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PubMed1980

Indications for operation in acute necrotizing enterocolitis of the neonate.

A study to evaluate criteria for operation was carried out in 61 infants with acute necrotizing enterocolitis (NEC). A total of 10 clinical, roentgenographic, and laboratory criteria were considered. Each proposed operative criterion was correlated with the documented presence or absence of intestinal gangrene in these infants. Indications for operation verified by this study were (1) pneumoperitoneum, (2) paracentesis findings positive for gangrenous intestine, (3) erythema of the abdominal wall, (4) a fixed abdominal mass, and (5) a persistently dilated loop of intestine on serial abdominal radiographs. The first two signs occurred frequently; the latter three were rare. Operative indications which proved to be invalid in this study were (1) clinical deterioration, (2) persistent abdominal tenderness, (3) profuse lower gastrointestinal hemorrhage, (4) the roentgenographic finding of gasless abdomen with ascites, and (5) severe thrombocytopenia. Twenty-four of the infants were operated on. The mortality rate among the infants operated on after free intestinal perforation had occurred (64%) was double that of infants operated on for intestinal gangrene without perforation (30%). Paracentesis may identify infants with intestinal gangrene prior to the development of perforation and may permit advantagenous timing of operation. This analysis of the frequency and reliability of proposed operative criteria may aid the surgical decision.

Ascites↗
PubMed1981

The mechanism of ascitic fluid protein concentration increase during diuresis in patients with chronic liver disease.

The mechanism of increase in the protein concentration of ascitic fluid during diuresis was investigated in 27 patients with chronic liver disease. The albumin concentration increased in ascites from .58 +/- .49 gm.% in the initial paracentesis to 1.48 +/- .69 gm.% in the final paracentesis (P less than .001) as the serum albumin concentration increased from 2.40 +/- .44 gm.% 2.94 +/- .56 gm.% (P less than .001). The serum to ascites albumin concentration gradient decreased significantly from 1.82 +/- .39 gm.%-1.46 +/- .45 gm.% (P less than .001). Despite this decrease, the serum to ascites albumin concentration gradient was relatively constant (decrease of .36 gm.% or 20% of initial value) compared to either the absolute or percentage change in ascites total protein concentration (increase of 1.48 gm.% or 107% of initial value). In four patients studied prospectively, the plasma volume did not change (3.53 +/- .80 1.-3.73 +/- .59 1.) during diuresis, despite increase in total intravascular albumin (85.7 +/- 25.6 gm.-99.9 +/- 22.3 gm.; P less than .05) and decrease in total albumin in combined intravascular and peritoneal compartments (156.0 +/- 30.1 gm.-143.4 +/- 35.3 gm.; P less than .05). Since neither concentration without decrease in plasma volume or synthesis of protein without increase in total compartmental protein appear to be the major mechanism of serum protein concentration increase, the increase in serum protein concentration was attributed to redistribution of protein from ascites to the intravascular compartment. The increase in ascitic fluid protein concentration during diuresis can be attributed to an increase in serum protein concentration in the presence of the relatively stable serum to ascites albumin concentration gradient.

Ascitic Fluid↗
PubMed1980

Spontaneous bacterial peritonitis: reversible cause of deterioration in patients with cirrhosis.

Spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites carries a mortality rate ranging from 50% to 90%. Eleven patients were diagnosed at The Royal Melbourne Hospital over a 25-year period. Fever was present in eight, abdominal pain in eight, rebound tenderness in six and pre-coma in four. In two, the peritonitis was silent. All five diagnosed by paracentesis survived, but the three patients first diagnosed at laparotomy died. The experience shows that SBP can be successfully treated with antibiotics. Because of the variable clinical features, a diagnostic paracentesis is recommended in all cirrhotic patients presenting with ascites.

Adolescent↗
PubMed1995

Use of laser flaremetry to measure aqueous humor protein concentration in dogs.

