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PubMed1975

Negative influences of ascites on the cardiac function of cirrhotic patients.

Right and left ventricular function was evaluated in 21 men with cirrhosis and tense ascites during staged removal of ascitic fluid. During paracentesis it was observed (1) that there was a significant increase in cardiac output, stroke volume, right and left ventricular stroke work and mean rate of systolic ejection; (2) that up to a certain stage of drainage (about 5,000 ml), there was a relationship between the amount of fluid removed and the intraabdominal and right atrial pressures and (3) that there was a direct relationship between improvement of cardiac function and normalization of right atrial pressure. It is believed that the increased intra-abdominal hydrostatic pressure acting upon the diaphragm affects the intrathoracic pressure to such an extent that the transmural filling pressure of the heart is reduced, and the mean pressure and respiratory pulsations of the right atrium increased, all of which impede venous return. Improved cardiac function during paracentesis appears to be due to an augmented filling of the heart and to a larger venous return.

Adult↗
PubMed1986

Bacterial peritonitis secondary to a perinephric abscess. Case report and differentiation from spontaneous bacterial peritonitis.

A cirrhotic patient is described who presented with Escherichia coli septic arthritis as the first manifestation of a perinephric abscess. Results of baseline abdominal paracentesis were unremarkable. After 10 days of antibiotics, abdominal paracentesis was repeated because of recurrence of fever; E. coli peritonitis was confirmed. Subsequent autopsy revealed a perinephric abscess. Development of bacterial peritonitis during antibiotic treatment is distinctly unusual in the "spontaneous" form of peritonitis and should raise suspicion of secondary bacterial peritonitis.

Abscess↗
PubMed1975

Aqueous humor pH changes after experimental alkali burns.

Following application of 2N sodium hydroxide, or 8.1N ammonium hydroxide to rabbit cornea, the aqueous humor pH reached a maximum of 10.2, 11.9, and 12 within six minutes following 20-, 50-, and 100-mu1 sodium hydroxide burns, respectively; after two hours the pH had fallen to 8.5, 10, and 10.5. The maximum rise following application of 100-mu1 of ammonium hydroxide was 10.8, declining to about 9 at two hours. The fall in pH following a 100-mu1 sodium hydroxide burn was not greatly influence by external lavage. However, the pH was significantly lowered (12 to 10) by paracentesis alone and further reduced by immediate or delayed intracameral administration of phosphate buffer. On the basis of these results moderately severe and severe alkali burns of the eye should be treated by paracentesis and if possible with anterior chamber reformation with a sterile solution.

Alkalies↗
PubMed1986

Critical analysis of open peritoneal lavage in blunt abdominal trauma.

Using the generally accepted paracentesis and lavage criteria for laparotomy for patients with blunt abdominal trauma, we found an accuracy rate of 97 percent but a nontherapeutic laparotomy rate of 27 percent. The 17 percent true false-positive rate of paracentesis and lavage is much higher than has been previously appreciated.

Abdominal Injuries↗
PubMed1989

Protein composition of human aqueous humor: SDS-PAGE analysis of surgical and post-mortem samples.

We analyzed the protein composition of human aqueous humor. Samples were obtained by paracentesis from 25 human eyes (age range 64-92 years) at elective cataract surgery, and from 20 age-matched post-mortem eyes within 1.5 to 18 hr after death. Individual samples were assayed for total protein, and the polypeptides were separated by qualitative SDS-PAGE into high-, medium- and low-molecular-weight ranges and then silver-stained. The clinical samples showed a remarkable consistency in the total protein values (mean +/- SEM: 12.4 +/- 2.0 mg per 100 ml) and no detectable variations in the profiles of the silver-stained proteins. Twelve major protein fractions, with apparent molecular weights of 140, 80 (doublet), 67, 60 (doublet), 35, 27, 25, 17, 14.6 and 9 kDa, were present. A preliminary analysis showed that the 17 kDa band contained a molecule resembling basic fibroblast growth factor. Two additional samples of aqueous humor from patients whose blood/aqueous barrier was compromised during paracentesis showed a quantitative and qualitative increase in the polypeptides that were present. Compared with the samples of aqueous humor obtained at surgery, the post-mortem samples exhibited a greater variability in total protein content (56.1 +/- 11.6 mg per 100 ml) and an increased number of high- and low-molecular-weight protein fractions. In view of wide differences in the clinical parameters, including ocular and systemic medications, systemic illness, surgical premedications, anesthesia and total serum protein values, the similarity in the protein profiles of the carefully drawn surgical samples is most remarkable. Our results indicate that, in patients who underwent elective cataract surgery, the levels of major proteins in human aqueous humor are not affected by wide individual variations in the clinical parameters. We attribute this finding to the care taken in the collection of aqueous humor samples.

