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PubMedDate not supplied

[ASCITES IN HEPATIC CIRRHOSIS: RECOGNITION INVESTIGATIONAND TREATMENT]

Hepatic cirrhosis is the most common cause of ascites. It is caused by liver failure leading to complex interrelated circulatory and renal changes resulting in retention of sodium and water and portal hypertension localising that sodium and water in the peritoneum. Ascites is an important development in cirrhosis as it implies a generally poor long term prognosis. Investigation is important as ascites is not always dueto cirrhosis, may bethe consequence of complications of cirrhosis such as hepatocellular carcinoma, and may be associated with infection which is fatal if untreated. Most patients respond to treatment with sodium restriction and diuretic drugs. This treatment takes time, and increasingly doctors use therapeutic paracentesis with sodium restriction and diuretics to prevent recurrence of ascites. Paracentesis, however, is not without complications, and it is particularly important to give colloid replacement to prevent hypovolaemia which can lead to renal failure. Patients who do not respond to this treatment may be helped by a TIPSS procedure or a peritoneovenous shunt. However, these patients usually have very poor liverfunction and the possibility of fiver transplantation should be considered. Infection is a very serious complication of ascites (spontaneous bacterial peritonitis) and carries a generally poor prognosis.Antibiotic prophylaxis is important to prevent recurrence and liver transpiantation shoulcl be considered.

Journal Article↗
PubMed1992

[Medical treatment of chylous effusions in newborn infants. Apropos of 3 cases].

BACKGROUND: Chylous effusions are the most frequent cause of non immunologic hydrops fetalis. They can be recognized antenatally by ultrasonography. Their evacuation is sometimes necessary and medical treatment often effective. CASE REPORTS: Case n. 1: fetal ascites was detected by ultrasonography at the 30th week of gestation. Paracentesis was performed at 36 weeks, followed 3 days later by spontaneous delivery. The newborn was fed milk formula. A second paracentesis showed a milky fluid, rich in cholesterol, triglycerides and chylomicrons. The child was fed formula rich in medium-chain triglycerides and the chylous ascites disappeared completely within 2 weeks. Case n. 2: a diagnosis of bilateral hydrothorax and hydramnios was made at the 27th week of gestation. An in utero evacuation of the hydrothorax performed at the 30th week was ineffective and a pleuro-amniotic drainage was performed 2 weeks later. The baby was born at the 35th week, and presented a moderate respiratory distress due to the hydrothorax and ascites. Aspiration of the thoracic fluid confirmed its chylous origin. The chylous effusions completely disappeared when the child was fed a high medium chain triglycerides diet. A lymphedema of legs appeared at the age of 1 month. Case n. 3: ascites, hydramnios, hydrothorax and peripheral edema were found at the 21st week of a third pregnancy (the 2 first pregnancies were complicated by lethal hydrops fetalis). Bilateral hydrothorax and peripheral edema were found again after birth at the 37th week. Diuresis and albumin-infusion led to recovery, but chylothorax and chylous ascites reaccumulated after introduction of milk formula, despite repeated evacuations and feeding medium-chain triglycerides formula. The thoracic fluid remains chylous at the age of 9 months. CONCLUSIONS: In utero, and sometimes post-natal, evacuation of fluid present in the thoracic and peritoneal cavities can be necessary, depending of the functional tolerance. Medical management including feeding a low fat and/or high medium-chain triglycerides diet, and sometimes temporary total parental nutrition, is necessary, together with salt restriction, diuresis and albumin infusion as required. Most cases recover spontaneously or as a result of therapy within a few weeks.

Chylothorax↗
PubMed1992

[Treatment of ascites in patients with liver cirrhosis without neither hyponatremia nor renal insufficiency. Results of a randomized study comparing diuretics and punctures compensated by albumin].

