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PubMed1993

Malignant ascites. A comparison of peritoneovenous shunting and nonoperative management.

BACKGROUND: Effective palliation of malignant ascites remains a difficult management problem. METHODS: Eighty-five patients with malignant ascites were studied. Forty-two patients had peritoneovenous shunts (PVS) inserted (16 LeVeen, 17 single-valve Denver, 9 double-valve Denver). RESULTS: Shunt patency was not related to the type of shunt, type of cancer, or any characteristic of the ascitic fluid. Ascites was controlled in 64% of patients with shunts and serum albumin levels were preserved. Survival and quality of life were not significantly different in comparison with those of patients treated by abdominal paracentesis. CONCLUSIONS: PVS allowed many patients to be treated successfully outside the hospital and are indicated in carefully selected cases.

Abdomen↗
PubMed1980

Spontaneous perforation of the extra-hepatic bile ducts in neonates and infants.

Biliary ascites due to "spontaneous" perforation of the extra-hepatic bile ducts is uncommon, and should be suspected in an infant who, after a period of good health, develops jaundice and progressive abdominal distension. When the presentation is acute without jaundice the diagnosis is unlikely to be considered unless paracentesis is performed. The perforation is typically located in the common bile duct near its junction with the cystic duct and simple peritoneal drainage without suture is recommended unless the bile duct is obstructed, in which case T tube drainage or a bypass procedure is required. The prognosis is good. Four patients are presented who illustrate the spectrum of clinical presentation and the different methods of management. Two patients in whom the perforation was in the cystic duct were successfully treated by cholecystectomy. In most cases the aetiology is not apparent, but important factors may be weakening of the common bile duct wall due to ischaemia or pancreatic juice, reflux, associated with a rise in choledochal pressure. In older children the onset of biliary ascites may be preceded by an acute gastrointestinal illness, which may be a predisposing factor.

Ascites↗
PubMed1983

Peritoneovenous shunts in the management of malignant ascites.

Peritoneovenous shunts have been inserted into 26 patients to control malignant ascites. All benefitted and most required no further paracentesis until death from progressive malignancy. Shunt blockage, which is the major problem at present, occurred in 8 patients. Five patients suffering from far advanced malignancy died within a month of operation. There was no clinical evidence of enhanced tumour spread or disseminated intravascular coagulation. We do not consider that the procedure is the first line of management, neither has it much to offer the patient with viscous, bloodstained or loculated ascites. We suggest criteria which help to identify the patient most likely to benefit from a peritoneovenous shunt.

Adult↗
PubMed1984

Selective conservative management of penetrating abdominal wounds: a prospective study.

This is a prospective study comprising 156 cases of abdominal stab wounds. The cases were assessed exclusively on clinical grounds: 37.18 per cent of them were treated conservatively without any mortality and minimal complications. Shock, blood on abdominal paracentesis, omentum protruding through the wound, and radiologically free air under the diaphragm, were not absolute indications for surgery. Alcohol consumption did not interfere with the clinical assessment. Of all 130 cases with proved peritoneal penetration, 28.46 per cent had no significant visceral injury. The incidence of negative laparotomies was 7.0 per cent.

Abdominal Injuries↗
PubMed1986

Non-operative management of penetrating liver injuries: a prospective study.

This is a report of a study of 63 cases of penetrating liver injuries. Forty-two patients (67 per cent) who presented with signs of an acute abdomen were operated on. The liver was routinely sutured and drained. There was no incidence of postoperative intra-abdominal sepsis or haematobilia. In the remaining 21 patients (33 per cent) liver involvement was suggested by the fact that the wound was over the liver region, and penetrated the peritoneum, and abdominal paracentesis for blood was positive or the patient was shocked or pale. The patients in this group had a soft abdomen and they were treated conservatively with observation and blood transfusions if necessary. No complications were recorded in this group. It is concluded that many civilian penetrating injuries of the liver may be managed non-surgically. If an operative approach is selected suturing of the liver with drainage is the recommended procedure.

Female↗
PubMed1996

Spontaneous rupture of hepatocellular carcinoma.

Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening condition; the mechanism is not clear but it is suggested that rupture is usually preceded by rapid expansion of the tumour secondary to bleeding from within its substance. Diagnosis may be made by abdominal paracentesis, ultrasonography, computed tomography or angiography; the positive rates of diagnosis are 86, 66, 100 and 20 per cent respectively. Prognosis is poor. Based on treatment results reported in the literature, the mean survival time for patients who underwent hepatectomy, transcatheter arterial embolization (TAE) and conservative therapy were 247, 98 and 13 days respectively. Judging from the reported results the first choice for emergency treatment of haemostasis is TAE. If laparotomy is undertaken, hepatic artery ligation, preferably of the branch supplying the liver lobe bearing the tumour, should be considered, together with haemostasis of the rupture site by various means (suture plication, packing, argon beam coagulation, use of microwave or absolute ethanol). Emergency hepatectomy should be reserved for patients with an easily resectable lesion who are in a stable cardiovascular condition. Conservative therapy may be used for selected patients in extremely poor condition. The rational treatment for the majority of patients with ruptured HCC is TAE, followed by hepatectomy if the lesion is resectable.

Carcinoma, Hepatocellular↗
PubMed2006

Hyponatremia in cirrhosis: Results of a patient population survey.

Low serum sodium concentration is an independent predictor of mortality in patients with cirrhosis, but its prevalence and clinical significance is unclear. To evaluate prospectively the prevalence of low serum sodium concentration and the association between serum sodium levels and severity of ascites and complications of cirrhosis, prospective data were collected on 997 consecutive patients from 28 centers in Europe, North and South America, and Asia for a period of 28 days. The prevalence of low serum sodium concentration as defined by a serum sodium concentration < or =135 mmol/L, < or =130 mmol/L, < or =125 mmol/L, and < or =120 mmol/L was 49.4%, 21.6%, 5.7%, and 1.2%, respectively. The prevalence of low serum sodium levels (<135 mmol/L) was high in both inpatients and outpatients (57% and 40%, respectively). The existence of serum sodium <135 mmol/L was associated with severe ascites, as indicated by high prevalence of refractory ascites, large fluid accumulation rate, frequent use of large-volume paracentesis, and impaired renal function, compared with normal serum sodium levels. Moreover, low serum sodium levels were also associated with greater frequency of hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome, but not gastrointestinal bleeding. Patients with serum sodium <130 mmol/L had the greatest frequency of these complications, but the frequency was also increased in patients with mild reduction in serum sodium levels (131-135 mmol/L). In conclusion, low serum sodium levels in cirrhosis are associated with severe ascites and high frequency of hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome.

Adolescent↗
PubMed1998

Management of adult patients with ascites caused by cirrhosis.

Ascites is the most common of the major complications of cirrhosis. The development of ascites is an important landmark in the natural history of cirrhosis and has been proposed as an indication for liver transplantation. The initial evaluation of a patient with ascites should include a history, physical evaluation, and abdominal paracentesis with ascitic fluid analysis. Treatment should consist of abstinence from alcohol, sodium restricted diet, and diuretics. This regimen is effective in approximately 90% of patients. The treatment options for the diuretic-resistant patients include serial therapeutic paracenteses, liver transplantation, and peritoneovenous shunting.

Ascites↗
PubMed1999

Nitric oxide production and inducible nitric oxide synthase expression in peritoneal macrophages of cirrhotic patients.

The present study assessed whether peritoneal macrophages isolated from cirrhotic patients produce nitric oxide (NO) and express NO synthase type II (NOS II) mRNA and protein. Patients with cirrhosis and ascites without peritonitis or with unresolved or resolved spontaneous bacterial peritonitis (SBP) were studied. Following paracentesis, ascites NO(2)(-) + NO(3)(-) content (NOx) was measured. Peritoneal macrophages from ascites were seeded on well plates, and NO(2)(-) in the medium was determined. NOx was higher in patients with unresolved or resolved SBP than in cirrhotic patients without peritonitis. Macrophages of patients with SBP or resolved SBP produced NO(2)(-) after 30 hours in culture, but those obtained from patients without peritonitis did not. Reverse-transcription polymerase chain reaction (RT-PCR) and immunocytochemical analysis revealed the presence of a clear signal for NOS II mRNA and protein in macrophages of SBP patients, regardless of whether or not the infection subsided. Therefore, peritoneal macrophages isolated from cirrhotic patients with unresolved or resolved SBP produce NO and express the NOS II mRNA and protein, suggesting that NOS II may contribute to the control of SBP, or to its associated pathology, in human cirrhosis.

