patients with SBP, including fever, abdominal pain, mental status changes, and ileus. A high index of suspicion should exist for SBP in patients with cirrhosis and ascites. Diagnostic abdominal paracentesis can be undertaken with minimal risk and should be performed in all patients admitted to the hospital, during times of worsening clinical appearance, or when gastrointestinal bleeding occurs. The ascitic fluid polymorphonuclear cell count is the most sensitive test in evaluating for infection. Cultures of the ascitic fluid are helpful in identifying the organism and are best performed by bedside injection of blood culture bottles. Ascites total protein, lactate dehydrogenase, and glucose levels can assist in distinguishing SBP from secondary peritonitis. Empirical therapy is recommended after paracentesis if suspicion for infection exists. Cefotaxime is the best-studied antibiotic for this purpose and has excellent penetration into ascites with no nephrotoxicity. Prophylaxis should be limited to high-risk settings. Mortality rates in SBP have declined dramatically, largely due to earlier detection and improved therapy.

Anti-Bacterial Agents↗
PubMed1997

Respiratory mechanics in patients with tense cirrhotic ascites.

Lung volumes are decreased by tense ascites and increase after large volume paracentesis (LVP). The overall effect of ascites and LVP on the respiratory function is poorly understood. We studied eight cirrhotic patients with tense ascites before and after LVP. Inspiratory muscle force (maximal transdiaphragmatic pressure (Pdi,max), and the lowest pleural pressure (Pp1,min)) was assessed while the patients were seated. Rib cage and abdominal volume displacements, as well as pleural and gastric pressures were measured during quiet breathing while the patients were supine. Pdi,max and Ppl,min were normal and did not change after LVP (from 84.2+/-19.7 to 85.2+/-17.0 cmH2O and from 68.3+/-19.7 to 74+/-15.9 cmH2O, respectively). The abdominal contribution to the generation of tidal volume was greater than that of the rib cage (79 vs 21%), a pattern which did not change after LVP (73 and 27%). Before LVP, tidal swings both of pleural pressure (Ppl,sw) and transdiaphragmatic pressure (Pdi,sw) were large (15.3+/-4.3 and 18.5+/-3.9 cmH2O, respectively) and the load on inspiratory muscles was increased as a consequence of elevated dynamic elastance of the lung (El,dyn) (11.4+/-2.6 cmH2O x L(-1)) and ("intrinsic") positive end-expiratory pressure (PEEPi) (4.3+/-3.5 cmH2O). LVP reduced the load on the inspiratory muscles, as shown by the significant decrease in Ppl,sw (10.6+/-2.0 cmH2O), Pdi,sw (12.8+/-3.0 cmH2O), El,dyn (10.0+/-2.0 cmH2O x L(-1)) and PEEPi (1.1+/-1.3 cmH2O). The amount of fluid removed was closely related to changes in Ppl,sw and PEEPi. We conclude that the strength of the inspiratory muscles is normal or reduced in seated cirrhotic patients. In the supine position, tense ascites results in an increase in lung elastic load and development of positive end-expiratory pressure, with a consequent overload and increased activation of inspiratory muscles. Large volume paracentesis decreases overloading and activation, but does not change the strength of the inspiratory muscles.

Ascites↗
PubMed1998

Performing radiologic gastrostomy or gastrojejunostomy in patients with malignant ascites.

OBJECTIVE: We describe our protocol for performing decompression radiologic gastrostomy and gastrojejunostomy in patients with ascites and small-bowel obstruction. We also assess the technical success rate, the complications, and the morbidity and mortality in 45 patients who underwent radiologic gastrostomy. MATERIALS AND METHODS: Forty-five consecutive patients with ascites associated with metastatic ovarian cancer underwent a radiologic gastrostomy or gastrojejunostomy with gastropexy. Six patients underwent gastrostomy, and 39 patients underwent gastrojejunostomy. Locking catheters were placed using the Seldinger technique after gastropexy in all patients. Paracentesis was performed before gastrostomy or gastrojejunostomy. Additional serial paracenteses were performed after the procedure when reaccumulation of ascites close to the site of gastropexy was detected on follow-up sonography. RESULTS: Forty-five procedures were attempted. The technical success rate was 97.8%. The complication rate was 15.6%. Three major complications (6.7%) and four minor complications (8.9%) occurred. One procedure-related death (2.2%) occurred 16 days after gastrojejunostomy. CONCLUSION: Radiologic gastrostomy and gastrojejunostomy can be performed safely in patients with ascites if the patients undergo paracentesis first and if the reaccumulation of ascites is prevented after tube placement. In patients with ascites, gastropexy plays an important role in preventing pericatheter leakage. Ascites and peritoneal carcinomatosis should not be considered contraindications for radiologic gastrostomy or gastrojejunostomy.

Ascites↗
PubMed2006

Efficacy of leukocyte esterase dipstick test as a rapid test in diagnosis of spontaneous bacterial peritonitis.