The blood-aqueous barrier in dogs is compromised by uveitis, surgery, and limbal paracentesis. Breakdown of the blood-aqueous barrier allows protein into the aqueous humor and results in mild to severe inflammation. Diagnosis of protein in the aqueous humor is traditionally a subjective measurement. Laser flaremetry was used for noninvasive quantitation of aqueous humor protein concentration in dogs. Flaremetry data were compared with aqueous humor protein concentrations obtained from aqueous humor paracentesis and slit-lamp flare evaluations. Results from clinically normal eyes and those with uveitis and cataracts were compared. Subjective evaluations of flare were correlated with a range of flaremetry readings and aqueous humor protein concentrations. Clinically normal eyes had a range of flaremetry readings of 1.4 to 7.0 photon counts (PC)/ms, with a mean of 3.8 PC/ms. Corresponding aqueous humor protein concentrations ranged from 5 to 28 mg/dl, with a mean of 15.1 mg/dl. Eyes with uveitis or cataracts had a range of aqueous protein concentrations of 13 to 729 mg/dl. Flaremetry readings accurately and sensitively measured total protein concentrations in the aqueous humor of dogs.

Animals↗
PubMed1995

Whole-body and segmental bioelectrical parameters in chronic liver disease: effect of gender and disease stages.

The aim of this study was to examine and compare whole-body and segmental impedance measurements in control subjects and patients with progression of liver disease and to investigate whole-body and segmental bioelectrical changes occurring during dehydration therapy or paracentesis. Males have lower resistance (R) and reactance (Xc) values than females in measurements both of the whole body and of the arm, leg, and trunk. This is not true in patients. In the three groups of patients, whole-body R and Xc were lower in each increased disease stage, suggesting that stage has a significant main effect on impedance measurements. The lower extremities were the segment most influenced by the progression of liver disease. The sum of the arm and leg R was only slightly lower than the value of whole-body resistance. The trunk has a meager influence on this parameter, as is clearly shown by the absence of variations before and immediately after paracentesis. In edematous cirrhotic patients without ascites treated with diuretics, our data also showed a significant correlation (r = .81; SEE = 1.2) between changes in body weight (BW) and in the bioelectrical evaluation of total body water (TBW). The association of a prevalent increment of Xc (approximately 40%) with a reduction of extracellular water is the most significant bioelectrical event during dehydration therapy. All these findings show that impedance measurements have a low sensitivity in detecting the volume of ascites in cirrhotic patients, whereas Xc has a clinical use in monitoring changes in extracellular water (EW).

Adult↗
PubMed1995

Abdominal stab wound protocol: prospective study documents applicability for widespread use.

Traditionally, stab wounds violating the abdominal wall fascia led to exploratory celiotomy that was often nontherapeutic. In an attempt to limit the number of nontherapeutic celiotomies (NTC), we devised a protocol to prospectively study stab wounds violating the anterior abdominal wall fascia. Through protocol, abdominal stab wounds were explored in stable adults. If the anterior fascia was violated, paracentesis and, if necessary, peritoneal lavage was undertaken in the absence of previous abdominal surgery. If evisceration was noted, it was reduced and the patient lavaged. Fascial penetration was noted in 72 patients. 46 patients underwent celiotomy: because of shock/peritonitis in 8 (2 NTC), fascial penetration with a history of previous celiotomy in 7 (5 NTC), positive paracentesis in 20 (5 NTC), or positive lavage in 10 (4 NTC). One patient underwent late celiotomy without ill-effect after a negative lavage because she subsequently developed fever and localized peritonitis (ice pick injury to cecum). Eleven patients had evisceration; nine underwent celiotomy. Patients with abdominal stab wounds can be selectively managed safely. More than one-third with fascial penetration, some with evisceration, avoided exploration. Only one patient underwent delayed celiotomy and did so without detriment. Nontherapeutic celiotomy rates were highest in patients with previous abdominal surgery who, thereby, could not undergo paracentesis/lavage; excluding these patients, the nontherapeutic celiotomy rate was 17% (11/65) for those with fascial penetration.

Abdomen↗
PubMedDate not supplied

Viscoelastic substance in the anterior chamber elevates intraocular pressure.