Adult↗
PubMed2004

Cloacal anomaly simulating megalocystis in the first trimester.

We present a case of cloacal anomaly that simulated megalocystis in the first trimester of gestation of a female fetus. During the second trimester, repeated paracentesis was necessary to treat increasing ascites, oligohydramnios, and hydronephrosis. Our data support findings that ascites presenting with a multiloculated cystic structure on sonography during the second trimester may be typical for cloacal anomalies. Active treatment of the fetal ascites is recommended to improve the child's prospects for survival.

Adult↗
PubMed1999

Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for patients with medically refractory ascites. Many patients with refractory ascites have umbilical herniation. Incarceration of umbilical hernia has been reported following diuresis, paracentesis, and peritoneovenous shunting. We report 2 cases of umbilical hernia incarceration following resolution of ascites after TIPS.

Ascites↗
PubMed1989

Antenatal diagnosis and palliative treatment of non-immune hydrops fetalis secondary to fetal parvovirus B19 infection.

Hydrops fetalis was diagnosed at 22 weeks. An ultrasound examination demonstrated cardiomegaly and a fetal blood specimen obtained by cordocentesis revealed thrombocytopenia, anaemia, and neutropenia. Fetal paracentesis yielded straw-coloured fluid with electrolytes indicative of a transudate. Non-enveloped icosahedral viral particles approximately 23 mm in diameter were visualized in the ascitic fluid by electron microscopy. Immune electron microscopy confirmed human parvovirus B19. Direct fetal digitalization led to a reduction in umbilical artery resistance, a decline in the abdominal circumference from 20.3 to 17.8 cm, and resolution of the ascites within 72 h. Despite this dramatic response to therapy, fetal death occurred on day 5 of treatment. The initial maternal serum was positive for anti-B19 IgM and IgG antibodies. Electron microscopy of fetal cardiac tissue obtained post-mortem revealed intranuclear viral particles typical of B19, confirming the antenatal diagnosis of myocarditis. This case demonstrates that direct viral identification is applicable to prenatal diagnosis. To our knowledge, this is the first reported case of the antenatal diagnosis and palliative treatment of fetal viral infection.

Adult↗
PubMed1994

Intrauterine intervention in a case of recurrent meconium peritonitis.

We present a case of recurrent meconium peritonitis detected in the second trimester and treated by intrauterine intervention. Antenatal ultrasound findings included fetal ascites and intra-abdominal calcification. Aspiration of fetal ascites under ultrasound guidance and determination of the bilirubin concentration established the diagnosis of meconium peritonitis. Paracentesis was repeated to remove irritating intestinal contents and to decrease pressure on the fetal thorax. Although the exact cause of the meconium peritonitis remains unknown, the recurrence of the condition suggests a genetic basis. A possibility of cystic fibrosis was not considered because the clinical picture did not suggest it. Intrauterine intervention helped to establish the diagnosis of meconium peritonitis and may have contributed to the good outcome.

Adult↗
PubMed1996

Endothelial toxicity of ceftazidime in anterior chamber irrigation solution.