Previous studies have suggested that treatment of ascites in cirrhotic patients by repeated paracenteses and albumin infusion is fast, effective and safe. In one of these studies including patients with hyponatremia or renal impairment, this treatment was associated with a reduction of duration of hospital stay in comparison with large dose diuretics. The aim of this randomized study was to compare paracentesis with albumin perfusion and low dose diuretics in cirrhotic patients with ascites, but without hyponatremia or renal impairment. Twenty-six patients (group 1) were treated with paracentesis (4 L/day) and 27 patients (group 2) were treated with spironolactone (225 to 300 mg/day), associated with furosemide (40 to 80 mg/day), when inefficient alone. Ascites and peripheric edema disappeared more rapidly in group 1 than in group 2, 8.6 +/- 9.6 vs 13.5 +/- 6.7 days (P = 0.001) and 4.1 +/- 2.6 vs 10.5 +/- 6.5 days (P = 0.001) respectively. During hospitalisation, the incidence of complications was higher in group 2 than in group 1: 56 vs 26% (P = 0.03). Hyponatremia occurred in 30% of patients in group 2 and 4% of patients in group 1 (P = 0.04). The duration of hospital stay was shorter in group 1 (15.0 +/- 10.4 days) than in group 2 (21.0 +/- 11.7 days) (P = 0.007). During follow-up, ascites reappeared in 32% of patients in group 1 and 57% of patients in group 2 (P = 0.09). At 3 months, one patient in group 1 and 2 patients in group 2 developed spontaneous peritonitis whereas survival was similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2004

[Spontaneous bacterial peritonitis in the patients with liver cirrhosis].

AIM OF THE STUDY: To assess objective incidence of spontaneous bacterial peritonitis (SBP), laboratory findings, effectivity of the treatment and mortality of cirrhotics with ascites and SBP. PATIENTS AND METHODS: From June 1994 to June 1999 we performed 692 abdominal paracenteses in 169 cirrhotic patients (mean age 52,63 +/- 8,02 years, mean Child-Pugh score 10,41 +/- 3,02). Culture of ascitic fluid, total leucocyte and granulocyte count in ascites and total protein, albumin and cholesterol levels in ascites and serum were examinated. Diagnosis of SBP was established by criteria of Wilcox and Dismukes. RESULTS: SBP was found in 27 patients by 1st paracentesis (16,0 %), in the other 13 patients by repeated paracentesis (7,7 %). 51 episodes of SBP (7,4 % of all paracenteses) were found in 40 patients. 48 episodes of SBP (94,7 %) were succesfully treated by ATB therapy, 8 patients with SBP died during hospitalization (15,7 %). Patients with SBP had significant lower total protein, albumin and cholesterol levels in serum and ascites compared to patients without ascites infection (all paramethers p <0,01). CONCLUSION: SBP is a common complication in patients with advanced liver cirrhosis and ascites. Despite of effectivity of ATB therapy the hospital mortality of patients with SBP is high. KEYWORDS: liver cirrhosis, ascites, spontaneous bacterial peritonitis, mortality.

Ascitic Fluid↗
PubMed2005

The use of albumin in patients with decompensated cirrhosis: the case in favor.

In conclusion, in the course of patients with advanced liver disease there are several indications for institution of intravenous albumin. These include: a) enhancement of diuretic effect on mobilization of ascites fluid, b) prevention of post-paracentesis circulatory dysfunction after total/large volume paracentesis, c) prevention of hepatorenal syndrome in patients affected with SBP, and d) administration of albumin in combination with vasoconstrictor drugs as the only effective therapy for hepatorenal syndrome. Albumin is relatively inexpensive and can be given in an outpatient setting.

Ascites↗
PubMed1992

[Hyponatremia in patients with ascites complicating liver cirrhosis].

Eighty unselected cases of hyponatremia complicating liver cirrhosis were analysed. Of these cases, 20 had sodium levels less than 135 mmol/L, 48 less than or equal to 130 mmol/L and 12 less than or equal to 125 mmol/L. 5 cases developed acute hyponatremic syndrome after abdominal paracentesis and high-dose of diuretics. Of these 5 cases, 1 died and 4 recovered after immediate infusion of 3% sodium chloride (200-300 ml/d intravenously for 7-10 days). Both the crystal and colloid pressure of blood determined in 10 cases were less than normal. The sodium level of the ascitic fluid determined in 5 cases was higher than that of serum. Respiratory alkalosis complicated with metabolic alkalosis or acidosis were the main features of acid-base disorders. These might be due to alkalinizing agents therapy, infection and hepato-renal syndrome. Based on these clinical studies, it was shown that paracentesis and diuretics are the main causes of acute hyponatremic syndrome, so these measures should be taken carefully in patients with hyponatremic state previously, especially in patients with poor general, hepatic and renal conditions.

