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PubMed2001

Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management.

BACKGROUND: Internal pancreatic fistulas are well recognized complications of chronic pancreatitis. METHODS: Six patients with internal pancreatic fistulas were treated over a period of 5 years from 1995 to 1999. Four patients presented with ascites, one patient presented with ascites and bilateral pleural effusion and the sixth patient presented with left-sided pleural effusion. Five patients were chronic alcoholics and in one patient the cause of pancreatitis was not clear. Although the serum amylase was mildly elevated the levels of amylase in the aspirated fluid were consistently elevated (more than 800 Somogyi units/100 mL), along with the level of proteins (> or = 3 g/100 mL), and on this basis the diagnosis was made. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated pancreatic ductal disruption in four cases. Initial treatment was conservative, consisting of nasogastric aspiration, nil per oral, antisecretory drugs, repeated paracentesis or thoracocenthesis and total parenteral nutrition (TPN). In two patients naso-pancreatic drains (NPD) were placed across the disrupted pancreatic duct. RESULTS: In one patient conservative treatment with NPD was successful, and the remaining five patients required surgical intervention. There was no mortality. Two patients developed surgery-related complications that were successfully managed, but they required an extended hospital stay. CONCLUSION: Internal pancreatic fistulas should be treated initially non-operatively; if this is not effective, operative therapy should be considered without delay.

Abdominal Pain↗
PubMed2001

Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites.

The diagnosis of refractory ascites in cirrhotic patients carries a poor prognosis and liver transplantation should always be considered in this situation. Identification of patients who will not respond to diuretic therapy usually requires several weeks of observation during which a trial of diuretics is instituted using stepwise increases in dosage in order to classify ascites as refractory. In the present study we evaluated the effect of a single dose of 80 mg intravenous furosemide on urinary sodium excretion over 8 hours in cirrhotic patients with ascites responsive to diuretic treatment (group 1; n = 14) and patients with refractory ascites (group 2; n = 15). The test was performed after 3 days without diuretics and patients were on a 80 mEq sodium/day diet. Refractory ascites was defined by the absence of response after 3 months of high doses of diuretics (spironolactone 200 mg/d + furosemide 80 mg/d + metolazone 2.5 mg/d) and the need for repeated paracentesis. The two groups had similar degrees of liver and renal dysfunction as assessed by the Pugh score and creatinine clearance. The effects of furosemide on 8-hour natriuresis was much higher in patients with responsive ascites as compared with patients with refractory ascites (125 +/- 46 vs. 30 +/- 16 mEq; mean +/- SD; P <.0001). A natriuresis lower than 50 mEq/8 hours was observed in all group-2 patients as compared with none from group 1. The present study shows that patients with refractory ascites can be identified quickly and accurately by using this simple furosemide-induced natriuresis test, which could be very useful to select patients for liver transplantation.

Ascites↗
PubMed2003

Rapid diagnosis of spontaneous bacterial peritonitis by use of reagent strips.

We studied the use of reagent strips for diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites. A reagent strip for leukocyte esterase designed for the testing of urine with a colorimetric 5-grade scale (0 to 4) was used to evaluate ascitic fluid in 228 nonselected paracentesis performed in 128 cirrhotic patients. We diagnosed 52 SBP and 5 secondary bacterial peritonitis by means of polymorphonuclear cell count and classical criteria. When we considered positive a reagent strip result of 3 or 4, sensitivity was 89% (51 of 57), specificity was 99% (170 of 171), and positive predictive value was 98%. When we considered positive a reagent strip result of 2 or more, sensitivity was 96% (55 of 57), specificity was 89% (152 of 171), and negative predictive value was 99%. In conclusion, the use of reagent strips is a rapid, easy to use, and inexpensive tool for diagnosis of ascitic fluid infection. A positive result should be an indication for empirical antibiotic therapy, and a negative result may be useful as a screening test to exclude SBP.

Aged↗
PubMed2001

[Anesthesia in mitochondrial encephalomyopathies].