Aged↗
PubMed1986

Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis.

To assess the risk of development of spontaneous bacterial peritonitis in relation to the ascitic fluid total protein concentration, routine admission abdominal paracentesis was performed on a group of 107 patients during 125 hospitalizations. The paracentesis was repeated if evidence of peritonitis developed during hospitalization. Twenty-one episodes of spontaneous peritonitis (or its culture-negative variant) were documented in 17 patients. The ascitic fluid protein concentration in the spontaneous peritonitis group (0.72 +/- 0.53 g/dl) was significantly lower (p less than 0.001) than that in the group of patients with sterile portal hypertension-related ascites (1.36 +/- 0.89 g/dl) and was significantly lower than that of patients with ascites due to miscellaneous causes. Of the patients whose initial sterile ascitic fluid protein concentration was less than or equal to 1.0 g/dl, 7 of 47 (15%) developed spontaneous peritonitis during their hospitalization; whereas only 1 of 65 (1.5%) patients who had an initial sterile ascitic fluid protein concentration greater than 1.0 g/dl developed spontaneous peritonitis. This difference in risk of development of peritonitis in relation to initial ascitic fluid protein concentration was also significant (p less than 0.01). Low-protein-concentration ascitic fluid predisposes to spontaneous bacterial peritonitis.

Ascitic Fluid↗
PubMed1991

Ascites increases the resting energy expenditure in liver cirrhosis.

The purpose of this study was to investigate the effect of ascites on the energy metabolism of patients with liver cirrhosis. The resting energy expenditure was determined in 10 patients with liver cirrhosis and ascites of moderate or large volume. The resting energy expenditure measurement was performed using indirect calorimetry and the resting energy expenditure predictive value was calculated with the Harris-Benedict equation, both before and after removal of ascitic fluid by paracentesis. Metabolic stress factors were absent in all cases. After an interval of 11.2 +/- 7.7 days between measurements, a weight loss of 16.6 +/- 10.3 kg was observed with paracentesis. The resting energy expenditure measured by indirect calorimetry showed a statistically significant decrease from 1682 +/- 291 to 1523 +/- 240 kcal/day (P less than 0.005) after removal of ascites. The repeatability of our indirect calorimetry method only allowed for the analysis of the results in 4 of 10 patients in whom ascites removal produced a consistent decrease in resting energy expenditure. There were no statistically significant differences between the measurements obtained by indirect calorimetry and those provided by the Harris-Benedict equation, but the latter had a moderate reliability in predicting the real resting energy expenditure of every patient. Our results suggest that, far from being an inert volume, ascites may be associated, at least in some patients, with an increased resting energy expenditure and therefore accelerate the appearance of protein energy malnutrition with corresponding complications.

Adult↗
PubMed1991

Effect of intrathoracic pressure on plasma arginine vasopressin levels.

Abdominal distention during pneumoperitoneum results in a marked increase in plasma arginine vasopressin levels, which has been ascribed to an increase in intrathoracic pressure. Because of this relationship, tense ascites could contribute to nonosmotic release of antidiuretic hormone, to the development of hyponatremia, and eventually to further ascites formation. The effect of pneumoperitoneum, thoracocentesis, and paracentesis on plasma arginine vasopressin levels was studied in three groups of patients, and the mechanism by which these maneuvers may induce these changes was investigated. Patients with pleural effusion, pneumothorax, or ascites showed a significant increase in plasma arginine vasopressin levels, and thoracocentesis or paracentesis resulted in a decrease in these levels. Plasma vasopressin levels increased significantly during pneumoperitoneum, as did intrathoracic and atrial pressures; the atrial transmural pressure gradient declined. However, no changes in plasma levels of norepinephrine, aldosterone, and renin activity were observed during pneumoperitoneum. Changes in plasma arginine vasopressin levels correlated with the changes in intrathoracic and atrial pressures and transmural pressure gradient. The authors conclude that increased intrathoracic pressure is associated with an increase in plasma arginine vasopressin levels and propose that ascites could be a factor promoting vasopressin release by acting on intrathoracic volume receptors in decompensated cirrhotics.

Adult↗
PubMed2004

The challenge of determining aqueous contamination rate in anterior segment intraocular surgery.