An 85-year-old man underwent an extracapsular cataract extraction OD with posterior chamber intraocular lens implantation. Sodium hyaluronate (0.3 mL) was used during the procedure, and approximately 1.0 mL of the solution, including the sodium hyaluronate, was aspirated before wound closure. The next day, the intraocular pressure OD was elevated to 60 mmHg, and it remained high despite medication. Three days later, the intraocular pressure was still high, a paracentesis was done, and viscous solution was obtained. After the paracentesis, the intraocular pressure OD normalized.

Aged↗
PubMed1993

Unusual isolated common bile duct injury after blunt trauma.

Isolated injury to the extrahepatic biliary tree after blunt trauma is rare. The authors describe the case of a 17-year-old boy who suffered such an injury after falling over the handlebar of his motorcycle. Ultrasonography, computed tomography and abdominal paracentesis were used to make the diagnosis. At laparotomy there was a partial tear of the common bile duct at its junction with the cystic duct. A cholecystectomy was performed and a T tube inserted. The patient recovered without complication. The authors emphasize that only awareness of the condition and diagnostic confirmation by computed tomography and abdominal paracentesis can expedite the diagnosis and treatment. The choice of surgical repair must be individualized according to the clinical findings and the nature of the injury.

Adolescent↗
PubMed1993

Pulmonary function tests in cirrhotic and non-cirrhotic portal hypertension.

OBJECTIVE: To determine pulmonary functions in portal hypertension of different etiologies and with various grades of ascites. SETTING: Gastrointestinal clinic in a large community based and secondary referral hospital. PATIENTS AND METHODS: Forty five patients with portal hypertension, including 19 cirrhotics with tense ascites, 8 with moderate ascites, 6 with no ascites and 12 patients with non-cirrhotic portal hypertension. All patients underwent basal pulmonary function testing by spirometry and helium dilution technique, and arterial blood gas estimation and measurement of ascitic fluid pressure. Patients with tense ascites underwent paracentesis of up to 2 liters following which ascitic fluid pressure and pulmonary functions were estimated again. MAIN RESULTS: In cirrhotic patients without ascites, FVC (forced vital capacity), RV (residual volume), TLC (total lung capacity) and FRC (functional residual capacity) were lower than predicted values. In patients with ascites, FVC, FEV1 (forced expired volume in one second) and FEF25-75 (forced expired volume in one second) and FEF25-75 (forced expiratory flow rate between 25% and 75% of forced vital capacity) were significantly lower as compared to predicted values. FVC, FEV1, FEF25-75, pO2, pCO2 and SaO2% decreased significantly with increasing ascites. Paracentesis in patients with tense ascites led to clinical improvement and significantly improved lung volumes. CONCLUSIONS: Pulmonary functions are impaired in patients with cirrhosis, and ascites causes further deterioration. Patients with non-cirrhotic portal hypertension have normal pulmonary functions.

Adult↗
PubMedDate not supplied

Refractory ascites: definition, pathogenesis and treatment.

Refractory ascites, that is ascites which cannot be mobilized by low sodium diet and maximal doses of diuretics (up to 400 mg spironolactone or potassium canrenoate and 160 mg furosemide per day), occurs in 5% of cirrhotic patients with ascites. The development of refractory ascites is mainly related to the progression of arterial vasodilation-mediated vascular underfilling and to the imbalance between reduced synthesis of renal vasodilating factors (especially renal prostaglandins) and extreme activation of vasoconstricting systems. Further features include increased sodium reabsorption in the proximal tubule and altered pharmacokinetics and pharmacodynamics of diuretics. In patients with impaired renal function (as is the case for most patients with refractory ascites), the marked reduction of renal perfusion and glomerular filtration rate, with the consequent decrease of filtered sodium load, becomes the main pathogenetic factor. The principal therapeutic options for refractory ascites include repeated paracentesis and implantation of the LeVeen shunt. Paracentesis is a rapid and safe procedure to remove ascites, but it does not correct sodium retention. Ascites recurrence, therefore, may occur after a brief interval. The LeVeen shunt allows for better long-term control of ascites, but severe complications may supervene, and shunt occlusion is common. Neither therapeutic procedure improves survival. Different experimental therapeutic procedures have been proposed. Administration of ornipressin corrects hyperdynamic circulation and improves renal function. Thromboxane synthase inhibitors, by reducing renal synthesis of thromboxane A2, potentiate the diuretic and natriuretic response to furosemide. More invasive procedures, including portosystemic shunt and transjugular intrahepatic stent, are rarely used in the treatment of refractory ascites.(ABSTRACT TRUNCATED AT 250 WORDS)

Ascites↗
PubMed1996

Characterization of intraperitoneal cytokines and nitrites in women with severe ovarian hyperstimulation syndrome.