A 6-year-old boy with a rare mitochondrial disease (MELAS: mitochondrial encephalopathy, lactic acidosis, stroke-like episodes) was presented to undergo adenoid resection and bilateral paracentesis. ENT surgery was performed without complications under general anaesthesia using propofol, fentanyl, and ventilation with nitrous oxide and oxygen. Routine intraoperative monitoring (ECG, noninvasive blood pressure, oxymetry and capnometry) was supplemented by frequent body temperature measurements and repeated laboratory analysis of venous blood gases, lactate, and glucose. Clinically, the postoperative course was uneventful and the boy was discharged from hospital on the first postoperative day. Signs or symptoms of malignant hyperthermia never occurred. Laboratory analysis only showed a remarkable serum lactate elevation postoperatively (6 mmol/l) which decreased on the first postoperative day (3.7 mmol/l). The present anaesthesiologic experiences with MELAS-syndrome are limited, and recommendations are mainly based on case reports. Careful preoperative physical examination with special regard to all available medical records, and anaesthetic management comparable with that in malignant hyperthermia susceptible resulted in an uneventful course in our patient. Pathogenetic aspects of mitochondrial diseases focussing on anaesthetic considerations are briefly discussed.

Adenoidectomy↗
PubMed1997

Spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis (SBP) is considered a bacterial infection of ascitic fluid without any intraabdominal, surgically treatable source of infection. Multiple variants of this infection with a different clinical setting and outcome have been described during the past decade. Bacterial translocation from the gut to mesenteric lymph nodes, depressed activity of the reticuloendothelial phagocytic system and decreased antimicrobial capacity of ascitic fluid seem to be the main steps in the pathogenesis of ascitic fluid infection. Diagnosis of ascitic fluid infection is based on clinical suspicion and analysis of ascitic fluid, especially white cell count and culture in blood culture bottles. A low threshold for performing an abdominal paracentesis is the key for an early diagnosis and treatment. A third-generation cephalosporin is the treatment of choice, achieving a cure rate higher than 80%. Nonazotemic patients with nonadvanced, uncomplicated SBP may be treated with oral ofloxacin. Prophylactic selective intestinal decontamination with oral norfloxacin is extremely useful in preventing SBP in patients that are at high risk for developing SBP, such as hospitalized cirrhotic patients with gastrointestinal hemorrhage or low ascitic fluid total protein. Primary or secondary long-term prophylaxis of SBP also decreases the incidence of SBP, but these patients should be carefully observed for detecting possible infections caused by quinolone-resistant organisms. Since long-term prognosis of SBP patients is poor, survivors should be considered for liver transplantation.

Anti-Bacterial Agents↗
PubMed1997

Increased concentrations of renin, aldosterone and Ca125 in a case of spontaneous, recurrent, familial, severe ovarian hyperstimulation syndrome.

We report for the first time increased concentrations of aldosterone and renin in a case of spontaneous, recurrent, familial, severe ovarian hyperstimulation syndrome (OHSS). High concentrations of Ca125 were also found. Our patient was a 26 year old woman, gravida 2, para 1, affected by severe OHSS, who denied having ever consumed any ovulation drug. Both the patient and her only sister had suffered from a similar condition in their previous pregnancies. The patient was treated with i.v. fluid therapy. Paracentesis was performed on one occasion. The patient was dismissed after 25 days in good condition. Blood count and blood chemistry confirmed the severity of the clinical picture. We conclude that spontaneous OHSS, although very rare, may have been underestimated so far. It can be recurrent and may also be familial. The intra-ovarian prorenin-renin-angiotensin system may play a role in its aetiopathogenesis.

Adult↗
PubMed2003

Repetitive phosphorus-32 peritoneal instillations in a patient with malignant ascites.

During the last decade, intraperitoneal injection of phosphorus-32 chromic phosphate (P-32 CP) has been used principally for its initial intended purpose, the palliative management of malignant ascites. The authors describe a patient with a stage IIIB well-differentiated extraovarian peritoneal serous papillary adenocarcinoma. As a palliative treatment for malignant ascites, P-32 CP was instilled intraabdominally eight times. Adverse effects were limited to the third instillation, when abdominal pain occurred as a result of leakage of the P-32 CP in the subcutaneous tissue. The P-32 CP instillations reduced the frequency of paracentesis for almost 1 year, until disease progression prevented palliation. Considering the few palliative options, there could be more widespread use of P-32 CP as a palliative treatment for patients with malignant ascites caused by ovarian cancer or extraovarian peritoneal adenocarcinoma. However, intraperitoneal P-32 CP is not without potential intestinal complications, which must be considered before it is recommended.