PURPOSE: To determine aqueous contamination rate in anterior segment intraocular surgery using two different techniques of obtaining aqueous fluid and to assess whether a 3-day application of topical 0.3% ofloxacin reduces this contamination rate compared with a 1-hour application. DESIGN: Randomized clinical trial. METHODS: One hundred and thirty-three eyes of 130 patients undergoing anterior segment intraocular surgery were randomized to either control (64 eyes received topical ofloxacin 1 hour before surgery) or study groups (69 eyes received topical ofloxacin four times a day for 3 days before surgery in addition to 1 hour preoperatively). Eyes in both groups received a periorbital iodine scrub and two drops of topical 5% iodine. Aqueous fluid was obtained at the beginning and conclusion of surgery using a cannula passed through a paracentesis or a needle passed through clear cornea. The aqueous, cannula, and needles were inoculated in blood culture media broth and bacterial growth was identified. RESULTS: Overall, eight of 89 aqueous samples (9%) obtained using a cannula at the beginning of surgery were culture-positive. Similarly, six of 41 aqueous samples (15%) obtained through a needle through clear cornea at the beginning of surgery showed contamination. At the conclusion of surgery, nine of 112 samples (8%) showed positive cultures. There was no difference in the aqueous contamination rates between the control and study groups. CONCLUSIONS: Despite the use of a needle to obtain aqueous fluid at the beginning of surgery before creating a paracentesis, the aqueous contamination rate remained higher than that found at the conclusion of surgery. A 3-day application of topical ofloxacin before surgery did not reduce the anterior chamber aqueous contamination rate relative to a 1-hour application.

Anterior Eye Segment↗
PubMed2005

Anterior chamber infiltration in a patient with Ph+ acute lymphoblastic leukemia in remission with imatinib.

PURPOSE: Anterior chamber involvement is unusual in patients with acute lymphoblastic leukemia (ALL) and has never been described in the setting of Ph+ (Philadelphia chromosome-positive) ALL. Moreover, there have been no reports of this complication as a primary relapse in a patient treated with imatinib. DESIGN: Interventional case report. METHODS: A 55-year-old woman with Ph+ ALL in complete remission with imatinib and presenting unilateral anterior uveitis at initial examination was clinically evaluated. Hematologic and ocular studies were performed: blood films, bone marrow smears, and anterior chamber paracentesis with aqueous fluid cytology. RESULTS: Although there was no evidence of leukemia in the blood or bone marrow samples, aqueous fluid cytology identified Ph+ positive lymphoblastic leukemic cells. CONCLUSIONS: The patient had developed anterior chamber infiltration without hematological relapse while treated with imatinib. In our opinion, paracentesis should be performed without delay when uveitis develops in ALL, regardless of systemic relapse.

Anterior Chamber↗
PubMed2007

Prevention and treatment of infections in patients with cirrhosis.

Patients with cirrhosis have altered immune defenses and are considered immunocompromised individuals. Changes in gut motility, mucosal defense and microflora allow for translocation of enteric bacteria into mesenteric lymph nodes and the blood stream. Additionally, the cirrhotic liver is ineffective at clearing bacteria and associated endotoxins from the blood thus allowing for seeding of the sterile peritoneal fluid. Thus, hospitalised cirrhotic patients, particularly those with gastrointestinal hemorrhage, are at high risk of developing bacterial infections, the most common being spontaneous bacterial peritonitis. Given the significant morbidity and mortality associated with spontaneous bacterial peritonitis and the fact that half of the cases are community acquired, all hospitalised cirrhotic patients should have a diagnostic paracentesis to exclude infection. Those admitted with gastrointestinal bleed and a negative paracentesis require short-term prophylaxis with norfloxacin. A third generation cephalosporin is the treatment of choice for spontaneous bacterial peritonitis and, once the acute infection is resolved, secondary prophylaxis with oral norfloxacin is warranted. Patients who develop renal dysfunction at the time of active infection have the highest mortality and require adjunctive albumin therapy. This article reviews the pathogenesis of SBP, the evidence behind the antibiotics used, the rationale for adjunctive albumin therapy in the setting of acute renal failure, and the role of prophylactic antibiotics in specific high-risk populations.

Anti-Bacterial Agents↗
PubMed2006

Octreotide in the outpatient therapy of cirrhotic chylous ascites: a case report.