Due to the high toxicity of aminoglycoside antibiotics, many authors prefer to use third generation cephalosporines in the prophylaxis and treatment of intraocular infections. The aim of the present study was to determine safe ceftazidime levels in anterior chamber irrigation solution. Twenty-two eyes of 12 white New Zealand rabbits were divided into six groups of two animals each. Double paracentesis was performed in both eyes, irrigating the right eye with 250 ml of BSS-Plus (BSS+) solution, and the left eye with 250 ml of BSS+ solution with increasing concentrations of ceftazidime (2, 3, 4, 6 and 8 mg ml-1). Each rabbit was killed at the end of surgery, except the last group, which received BSS+ and BSS+ with 8 mg ml-1 of ceftazidime, respectively, in one eye, and were then killed 24 hr later. Endothelial lesions were assessed by silver nitrate staining. We considered lesions endothelial silver affinity ranging from minimal (1-2+) to intense (3-4+). 1-2+ silver affinity was found in 4 +/- 1.35% of endothelial cells in the controls; this percentage in turn increased with antibiotic concentration (6.1 +/- 1.13%, 6.7 +/- 0.4%, 7.2 +/- 1.36%, 7.3 +/- 1.93% and 7.5 +/- 1.83%, respectively). The percentage of 3-4+ silver affinity was 0.18 +/- 0.17% in the controls, and likewise increased with antibiotic concentration (0.22 +/- 0.11%, 0.37 +/- 0.09%, 2.8 +/- 0.63% and 3.1 +/- 0.46%, respectively). The increase in affinity was greatest up to the 4 mg ml-1 concentration. In the last group there were zones of endothelial alterations in morphology and size, with signs of attempted repair in the eye treated with antibiotic, but none in the case treated only with BSS+. Ceftazidime concentrations above 3 mg ml-1 in intraocular infusions induce endothelial cell toxicity.

Animals↗
PubMed1998

Pharmacokinetics of topical beta-adrenergic antagonists in rabbit aqueous humor evaluated with the microdialysis method.

The microdialysis method was used to evaluate the pharmacokinetics of the beta-adrenergic antagonists carteolol and timolol and the new ophthalmic solution WP-934 in rabbit aqueous humor, following instillation. A probe with a microdialysis membrane (length, 5 mm; diameter, 0.2 mm) was implanted in the anterior chamber of the pigmented rabbit and perfused with Ringer's solution. Twenty microliters of 0.5% timolol maleate (0.5% Timoptol(R)), 2% carteolol hydrochloride (2% Mikelan(R)), or a novel preparation of 0.5% timolol maleate (WP-934) that gels after instillation were then instilled. The concentrations of these drugs in dialysates were measured using high-performance liquid chromatography and an electrochemical detection system. In vitro relative recovery of the membrane with timolol and carteolol was approximately 17.5% and 21. 6%, respectively. Timolol and carteolol levels in aqueous humor increased rapidly after instillation of Timoptol and Mikelan and reached maximal levels (Cmax) within 60 minutes. The Cmax of carteolol (4.25 microg ml-1) was lower than that of timolol (5.52 microg ml-1), suggesting that the corneal permeability of timolol is higher than that of carteolol. After instillation of WP-934, the Cmax of timolol (12.32 microg ml-1) was 2.2-fold higher than that after instillation of Timoptol. However, t1/2 values of beta-adrenergic antagonists after instillation of the three preparations were not significantly different. These data suggest that the microdialysis technique is useful for continuous monitoring of aqueous levels of beta-blockers and for analysis of their pharmacokinetic parameters while requiring much fewer animals than conventional sampling with paracentesis.

Administration, Topical↗
PubMed1994

Noninvasive monitoring of ovarian cancer: improved results using CT with intraperitoneal contrast combined with immunocytology.

The purpose of this study was to evaluate whether CT with intraperitoneal contrast (ipc/CT) in combination with immunocytochemical (ICC) tests could improve the diagnostic accuracy over conventional methods in the follow-up of ovarian carcinoma. Forty-five clinically disease-free ovarian cancer patients eligible for a second-look laparotomy were given an intraperitoneal infusion of positive contrast material followed by pelvic and abdominal CT. After the radiographic examination, the contrast fluid was collected by paracentesis and processed for morphological as well as for immunocytochemical analysis employing a panel of monoclonal antibodies identifying distinct ovarian tumor-associated antigens. While ipc/CT correctly detected the presence of peritoneal recurrences in 22 of 45 (49%) patients, the immunocytochemical tests demonstrated the presence of otherwise undiagnosed microscopic disease in an additional 8 patients (18%). Our results demonstrate that the combination of radiological and immunological methods may represent a more accurate, noninvasive means of monitoring ovarian cancer, thus reducing the need for a second-look laparotomy.