Adenocarcinoma, Papillary↗
PubMed2006

Total ascitic fluid leukocyte count for reliable exclusion of spontaneous bacterial peritonitis in patients with ascites.

BACKGROUND AND AIMS: The diagnosis of spontaneous bacterial peritonitis (SBP) in patients with ascites is established by definition with a polymorphonuclear (PMN) cell count in the ascitic fluid greater than 0.250 g/l determined via cytological (microscopic) examination. In this study, we correlated the automatically assessed total ascitic nucleated cell count with PMN and determined its predictive value for diagnosis of SBP. METHODS: Six hundred and eleven consecutive paracenteses of 179 patients with ascites of various aetiologies (liver cirrhosis, hepatocellular carcinoma, peritoneal carcinomatosis, and ascites of other aetiology) were studied retrospectively. RESULTS: The most reliable diagnostic cut-off level was determined for differentiation between SBP and non-SBP via receiver operating characteristics analysis. A total ascitic nucleated cell count less than 1.0 g/l is unlikely to represent SBP (negative predictive value, 95.5%). CONCLUSIONS: If ascitic fluid samples with machine-made total ascitic nucleated cell count below 1.0 g/l are not followed by additional laboratory tests, the risk of missing the diagnosis of SBP is low. Applying these criteria we would have classified 51 samples of 611 samples (20 of 179 patients) wrongly using the cut-off value of 1 g/l. On the other hand we would have spared cytologic evaluation in about 63% of paracentesis performed in our hospital. Nevertheless, to insure patient safety, standard laboratory analysis is recommended in circumstances of clinical uncertainty. Thus, patients with first manifestation of ascites should always receive cytologic examination and full diagnostic investigation to exclude other causes of ascites.

Adult↗
PubMed1998

Hepatic hydrothorax.

Hepatic hydrothorax is the accumulation of ascitic fluid in the pleural space and requires the same treatment as ascites: salt restriction, diuretics, and paracentesis. Refractory hydrothorax appears when there is no response to those measures and its management is not well established. Videothoracoscopy is a promising therapy that permits the detection and closure of diaphragmatic defects, and when used with pleurodesis resulted in long-lasting control of hydrothorax in six of eight patients without appreciable morbidity. The transjugular intrahepatic portosystemic shunt is an effective therapy in more than 75% of refractory hydrothorax cases. Hepatic encephalopathy and worsening of liver function in some patients are the main adverse effects. Spontaneous bacterial empyema, the infection of a hydrothorax, was reported in 13% of 120 cirrhotic patients with hydrothorax. Forty percent of the episodes of spontaneous bacterial empyema were not associated with spontaneous bacterial peritonitis. The sensibility of pleural fluid culture improves inoculating pleural fluid into a blood culture bottle at the bedside. Patients with refractory hydrothorax or those having an episode of spontaneous bacterial empyema should be considered candidates for liver transplantation.

Anti-Bacterial Agents↗
PubMed2003

Hepatic hydrothorax.

A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. The pleural fluid usually has the characteristics of a transudate. However, an occasional patient with hepatic hydrothorax will develop spontaneous bacterial pleuritis manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.

Humans↗
PubMed2025

Clinical outcomes and care for spontaneous bacterial peritonitis: A national cohort study.