Acid-Base Imbalance↗
PubMed2005

[The clinical and pathological characteristics and prognosis of pseudomyxoma peritonei].

OBJECTIVE: To investigate the clinical and pathological characteristics, treatment measures and prognosis of pseudomyxoma peritonei (PMP). METHODS: The clinical records and follow-up data of the patients with PMP were retrospectively analyzed. Survival analysis (Kaplan-Meier method and Cox regression) was used to investigate the prognosis. RESULTS: Thirty-three patients (twenty-two women, eleven men) have a median interval between onset and definite diagnosis of 12 months with an average age of 50. The main clinical presentation includes bloating, abdominal mass and abdominal distention. A delay in diagnosis is common and many patients are labeled as other diseases (84.8%). Positive results were often found in the assistant examinations such as erythrocyte sedimentation rate, gastrointestinal tumor markers (carcinoembryonic antigen, carcinomatous antigen 19-9 and so on), imaging (B ultrasound and computer tomography) and abdominal paracentesis which was usually unsuccessful. The most frequently practiced approach is debulking surgery with the main assistant means of chemotherapy which was lack of the uniform rationale. Benign type of pathological samples accounts for 66.7% of all, while mid-type 21.2% and malignant 12.1%. The general median survival time is 70 months with a follow-up rate of 79%. The pathological type and chemotherapy are main factors which influence the cumulative survival rate (P < 0.05). Up to the end of 2004, sixteen patients died of various complications, multiple organ failure and severe infection, while ten patients survival and seven patients lost. CONCLUSIONS: PMP is a rare condition of borderline malignancy with its unique clinical and pathological characteristics. Gastrointestinal tumor markers, imaging and abdominal paracentesis are very important to the diagnosis. The existing treatment measures need to be improved further. The pathological type and chemotherapy are main factors which influence the prognosis.

Adolescent↗
PubMed1998

Ascites free-water dynamics in decompensated cirrhosis: effects of an acute Hemaccel infusion.

BACKGROUND: Plasma-expanders (PE) are commonly employed to reduce the hemodynamic effects of large-volume paracentesis in patients with decompensated cirrhosis. The aim of this paper is to investigate the effects of PE acute administration on ascites dynamics in cirrhotic patients. METHODS: Wash-out intraabdominal pressure (IAP), ascites volume and free-water peritoneal clearance (FWPC) were evaluated in six decompensated cirrhosis by means of a methylene-blue (MB) dilution method. The method is based on the compartmental analysis of MB peritoneal clearance and has been validated by previous deuterium oxide studies. Immediately after the MB dilution test, a rapid Hemaccel i.v. infusion (500 ml 3.5% in 15 min) was perform-ed in all subjects, thereafter carrying out a second MB test. The obtained results were analyzed by two-way variance analysis. RESULTS: IAP and ascites volume values were not appreciably modified by the PE treatment. Following the Hemaccel infusion, only a fair reduction of FWPC values (from 88.33+/-7.78 to 76.98+/-8.09 ml/min) was observed. CONCLUSIONS: The results obtained indicate that, at least at the employed doses, Hemaccel acute administration has a low impact on the ascites dynamics in decompensated cirrhotics. These data cannot therefore support the hypothesis of a therapeutic use of PE in ascitic patients, but to avoid excessive plasma volume reductions in association with a large volume paracentesis.

Journal Article↗
PubMedDate not supplied

The use of TIPS in chronic liver disease.