Chylous ascites is a rare complication of liver cirrhosis associated with a poor short-term prognosis. We report the case of an 80-year-old male cirrhotic patient with refractory chylous ascites associated with portal hypertension. He was treated with total parenteral nutrition but chylous ascites relapsed at suspension. Patient was put on long-term subcutaneous octreotide (100 microg t.i.d.) as an outpatient. The treatment was well tolerated and led to clinical improvement, markedly reducing the need of total paracentesis and the amount of ascites. Octreotide was stopped after 6 months, and massive ascites did not relapse. After 1 year the patient was alive, with no need of paracentesis. Octreotide therapy should be considered in patients with cirrhosis and chylous ascites to simplify the outpatient management of the disease.

Aged, 80 and over↗
PubMed2005

Ectopic mesothelial cell proliferation in cervical lymph nodes after severe ovarian hyperstimulation syndrome.

OBJECTIVE: To report a case of ectopic mesothelial proliferation in cervical lymph nodes after severe ovarian hyperstimulation syndrome. DESIGN: Case report. SETTING: University-affiliated teaching hospital. PATIENT(S): A 42-year-old woman underwent a successful IVF attempt and developed severe ovarian hyperstimulation syndrome and pathologically enlarged cervical lymph nodes. INTERVENTION(S): Paracentesis, cervical lymph node biopsy followed by cytology, histology, and immunohistochemistry. MAIN OUTCOME MEASURE(S): Resolution of symptoms, pregnancy outcome, correct pathological diagnosis. RESULT(S): Paracentesis resulted in resolution of symptoms of ovarian hyperstimulation. The diagnosis of ectopic mesothelial proliferation in cervical lymph nodes was made after immunohistochemical examination of cervical lymph nodes. The pregnancy progressed normally, and at 40 weeks the patient spontaneously delivered a healthy son weighing 3,060 g. CONCLUSION(S): This case describes ectopic mesothelial cell proliferation localized in and around cervical lymph nodes occurring at 9 weeks' gestation in a patient who earlier developed severe ovarian hyperstimulation syndrome 10 days after ET. Ectopic mesothelial cell proliferation in lymph nodes is an extremely rare event, and this is the first case described after ovarian hyperstimulation. Familiarity with this event is important for the clinician as well as for the pathologist in preventing the misdiagnosis of malignancy.

Adult↗
PubMed2001

Surgical technique for transcleral-fixation of a dislocated posterior chamber intraocular lens.

PURPOSE: To report a cornea-pars plana through-and-through technique for the repositioning and transcleral suture fixation of a dislocated posterior chamber intraocular lens. DESIGN: Interventional case series. METHODS: For transscleral suture fixation of a dislocated posterior chamber intraocular lens, one needle of a double-arm 10-0 Prolene needle is passed through the paracentesis site then underneath the intraocular lens haptic, and through the intended scleral outlet on the opposite side. The other needle of the Prolene suture is also passed through the same paracentesis, above the same haptic, and through the intended scleral outlet on the opposite side. The haptic is now well supported, and the knot is tied. A similar procedure is performed for the second haptic if necessary. RESULTS: Three eyes (three patients) were operated on using this technique with good visual and anatomic outcome. CONCLUSION: The described technique is simple, safe, allows early visual rehabilitation, and can be accomplished without an assistant.

Female↗
PubMed1996

Diagnosis and treatment of an ophthalmic artery occlusion during an intralesional injection of corticosteroid into an eyelid capillary hemangioma.

PURPOSE: To demonstrate the usefulness of simultaneous indirect ophthalmoscopy in the diagnosis and treatment of embolization of the ocular circulation during intralesional injection of corticosteroids into capillary hemangiomas. METHODS: A 4-month-old infant had an ophthalmic artery occlusion during an intralesional injection of corticosteroids into a right upper eyelid capillary hemangioma. The injection was discontinued immediately and a paracentesis was performed. Fluorescein angiography was performed 20 minutes and three weeks after the ophthalmic artery occlusion. RESULTS: Fluorescein angiography after the paracentesis showed delayed retinal and choroidal filling and large areas of retinal and choroidal ischemia. Three weeks after treatment, the angiographic abnormalities had resolved, and the retinal and choroidal circulations were normal. Twenty-eight months after treatment, the visual acuity was 20/20 in each eye. CONCLUSION: Ophthalmic artery occlusion can occur during intralesional injection of corticosteroids into capillary hemangiomas. Simultaneous indirect ophthalmoscopy allows the surgeon to discontinue the injection and provide treatment to allow for the best possible visual outcome after this complication.