OBJECTIVE: To assess the potential involvement of cytokines and nitrites in the hyperpermeability characterizing the ovarian hyperstimulation syndrome (OHSS). DESIGN: A controlled clinical study comparing peritoneal fluid (PF) from patients with severe OHSS and from non-OHSS controls. SETTING: Women hospitalized with severe OHSS in three tertiary medical centers. PATIENTS: Twelve patients with severe OHSS necessitating paracentesis and 20 non-OHSS controls. INTERVENTIONS: The criteria for ultrasound-guided paracentesis were tense ascites, hydrothorax, hemoconcentration, or oliguria. MAIN OUTCOME MEASURES: Interleukin (IL) 1 beta IL-1 receptor agonist, IL-2, IL-6, IL-8, and tumor necrosis factor alpha (TNF alpha) levels in PF were assayed by ELISA; nitrites were measured by the "Griess" reaction. Estradiol and P were determined by RIA. RESULTS: Ovarian hyperstimulation syndrome patients had significantly higher PF IL-6 (3,523 versus 30 pg/mL), TNF alpha (14 versus 4.2 pg/mL), and IL-8 (1,695 versus 900 pg/mL). In the serum, only IL-6 levels were significantly higher (375 versus 11 pg/mL). Conversely, nitrite levels were significantly lower in PF of OHSS patients (0.5 versus 34 nmol/mL). Interleukin 1 levels were higher and IL-1 receptor antagonist levels were lower in OHSS patients, suggesting potentially increased biologic potency of IL-1. CONCLUSION: These findings suggest that these substances could be involved in mediating the capillary hyperpermeability characterizing this syndrome.

Ascitic Fluid↗
PubMed1996

Evaluation and initial management of patients with ascites.

Large amounts of ascitic fluid may cause distention, weight gain, anorexia and nausea. Smaller accumulations may be asymptomatic and difficult to detect clinically. In addition to signs associated with the cause of ascites, the physical examination may reveal shifting dullness, a fluid wave and peripheral edema. Ultrasound examination is useful in establishing the diagnosis and in locating the optimal site for paracentesis. Calculation of the serum-ascites albumin gradient provides useful diagnostic information. High gradients usually indicate portal hypertension, while low gradients may indicate infection or carcinomatosis. Management is directed toward alleviating the underlying cause of ascites and reducing symptoms. Initially, restriction of salt intake to 2 g per day is usually advised. Most patients require diuretic therapy. Spironolactone, the usual first-choice agent, may be combined with furosemide in selected patients. If diuretic therapy is unsuccessful, large-volume paracentesis, peritoneovenous portosystemic shunting, transjugular intrahepatic shunting or liver transplantation may be required.

Algorithms↗
PubMed1996

[Transjugular intrahepatic portosystemic shunt in the treatment of refractory ascites in 21 patients].

OBJECTIVE: To determine the value of the transjugular intrahepatic portosystemic stent shunt (TIPS) in the treatment of patients with cirrhosis and refractory ascites. DESIGN: Descriptive follow-up study. SETTING: University Hospital Gasthuisberg, Leuven, Belgium. METHODS: In a period of three years, 21 consecutive patients with cirrhosis and refractory ascites were treated with TIPS. Refractory ascites was defined as ascites resistant to maximum diuretic therapy and repeated paracentesis. The mean follow-up was 9 months (range 3-26). RESULTS: Creation of the stent shunt was technically successful in 20 patients and resulted in a decrease of the pressure gradient between the portal vein and the inferior vena cava by approximately 47%. The procedure was immediately lethal in two patients. Complications occurred later on in four patients: thrombosis of the stent in 3 patients and disabling encephalopathy in one. Five other patients died from liver failure, four of them possibly related to the increase of the portosystemic shunting. The stent shunt had no ill effects on kidney function. Thirteen patients were still alive at the end of follow-up. Five patients (24%) had a total and sustained remission of the ascites. Seven patients (33%) still had ascites but needed no paracentesis. One patient did not respond to the treatment. The best results were observed in 14 alcoholics: 9 (64%) responded favourably (43% in non-alcoholics), in 4 of these the ascites had disappeared. CONCLUSIONS: TIPS placement needs substantial experience to avoid technical complications. In case of refractory ascites, only patients for whom later liver transplantation is considered should be submitted to the procedure, because TIPS placement can lead to deterioration of liver function.