The development of cirrhosis and portal hypertension in the natural history of chronic liver disease is associated with many complications. A transjugular intrahepatic portosystemic stent shunt (TIPS) is a metal prosthesis that has been shown to be very effective in lowering sinusoidal portal pressure, and therefore is effective in the management of complications of cirrhosis, especially those related to portal hypertensive bleeding and sodium and water retention. In patients with acute variceal bleeding not responding to pharmacologic and endoscopic treatments, a reduction of the hepatic venous pressure gradient to < 12 mmHg or by > 20% with TIPS has been shown to be effective in controlling the acute bleed and in preventing rebleeding. For stable patients whose acute variceal bleed is controlled, TIPS is equal to combined beta-blocker and band ligation in the prevention of recurrent variceal bleed. TIPS is also more effective than large volume paracentesis in the control of refractory ascites, and may confer a survival advantage over repeated large volume paracentesis. TIPS has also been used in the management of other complications related to portal hypertension including ectopic varices, hepatic hydrothorax, and hepatorenal syndrome with some success, but experience is still rather limited. Miscellaneous uses include treatment of Budd Chiari Syndrome, portal hypertensive gastropathy and hepatopulmonary syndrome. Careful patient selection is vital to a successful outcome, as patients with severe liver dysfunction tend to die post-TIPS despite a functioning shunt. All patients who require a TIPS for treatment of complications of cirrhosis should be referred for consideration of liver transplant.

Chronic Disease↗
PubMed1991

The role of endogenous eicosanoids in rabbit-intraocular inflammation.

The role of endogenously released eicosanoids in intraocular inflammation was assessed in two rabbit models. The models were: (1) paracentesis in which only breakdown of blood-aqueous barrier (BAB) occurs and (2) uveitis induced by endotoxin in which the disruption of the BAB and polymorphonuclear leukocyte infiltration are the predominant events. Indomethacin (a specific cyclooxygenase inhibitor) applied topically inhibited both the disruption of the BAB and increased levels of aqueous humor 6-keto-Prostaglandin (PG)F1 alpha. However, indomethacin and flurbiprofen applied topically and BWA4C or BWA218C (both selective lipoxygenase inhibitors) given parenterally, did not inhibit BAB response in endotoxin-induced uveitis. The cyclooxygenase inhibitors attenuated PGE2 release into aqueous humor. The 5-lipoxygenase inhibitors reduced the PMN infiltration as well as LTB4 release into aqueous humor. However, myeloperoxidase activity (an index for PMN chemotaxis) in iris-ciliary body was not affected by these drugs. Furthermore, concentrations of LTB4 in aqueous humor after paracentesis and uveitis-induced by endotoxin were similar, although in the former model there was no leukocyte infiltration, but in the latter model this leukocyte response was predominant. The results of this study suggest that locally released autocoids may not initiate ocular inflammation and other mediators such as cytokines may be involved in the inflammatory responses of the rabbit eye. We tried to detect IL-1 activity in aqueous humor following endotoxin. However, we could not detect the presence of IL-1-like activity, possibly because endotoxin also releases PGs, which inhibit IL-1 bioassay.

Animals↗
PubMed1991

Kinetics of uptake and effects of topical indomethacin application on protein concentration in the aqueous humor of dogs.

The pharmacokinetic properties of indomethacin and its effects on aqueous protein values were studied in 15 clinically normal Beagles. The dogs were treated every 6 hours with 1% indomethacin suspension in 1 eye, with the other eye serving as a control. After 24 hours, the dogs were anesthetized and samples of aqueous humor (AH) were drawn by aqueocentesis at 0, 15, 30, 60, and 90 minutes after initial paracentesis. Additional samples were drawn at the time of euthanasia, 180 (6 dogs) and 360 minutes (9 dogs) minutes after initial paracentesis. Blood samples were obtained at each treatment and at each aqueocentesis. The eyes were enucleated after dogs were euthanatized. Aqueous protein concentrations and indomethacin concentrations in AH, plasma, and different ocular tissues were determined. Topical indomethacin administration had no effect on baseline protein concentrations of AH. It reduced protein concentrations in AH significantly at all times after initial aqueocentesis. This reduction was approximately 30%. Indomethacin in the AH is mostly protein-bound. Concentrations were 350 ng/ml in primary AH and 1,305 ng/ml in secondary AH, 90 minutes after initial aqueocentesis. Free-drug concentrations were relatively constant at about 220 ng/ml. Indomethacin administered topically is readily absorbed by the ocular adnexae, reaching a steady-state concentration of 25 ng/ml in blood plasma 18 hours after the start of treatment. Plasma concentrations were 50 times lower than therapeutically effective concentrations. High indomethacin concentrations were found in the cornea only. Low concentrations were found in the iris and ciliary body, the lens, and in the choroid.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Topical↗
PubMed1990

Clinical pattern of extra-uterine gestation in peri-urban Kenya.