Anti-Inflammatory Agents↗
PubMed2001

Saphenoperitoneal anastomosis for resistant ascites in patients with cirrhosis.

BACKGROUND: Restriction of salt intake and diuretics combined with repeated paracentesis has been the mainstay of managing longstanding ascites. Peritoneal-venous shunts have been employed in refractory ascites but are not without complication. We evaluated an autologous reversed segment of proximal long saphenous vein anastomosed to the peritoneum in management of patients with resistant ascites. METHODS: Eleven patients (8 male, median age 48 years, range 37 to 68) with tense refractory ascites associated with cirrhosis of the liver and portal hypertension underwent saphenous vein-peritoneal anastomosis by rotating the proximal vein cephalad which was anastomosed to peritoneum in the posterior wall of the inguinal canal. Ten of 11 procedures were performed under general anesthetic. RESULTS: Thirty-day mortality was 1 patient. Morbidity included transient hepatic encephalopathy in 4 (36%), minor wound hemorrhage in 3 (27%), fluid leakage in 7 (64%), and wound infection in 7 (64%). Hospital stay (median) was 16 days (range 11 to 23). In the short term (median of 9 months) significant reduction in body weight and abdominal girth was seen in 9 (90%), 6 (60%) were not on diuretics while 3 (30%) continued to remain on reduced doses of diuretic. Furthermore, 7 (70%) did not require paracentesis. At 2-year follow-up, 5 (45%) patients had died and 3 were lost to follow-up. The remaining 3 were all in active employment, 1 was off diuretics, and 2 were on reduced doses. All 3 patients maintained reduced body weights and abdominal girths compared with preoperative values. CONCLUSIONS: Saphenous-peritoneal anastomosis appears a simple, safe, and effective method of achieving long-term control of refractory ascites. The use of a biological shunt is an added advantage over prosthetic shunts for drainage of ascitic fluid.

Anesthesia, General↗
PubMed1981

Treatment of ovarian hyperstimulation syndrome: the physiologic basis for a modified approach.

A case of severe ovarian hyperstimulation syndrome (OHSS) secondary to human menopausal gonadotropin-human chorionic gonadotropin therapy is presented. Draining 4000 ml of exudate by abdominal paracentesis under real-time B-scan imaging induced a marked improvement in the patient's condition. Fluids from the third space were rapidly excreted, renal function improved, and the patient's weight decreased substantially. The underlying physiologic factors responsible for these changes are discussed. Other modes of treatment, including salt and water restriction and the use of volume expanders and diuretics, had no significant effect on the course of the syndrome. Paracentesis has a definite therapeutic value and is recommended in cases of OHSS with tense ascites.

Adult↗
PubMed1994

Angiotensin II immunoreactivity is elevated in ascites during severe ovarian hyperstimulation syndrome: implications for pathophysiology and clinical management.

OBJECTIVE: To investigate the ovarian renin-angiotensin system (RAS) during severe ovarian hyperstimulation syndrome (OHSS). DESIGN: Simultaneous sampling of blood and ascitic or peritoneal fluid (PF) during therapeutic paracentesis or laparoscopy. SETTING: University Hospital. PATIENTS: Twelve patients were investigated: three patients presenting severe OHSS, three patients with a spontaneous first trimester pregnancy, three normally cycling women during the early luteal phase, and three patients with ascites of nonovarian origin. MAIN OUTCOME MEASURE: Renin-like activity and angiotensin II (ANG II) immunoreactivity were measured simultaneously in the plasma and the ascites or PF. RESULTS: Angiotensin II immunoreactivity was much higher in the ascites or PF than in corresponding plasma during severe OHSS, first trimester pregnancy, and in the early luteal phase, while it was lower in ascites of nonovarian origin. Renin-like activity and ANG II immunoreactivity were the highest in the ascites of severe OHSS and in the PF from part of the patients with a spontaneous first trimester pregnancy. CONCLUSIONS: The present findings argue for the ovarian origin of the elevated renin-like activity and ANG II immunoreactivity in the ascites of severe OHSS and suggest a stimulatory role of hCG on the ovarian RAS whether during severe OHSS or first trimester spontaneous pregnancy. The vasoactive peptide ANG II may contribute to the maintenance of the ascites in severe OHSS but is probably not responsible for the formation of the ascites. The efficiency of paracentesis during severe OHSS could be explained at least partially by the removing of great amounts of ANG II from the peritoneal cavity.

Adult↗