Ascites↗
PubMed1997

Fine structure of the choroidal coat of the avian eye. Lymphatic vessels.

PURPOSE: To clarify the fine structure of the avian choroid and thus help explain the mechanisms for normal and abnormal eye function and growth. METHODS: Eyes from normal chickens and from experimental chickens subjected to unilateral paracentesis were fixed either by perfusion or in situ, with or without post-fixation by microwave irradiation, and then processed for light and electron microscopic analysis. RESULTS: The avian choroid contains thin-walled lacunae, whose fine structure is identical to that of lymphatic vessels. The lacunae are much smaller toward the anterior chamber and the Schlemm's canal than posteriorly in the eye bulb. Large lacunae are situated primarily in the suprachoroidea, and their blind-ended capillary branches enter the choriocapillaris and the walls of large veins. The walls of the large veins contain villous structures that protrude into their lumina and are penetrated by thin lacunar branches and by side lines of the venous lumen. In normal chickens, the lacunae usually are devoid of blood cells. After paracentesis of the anterior eye chamber, the lacunae become filled with erythrocytes on the side that was operated on, but not on the contralateral side. CONCLUSIONS: The authors propose that the lacunae of the avian choroid represent a system of posterior short lymphatic vessels, which drain intraocular fluids directly into the eye's venous system, and that the villous structures are sites of communication between lacunae and veins. The demonstration of a choroidal lymphatic system opens new insights into the processes of fluid removal, control of intraocular pressure, and regulation of choroidal thickness in the avian eye under normal and experimental conditions.

Animals↗
PubMedDate not supplied

Diagnosing ascitic etiology on a biochemical basis.

BACKGROUND/AIMS: The analysis of ascitic fluid has been complicated by several new tests. To simplify its assessment, we evaluated ascitic fluid pH with six other parameters prospectively and simultaneously in blood and ascitic fluid in sixty patients with ascites. METHODOLOGY: Sixty patients were selected on whom abdominal paracentesis was performed in order to determine which tests were the most reliable for the etiological diagnosis of ascites. Their ascitic fluid pH, cholesterol, albumin, and total proteins were analyzed to distinguish between malignant and cirrhotic ascites. The diagnosis of cirrhosis was based on histological findings, and/or clinical, biochemical, and endoscopic/ultrasonographic findings in whom percutaneous liver biopsy was contraindicated. RESULTS: The serum-ascites albumin gradient was higher (p<0.001) in cirrhotic as compared to tubercular, malignant or cardiac ascites. We discovered that ascitic fluid lactate dehydrogenase and cholesterol were best for diagnosing malignant ascites, ascitic fluid glucose and ascitic fluid/blood glucose ratio were perfect for diagnosing tubercular ascites, and ascitic fluid pH and lactate dehydrogenase were suitable for diagnosing spontaneous bacterial peritonitis. Correspondingly, ascitic fluid albumin, ascitic fluid/serum albumin, total proteins, and serum ascites albumin gradient were best for diagnosing sterile cirrhotic ascites. CONCLUSIONS: Diagnostic paracentesis is a useful procedure. The practice of ordering a battery of tests on every ascitic fluid specimen should be abandoned. Rather, an algorithm approach should be adopted in which the results of initial analysis guide us to further relent tests that help in arriving at the etiology of ascites.

Albumins↗
PubMedDate not supplied

Malignant ascites: new concepts in pathophysiology, diagnosis, and management.