One hundred and sixty five cases of extra-uterine pregnancy (EP) were managed in Thika District in peri-urban Kenya between January 1985 and June 1988, giving an incidence of 66:10,000 deliveries. 55.8% of the patients were in the age group 23-27 years, and 88.5% were para 0-2. 78.8% of the extra-uterine pregnancies were ruptured at the time of diagnosis. Paracentesis was performed in 126 cases with 13.5% false negatives. There were seven false positive paracentesis. All the false positives had conditions that would probably have required surgical intervention in any case. There were two patients encountered with advanced abdominal pregnancy. Total salpingectomy or salpingo-oophorectomy was performed in 50.9% of the patients--a case could be put forward for more conservative surgery in anticipation of future fertility.

Adolescent↗
PubMed1989

Integrity of the blood-ocular barrier after intravitreal gas injection.

The authors studied the effect of various intravitreal gases on the integrity of the blood-ocular barrier using a fluorophotometric technique. The gas (0.3 ml) was injected into the vitreous cavity of a pigment rabbit after paracentesis. Air and two long-acting gases, sulfur hexafluoride and perfluoropropane, were studied. The eyes that received only paracentesis served as controls. Fluorescein concentrations in the anterior chamber were determined by slit-lamp fluorophotometer 30 minutes following intravenous fluorescein administration. Fluorophotometry was repeated on days 1, 3, 7, and 14 after the gas injections. The eyes that received sulfur hexafluoride and perfluoropropane showed increased aqueous fluorescein concentrations in comparison with the control eyes and the air-injected eyes, although conventional slit-lamp biomicroscopic examination detected no anterior chamber inflammatory signs in these eyes. The aqueous fluorescein leakage decreased to the normal level after the intravitreal gas bubble was absorbed. These results suggest that intravitreal gas bubbles induce subclinical breakdown of the blood-aqueous barrier, which becomes re-established soon after the gas is absorbed.

Absorption↗
PubMed1989

Ascites.

In summary, the diagnosis of ascites should be considered in all patients presenting with abdominal distention. A careful history and physical examination should be performed to rule out conditions that mimic ascites. Ultrasonography should be performed in questionable cases of ascites since physical examination and radiographic signs of ascites are unreliable. Paracentesis can help determine the etiology. Ascitic fluid should be examined to rule out spontaneous bacterial peritonitis, one of the few curable complications of cirrhosis. An ascitic fluid PMN count of greater than 250 per mm3 proves a sensitive indicator of infection. Medical treatment of cirrhotic ascites includes dietary sodium restriction and diuretics++. Large-volume paracentesis, with or without the use of colloid infusions, may provide useful adjunctive therapy. In rare instances, intractable ascites may be treated with a peritoneovenous shunt, although the complications and mortality rate of this procedure are significant. Peritoneovenous shunting, however, has not been shown to improve survival.

Ascites↗
PubMed1989

[Study of blunt hepatic injury by ultrasonography].

Sixty five consecutive patients with blunt hepatic injury were evaluated retrospectively to assess the clinical usefulness of emergency ultrasonography (US). In 30 patients before introduction of US, five patients (16.7%) were treated nonoperatively since they were hemodynamically stable with negative paracentesis. Another four hemodynamically stable patients were surgically treated due to positive paracentesis. After introduction of US, on the other hand, 17 out of 35 patients (48%) were successfully managed nonoperatively. Furthermore, US revealed small intraperitoneal bleeding and enabled conservative treatment of four hemodynamically unstable patients. There was no change in the management of central liver rupture or Makiya's type III injury. The number of nonoperatively managed cases of Makiya's types I and II increased from 1 to 7 after using US, and that of operative cases decreased from 21 to 12. Thus US was helpful to exactly assess the amount of intraperitoneal bleeding and successfully reduce the number of unnecessary laparotomy. We conclude that US provides useful information to decide early management of blunt hepatic injury.