AIM: To evaluate the efficacy of dipstick test in diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients who underwent abdominal paracentesis based on the locally available dipstick test. METHODS: There were 200 consecutive samples from cirrhotic patients who underwent abdominal paracentesis. Urine dipstick (Combur10 TestM, Roche, Mannheim, Germany) was used as a screening test. A manual cell count with differential study was done in all samples by experienced technicians. The polymorphonuclear (PMN) cell count more than 250 cells/mm3 was used as a diagnostic cut off level. One to three plus dipstick results were used as cut off levels for a positive result. The dipstick test results had to be agreed by three experienced readers. The sensitivity, specificity, positive and negative predictive values and accuracy of two different colorimetric cut off scales (1+ and 2+) were calculated and compared. RESULTS: The prevalence of SBP diagnosed by manual cell count was 21.0%. There were 128 specimens that had a true negative result by dipstick. The sensitivity, specificity, positive and negative predictive values and accuracy of 1+ and 2+ cut off scale to diagnose SBP were 88%, 81%, 55%, 96% and 83% respectively, and 63%, 96%, 82%, 81% and 89% respectively. CONCLUSION: Dipstick test can be used as a rapid test for screening of SBP. The higher cut off colorimetric scale has a better specificity and positive predictive value but a lower sensitivity.

Adult↗
PubMedDate not supplied

Current concepts in the management of refractory cirrhotic ascites.

BACKGROUND: Ascites is the pathologic accumulation of fluid within the peritoneal cavity. This condition when refractory to treatment heralds more severe complications and a poor prognosis. The aim of this paper is to review literature on the pathogenesis and current management of refractory cirrhotic ascites. METHODS: An English language literature search using Medline and PubMed (1976-2006 March) was done to assess all research/review articles on the pathogenesis and management of refractory cirrhotic ascites. RESULTS: The onset of ascites in cirrhotic patients signifies poor prognosis. Only a small percentage of patients with cirrhotic ascites develop true resistance to diuretics. Serial therapeutic paracentesis remains the available option for the majority of patients. Liver transplantation is the only definitive therapy, but the use of this method is limited by the availability of the organ and the cost of such procedure. Transjugular intrahepatic portosystemic stent shunt is a useful procedure but limited by the complication of disseminated intravascular coagulopathy. The role of other alternatives is less clearly defined. CONCLUSION: Therapeutic options in patient with cirrhotic ascites remains serial therapeutic paracentesis with or without plasma expansion. Transjugular intrahepatic portosystemic stent-shunt is a useful alternative. The unavailability of liver donors serves as a barrier to liver transplantation.

Ascites↗
PubMedDate not supplied

Effect of tense ascites on esophageal body motility and lower esophageal sphincter pressure.

BACKGROUND: Esophageal motility and lower esophageal sphincter (LES) pressure change with rapid changes in intraabdominal pressure (IAP); the response of these to slow change in IAP is not known. AIMS: To study esophageal body motility and LES pressures in patients with cirrhosis with tense ascites in the basal state and after paracentesis. METHODS: Twenty four patients with cirrhosis of liver and tense ascites and 13 with cirrhosis without ascites (controls) were studied. Basal intragastric (IGP) and LES pressures, and esophageal body response to water swallows, were recorded using a water perfusion system; IAP was measured in patients with ascites. In patients with ascites, the study was repeated twice: after paracentesis of two liters of fluid and after adequate control of ascites. RESULTS: Basal IGP (p = 0.002) and duration of esophageal contraction (p = 0.01) were lower in controls, but basal LES pressures were similar in the two groups. After control of ascites, IAP (p = 0.02) and IGP (p = 0.005) decreased; amplitude and duration of distal esophageal contraction decreased (p < 0.05). The frequency of high-amplitude waves also decreased (p = 0.04). LES pressure remained unaltered. CONCLUSIONS: Esophageal contraction duration is increased in the presence of ascites, and decreases after control of ascites; LES pressure is not affected by ascites.

Ascites↗
PubMed2002

[The use of albumin infusion in decompensated liver cirrhosis].

For patients with refractory ascites, paracentesis is the standard therapy and for many it is the only treatment option. When more than five litres of ascitic fluid are removed, the use of a plasma expander effectively prevents "postparacentesis circulatory dysfunction", which is associated with a high mortality. Randomised controlled studies show that albumin is more effective than synthetic plasma expanders in the prevention of this complication. In selected patients with ascites, long-term administration of albumin may improve the diuretic response. A randomised controlled study in patients with spontaneous bacterial peritonitis has demonstrated that treatment with albumin infusion in addition to an antibiotic reduces the incidence of hepatorenal syndrome. Albumin infusion in combination with the administration of a vasopressin analogue may be able to reverse established hepatorenal syndrome; however, no controlled studies have been published. Whereas the use of albumin infusion with large-volume paracentesis is strongly supported by the available evidence, additional conclusive studies of the use of albumin for spontaneous bacterial peritonitis are awaited.

Ascites↗
PubMed2004

Management of ascites in patients with end-stage liver disease.

Ascites is the most common complication in patients with decompensated cirrhosis. Approximately 50% of patients with compensated cirrhosis will develop ascites over a 10-year period. This occurrence is an important milestone in the natural history of end-stage liver disease because only 50% of patients survive 2 to 5 years (depending on the cause of cirrhosis) after its onset. Salt restriction and diuretics are the mainstays of therapy, and these measures are effective in approximately 90% of patients. Large-volume paracentesis or transjugular intrahepatic portosystemic shunt can be used in patients with refractory ascites as either a bridge to transplant or as palliation. Cirrhotic patients with ascites should be carefully monitored for the development of bacterial peritonitis, and those at greatest risk should receive antibiotic prophylaxis. When spontaneous bacterial peritonitis is suspected, prompt diagnostic paracentesis followed by broad-spectrum antibiotics and albumin infusion can be life saving. Orthotopic liver transplantation should be considered in all patients with decompensated liver disease with or without ascites.

Ascites↗