Adult↗
PubMed1997

Characterization of highly radiosensitive cell lines from a human ovarian small-cell cancer.

Cells were obtained at paracentesis from a patient with a rapidly growing ovarian tumor. A monolayer cell line (V7S), a xenograft tumor line (V7), and subsequently a xenograft-derived monolayer cell line (V7M) were established. Histological and immunohistochemical studies of the original tumor, xenograft, and cell lines provided a diagnosis of small-cell carcinoma of the ovary-which is consistent with the clinical course of the patient. V7S and V7M had a predominantly hypodiploid karyotype with a small tetraploid population. The V7M, which has been in long-term culture, also showed a nonrandom translocation involving chromosomes 1 and 14 and monosomy of X. Radiobiologically, V7S, V7, and V7M showed marked radiosensitivity with surviving fractions at 2 Gy, measured by clonogenic assay, of between 0.022 and 0.147. Split-dose experiments provided evidence that this radiosensitivity was not due to an inability in cellular repair. In vivo data from the xenograft (V7) revealed a highly radiosensitive tumor, corroborating the in vitro studies.

Carcinoma, Small Cell↗
PubMed1999

IL-2 enhances standard IFNgamma/LPS activation of macrophage cytotoxicity to human ovarian carcinoma in vitro: a potential for adoptive cellular immunotherapy.

OBJECTIVE: The objective was to evaluate the enhancement of human peritoneal macrophage cytotoxic in vitro activity by the addition of interleukin-2 (IL-2) to the standard interferon gama (IFNgamma) and lipopolysaccharide (LPS) activation procedure used for cellular adoptive immunotherapy in a human ovarian cancer system. This cytotoxic effect of these activated macrophages was tested on cells from ovarian cancers of various stages, histology type, and grade, both prior to chemotherapy and at recurrence, in ovarian carcinoma cells lines and normal cells. Increased activation of the macrophage may make it a better candidate for intraperitoneal cellular adoptive immunotherapy as a component of ovarian cancer therapy. This was not a study of the mechanism of macrophage killing. METHODS: Ascites specimens were collected from 24 ovarian cancer patients at the time of surgery or by paracentesis. The mononuclear cell fraction was isolated by discontinuous density gradient centrifugation and used as a cellular source of peritoneal macrophages (PMs) and primary cultured ovarian cancer cells. PMs were separated by 1-h adhesion followed by intensive washing to remove floating cells. The floating cells were cultured for 24 h which left the cancer cells attached after unattached cells were removed by washing. These cells formed a monolayer of cancer cells, which could be subcultured in 22 patients. The cells from the third to fifth passages were used as target cells without coculture with other cells. PMs were identified by latex ingestion, and their purity after isolation by adhesion culture was tested by flow cytometry and immunofluorescence. PMs were activated by culturing in the presence of IFNgamma, with or without IL-2, for 18 h followed by the addition of LPS 6 h prior to use as effector cells in cytotoxicity assays. Ovarian cancer cells of both established cell lines and primary cultures were labeled with (51)Cr and utilized as target cells to quantitatively measure PM-mediated cytotoxicity. Ovarian cancer cells were also cocultured with PMs for morphologic observations to provide supporting evidence to the cytotoxicity assays. RESULTS: IL-2 enhances the cytotoxicity of the standard IFNgamma/LPS macrophage activation in this system. Peritoneal macrophages so activated are cytotoxic to autologous and allogenic primary cultured ovarian tumors and to ovarian carcinoma cell lines. The macrophages are cytotoxic to cells both prior to treatment and at recurrence, but the data from the few recurrent patients did reach statistical significance. This cytotoxicity is not MHC associated. Normal cells are minimally affected. CONCLUSIONS: IL-2 augmented the standard IFNgamma/LPS method of activating peritoneal macrophage cell killing of human ovarian cancer cells in this in vitro system. The cell killing occurred with autologous and allogenic tumor cells from patients with primary and possibly recurrent tumors. Activated PMs minimally affected the normal cells tested. This enhanced activation may improve the disappointing results of previous adoptive cellular immunotherapy human trials and should be considered for ovarian cancer clinical trials.

Adult↗