Malignant ascites is a manifestation of advanced malignant disease that is associated with significant morbidity. Mainstays of treatment include diuretics and recurrent large volume paracentesis. Although lymphatic obstruction has been considered the major pathophysiologic mechanism behind its formation, recent evidence suggests that immune modulators, vascular permeability factors, and metalloproteinases are contributing significantly to the process. These new observations offer the opportunity for development of new, more targeted therapies for the treatment of malignant ascites. This article uses a clinical case to highlight the problem, then reviews these new concepts in the pathophysiology of malignant ascites formation. The diagnosis and management of this challenging medical problem are subsequently discussed, with emphasis on how these new pathophysiologic insights are being applied to the development of novel therapies that may soon change how we manage this troubling clinical condition.

Ascites↗
PubMed2003

Evaluation of minimally invasive therapies and rationale for a prospective randomized trial to evaluate selective intra-arterial lysis for clinically complete central retinal artery occlusion.

OBJECTIVES: To determine the effect of commonly used minimally invasive treatments for clinically complete nonarteritic central retinal artery occlusion (CRAO) and design a prospective randomized trial to evaluate selective intra-arterial lysis for this condition. METHODS: In this retrospective noncomparative case series, all medical records of patients with a diagnosis of CRAO treated at the Department of Ophthalmology, Ludwig-Maximilians-Universität, Munich, Germany, from 1994 through 1999 were reviewed for treatments administered and course of visual acuity. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA) at initial and last visit. RESULTS: We identified 102 patient medical records; 71 were suitable for further analysis. Forty-four (62%) of the 71 patients included were treated with oral acetylsalicylate; 44 (62%), with oral acetazolamide; 32 (45%), with ocular massage; 22 (31%), with isovolemic hemodilution; 19 (27%), with oral pentoxifylline; 8 (11%), with topical beta-blocker; 6 (8%), with paracentesis of the anterior chamber; 4 (6%), with subcutaneous heparin. A mean +/- SD number of treatments of 2.5 +/- 1.4 was administered per patient, and BCVA increased by a mean +/- SD number of Snellen lines of 0.7 +/- 2.8. The BCVA in 11 patients (15%) increased by 3 or more lines. Multivariate stepwise regression did not reveal any single or combination treatment as a significant factor for improvement in BCVA. Patient age and duration of visual impairment before initial examination were not significant predictors of final BCVA. CONCLUSIONS: Commonly used minimally invasive treatments of CRAO do not improve the natural course of the disease. A prospective trial by the European Assessment Group for Lysis in the Eye is under way to evaluate selective intra-arterial lysis, and in this trial some of these minimally invasive treatments are used in the control group.

Acetazolamide↗
PubMed2005

Quality of life in refractory ascites: transjugular intrahepatic portal-systemic shunting versus medical therapy.

Uncontrolled studies suggest that transjugular intrahepatic portal-systemic shunting (TIPS) may improve quality of life in patients with refractory ascites. We hypothesized that any improvement of quality of life in patients with TIPS would be matched in controls due to the competing effects of improved ascites and worsened hepatic encephalopathy. Thus, an analysis of quality of life was performed using original data from the North American Study for the Treatment of Refractory Ascites, a multicenter trial of 109 patients randomized to TIPS or repeated large volume paracentesis (LVP) for refractory ascites. Short form 36 (SF-36) surveys were completed at baseline and at 6- and 12-month follow-up. Variables analyzed were: randomization group, number of LVP performed, cumulative volume from LVP, shortness of breath, abdominal distention, abdominal pain, diuretic usage, confusion, hospitalizations, and emergency room visits. Outcomes were changes in physical component scale (PCS) and mental component scale (MCS) of SF-36 results. We constructed multivariable, mixed effects models, including randomization group and baseline MCS and PCS. Changes in PCS and MCS from baseline were similar between the two randomization groups. In multivariate analysis, PCS improvement was associated with lack of confusion, improved ascites, and lack of hospitalizations, but not directly with randomization group. Improvement in MCS was associated with randomization to TIPS and lack of confusion. In conclusion, patients with refractory ascites randomized to TIPS or repeated LVP had similar changes in quality of life. Competing effects of hepatic encephalopathy, requirement for repeated LVP, and need for hospitalizations explain similar changes in quality of life between the two groups.

Analysis of Variance↗