Adult↗
PubMed1988

Diagnosis and treatment of chronic postoperative bacterial endophthalmitis.

Chronic postoperative bacterial endophthalmitis has recently assumed a prominent role in differential diagnosis of inflammation following extracapsular cataract extraction with posterior chamber intraocular lens implantation. The optimal diagnostic and therapeutic approach to this entity has not yet been clearly defined. We present a case of chronic postoperative Propionibacterium acnes endophthalmitis in which the diagnosis was made by anterior chamber paracentesis, and topical, periocular, and systemic antibiotic therapy resolved the inflammation. Anterior chamber paracentesis for aerobic and anaerobic cultures may be an appropriate initial diagnostic step in suspected cases. While successful treatment may require surgical intervention in some cases, others may respond to antibiotic therapy alone.

Bacterial Infections↗
PubMed1977

Mechanism of steroid action in ocular inflammation: Inhibition of prostaglandin production.

Prostaglandin E (PGE) concentration the aqueous humor of an intact rabbit eye was less than 0.1 ng. per milliliter and increased to 19 +/- 3 ng. per milliliter 60 minutes following paracentesis. The rise in PGE level was associated with clinical signs of ocular inflammation. Pretreatment with triamcinolone reduced both the accumulation of PGE in the aqueous humor and the inflammatory response following paracentesis. intravitreal injection of E. coli endotoxin into rabbit eyes increases PGE level in the anterior chamber to 72 +/- 17 ng. per milliliter and induced acute uveitis. slices of iris and ciliary body (ICB) derived from either rabbit eyes with endotoxin-induced uveitis or normal eyes were incubated for 60 to 240 minutes and the rate of PGE release into the medium was measured by radioimmunoassay. after a 4 hour incubation, the PGE release from inflamed ICB was threefold higher than that of normal ICB. incubation of inflamed ICB with hydrocortisone, or Millicorten (100 mug per milliliter) for 4 hours reduced PGE accumulation in the medium by 50 and 81 per cent, respectively. Aldosterone had no effect on the rate of PGE release from inflamed ICB throughout the incubation period. Hydrocortisone or Millicorten also reduced PGE tissue content of inflamed ICB by about 74 per cent during the period of incubation. Indomethacin (100 mug per milliliter) abolished PGE accumulation. The suppressive action of hydrocortisone on PGE release into the incubation medium was prevented by the addition of arachidonic acid (2 mug per milliliter), a substrate for prostaglandin synthesis. By contrast , the inhibitory action of indomethacin was not affected by provision of arachidonic acid. We suggest that glucocorticosteroids reduce PGE accumulation by limiting the availability of the substrate for prostaglandin biosynthesis and thus suppress the inflammatory response.

Aldosterone↗
PubMedDate not supplied

[Peritoneal effusions : characteristic radiological images (author's transl)].

The early radiological diagnosis of peritoneal effusion (ascites or hemoperitoneum) can be achieved by studying three recesses of the peritoneal cavity : the pelvis and the paracolic gutters. The author describes a method which consists in insufflating the colon in order to obtain a better delineation of the rectum and of the internal limits of the gutters, in accumulating the fluid in each recessus by positioning the patient and in using X-ray parameters suitable for the soft tissues. The recesses are examined separately. The characteristic features of effusion are described. Three different pictures can be found, an attempt is made to define their significance due to the anatomy of the recessus and to the amount of fluid. Such a procedure was performed in 99 patients : 58 were suspected of ascites and 41 of hemoperitoneum. A diagnosis of effusion was made when the characteristic images were recognized in one or several recesses. The results were compared with the findings of laparotomy, needle puncture of paracentesis. The radiological diagnosis of peritoneal effusion was confirmed in 92% of cases. This radiological method is equal value to paracentesis for the diagnosis of hemoperitoneum and of superior value to clinical examination in ascites. The author points out the fact that effusions less than 150 ml were detected in 96% of cases. Since the radiological signs of ascites mentioned in the literature are valid only when about a litre of fluid is present, such methods should be replaced by the above mentioned radiological procedure.

Ascites↗