BACKGROUND AND AIMS: Spontaneous bacterial peritonitis (SBP) leads to high rates of acute kidney injury (AKI), hepatorenal syndrome, and mortality. Population-based studies on contemporary SBP epidemiology are needed to inform care. In a large, national cohort of patients diagnosed with SBP and confirmed by ascitic fluid criteria, we characterized ascitic fluid characteristics, in-hospital and 12-month mortality, AKI, and recurrent SBP. APPROACH AND RESULTS: We investigated how individual and bundled quality measures for SBP associated with outcomes after multi-level adjustment for health-system, patient clinical factors, and quality measures. Individual and bundled quality metrics were inpatient antibiotics within 48 hours, i.v. albumin, repeat paracentesis within 48 hours, recognition of SBP, and prophylactic antibiotics upon discharge. Among 4330 patients with newly diagnosed SBP, in-hospital mortality was 15.5%, and 12-month mortality was 56.6%. The incidence of stage 1 AKI was 26.6%, 15.7% for stage 2, and 22.8% for stage 3. The cumulative incidence of recurrent SBP was 10.3%. Guideline-recommended albumin was the only individual metric associated with reduced in-hospital mortality (HR: 0.73, 95% CI: 0.59-0.91). Receipt of a higher number of metrics from the SBP bundle was associated with progressively lower 12-month post-discharge mortality: patients who received 3, 4, and 5 SBP bundle components had 20%, 38%, and 56% lower hazard of mortality, respectively, relative to those receiving 2 or fewer (all p <0.001). The SBP bundle was associated with a lower incidence of stage 3 versus stage 0-2 AKI (OR: 0.66, 95% CI: 0.51-0.86). CONCLUSIONS: Prospective implementation of evidence-based SBP bundles may improve care outcomes and mortality in SBP.

Humans↗
PubMed2004

Review article: future indications for terlipressin therapy.

Vasoconstrictor agents such as terlipressin (Glypressin) have been shown to have beneficial effects in the treatment of hepatorenal syndrome (HRS), in terms of improving renal function and subsequent survival rates. Patients with HRS have also been shown to have improved survival after liver transplantation if they receive terlipressin treatment prior to transplantation. In addition, studies show that terlipressin may have beneficial effects in treating other indications, including paracentesis-induced circulatory dysfunction and endotoxic shock. A positive effect has also been demonstrated with vasopressin in cardiopulmonary resuscitation.

Animals↗
PubMedDate not supplied

Bilateral perinephric pseudocysts and polycystic kidneys in a ferret.

A 3-year-old castrated male domestic ferret was evaluated for abdominal distention. Survey lateral and dorsoventral abdominal radiographs were made. There were two soft tissue radiopacities consistent with grossly enlarged kidneys displacing small bowel and colon cranially, ventrally and caudally. Abdominal ultrasound was performed and revealed bilateral perinephric pseudocysts and polycystic kidneys. The perinephric pseudocysts were found to be dilated renal capsules on exploratory surgery and were drained. On follow up examinations, the pseudocysts were drained by ultrasound-guided paracentesis. The perinephric cyst fluid was distinguished from urine by measuring creatinine concentration and plans were made to resect the renal capsules due to rapid re-accumulation of pseudocyst fluid. The ferret's condition deteriorated and euthanasia was performed. Post-mortem examination was declined by the owner. Perinephric pseudocysts are rare and this is the first published report in a ferret. Ultrasound examination is the most rapid, accurate and non-invasive method for diagnosis of perinephric pseudocysts.

Animals↗
PubMed2006

Cardiovascular abnormalities in special conditions of advanced cirrhosis. The circulatory adaptative changes to specific therapeutic procedures for the management of refractory ascites.

Advanced liver disease is characterized by decreased arterial blood pressure and peripheral vascular resistances, increased cardiac output and heart rate in the setting of a hyperdynamic circulatory pattern favoured by total blood volume expansion, circulatory overload and overactivity of the endogenous vasoactive systems. Reduced heart responses to stressful conditions such as changes in loading conditions of the heart in presence of further deterioration of liver function such as refractory ascites, hepatorenal syndrome, spontaneous bacterial peritonitis and bleeding esophageal varices have been recently identified and the knowledge of the cirrhotic cardiomyopathy syndrome has gained the dignity of a new clinical entity. Facing the availability of therapeutic interventions (paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, orthotopic liver transplantation) currently employed to manage the life-threatening complications of the most advanced phases of cirrhotic disease, the knowledge of their impact on cardiovascular function is of paramount relevance.

Adaptation, Physiological↗
PubMed2005

Refractory ascites.

Patients with cirrhosis have significant abnormalities in their fluid and electrolyte balance; this is manifested mainly by the development of ascites and edema. Ascites is the most common complication of patients with cirrhosis and its development constitutes the first and most important manifestation of the disease. With disease progression, patients with advanced cirrhosis and severe urinary sodium retention develop refractory ascites, a condition in which patients do not respond to diuretics or develop severe side effects to these that preclude their use. This condition occurs in 5-10% of cases admitted to the hospital for treatment of ascites. Approximately half of these patients will die within 1 year if not transplanted; therefore, the best therapy is liver transplantation in suitable candidates. During the last two decades, significant advances have been made in regard to pathogenesis and treatment of refractory ascites. The re-introduction of therapeutic paracentesis with plasma expansion in the 1980s was a milestone in the treatment of these patients. In addition, the introduction of transjugular intrahepatic portosystemic shunts as a therapy for refractory ascites has certainly provided a reasonable alternative for those patients with preserved liver function and unwilling to undergo several taps per month. This article will discuss the pathophysiology, clinical features and therapy of refractory ascites in cirrhosis.

Ascites↗
PubMedDate not supplied

Treatment of ascites: old and new remedies.

Ascites is a common complication of chronic liver disease. Treatment of the underlying liver disease with modalities such as abstinence from alcohol in Laennec's cirrhosis, phlebotomy in hemochromatosis, copper removal in Wilson's disease, and steroids in autoimmune liver disease, can improve survival in many patients. In addition, therapy of ascites alleviates the symptoms and improves the quality of life of the patients, and probably decreases the incidence of life-threatening conditions including spontaneous bacterial peritonitis and hepatorenal syndrome. The mean survival rate at 2 years is approximately 50%. Precipitating factors such as gastrointestinal bleeding, nonsteroidal anti-inflammatory drugs and infections, should be identified, since most of them can be corrected. Most cirrhotics with ascites can be managed with a 'step-by-step' approach, including dietary salt restrictions, aldosterone antagonists, and loop diuretics. When tense or refractory ascites is present, large-volume paracentesis is safe and effective. Peritoneovenous shunting (i.e. Denver, LeVeen) is less frequently used because of perioperative morbidity and mortality, and thrombotic complications with occlusion of the stent. Reinfusion of concentrated ascites is of potential benefit and has been used in Europe. Transjugular intrahepatic portosystemic shunt (TIPS) is an alternative procedure performed by interventional radiologists that allows decompression of portal hypertension. In many cases, ascites is improved after TIPS, but long-term randomized trials for tense or refractory ascites comparing TIPS with standard therapy are not conclusive. Liver transplantation is the ultimate step for the treatment of ascites, providing the cure for the underlying liver disease as well. Transplantation is indicated when quality of life of the patient is impaired due to recurrent episodes of ascites, or in the presence of spontaneous bacterial peritonitis and hepatorenal syndrome.

Ascites↗
PubMed1998

Selective intra-arterial fibrinolysis of acute central retinal artery occlusion.

BACKGROUND AND PURPOSE: Occlusion of the central retinal artery (CRAO) causes a sudden decrease of monocular vision. Because early restoration of blood flow may improve outcome, we attempted to treat CRAO with selective intra-arterial fibrinolysis. METHODS: Intra-arterial fibrinolysis was performed within 6 hours after symptom onset in 17 patients with thromboembolic CRAO. Symptoms were painless, acute and severe decrease of vision. Urokinase (100 000 to 900 000 IU) was given through a microcatheter into the ophthalmic artery over 10 to 90 minutes. For comparison, the history and visual outcome of 15 control patients who did not receive fibrinolytics were evaluated. In both groups some of the patients underwent paracentesis and/or received carboanhydrase inhibitors. RESULTS: Patients who underwent fibrinolysis fared better than control patients (P=0.01). Three patients (17.6%) recovered completely after fibrinolysis and regained visual acuity of 20/20 (n=2) to 25/20 (n=1). Two additional patients (11.8%) showed a marked improvement to a visual acuity of 20/30. In 6 patients (35. 3%) vision improved slightly. They were able to count fingers, detect hand movements, or perceive light. In 6 patients (35.3%), fibrinolytic treatment was without effect. Among control patients, 1 patient (6.7%) showed partial, 4 patients (26.7%) minimal, and 10 (66.7%) no improvement of vision. CONCLUSIONS: A complete or marked improvement of visual acuity was achieved in one third of intra-arterial fibrinolysis patients but in none of the control patients. Intra-arterial fibrinolysis seems to have the potential to "lighten" the spontaneously poor outcome of CRAO.

Acute Disease↗