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PubMed1995

The lipoprotein composition of plasma and ascitic fluid in liver cirrhosis.

Lipoprotein particles were examined in plasma and ascitic fluid from nine patients (5 males and 4 females) with liver cirrhosis and in plasma from nine control subjects. LDL and HDL fractions were isolated by ultracentrifugation under rate flotation conditions in a zonal rotor. LDL size was analysed by non-denaturing polyacrylamide gradient gel electrophoresis. Plasma lipids in cirrhotic patients were markedly reduced compared to controls. Free cholesterol represented 45.3% of the total cholesterol in plasma and 70.4% of the total cholesterol in the ascitic fluid. The total cholesterol-triglyceride ratio was three times higher in the plasma than in the ascitic fluid of cirrhotic patients. The LDL particles had the same flotation properties in plasma from cirrhotic patients as in that from controls. In cirrhotic patients the IDL concentration was higher than that in controls. In ascitic fluid the LDL particles had a higher flotation rate than in the plasma. The LDL diameter as measured by gradient gel electrophoresis was similar in both plasma and ascitic fluid of the cirrhotic patients as well as in the plasma of controls. In plasma and ascitic fluid of cirrhotic patients only a single HDL subclass (HDL1) could be identified. HDL1 particles had a higher flotation rate than normal HDL particles. The plasma levels of all the apoproteins were reduced in cirrhotic subjects compared to controls, but to a variable degree; while apo CII level in cirrhosis represented only 9% of the control level, the apo E level represented 77% of the control level.(ABSTRACT TRUNCATED AT 250 WORDS)

Ascites↗
PubMed2006

Increased calcium deposits and decreased Ca2+-ATPase in right ventricular myocardium of ascitic broiler chickens.

Right ventricular hypertrophy and failure is an important step in the development of ascites syndrome (AS) in broiler chickens. Cytoplasmic calcium concentration is a major regulator of cardiac contractile function and various physiological processes in cardiac muscle cells. The purpose of this study was to measure the right ventricular pressure and investigate the precise ultrastructural location of Ca(2+) and Ca(2+)-ATPase in the right ventricular myocardium of chickens with AS induced by low ambient temperature. The results showed that the right ventricular diastolic pressure of ascitic broilers was significantly higher than that of control broilers (P < 0.01), and the maximum change ratio of right intraventricular pressure (RV +/- dp/dt(max)) of ascitic broilers was significantly lower than that of the controls (P < 0.01). Extensively increased calcium deposits were observed in the right ventricular myocardium of ascitic broilers, whereas in the age-matched control broilers, calcium deposits were much less. The Ca(2+)-ATPase reactive products were obviously found on the sarcoplasmic reticulum and mitochondrial membrane of the control right ventricular myocardium, but rarely observed in the ascitic broilers. The data suggest that in ascitic broilers there is the right ventricular diastolic dysfunction, in which the overload of intracellular calcium and the decreased Ca(2+)-ATPase activity might be the important factors.

Animals↗
PubMed1997

Review: the controversy over the pathophysiology of ascites formation in cirrhosis.

The pathogenesis of renal sodium retention and ascites formation in cirrhosis is a subject of much controversy. The generally accepted 'peripheral arterial vasodilatation hypothesis' seems to best explain the mechanism of sodium retention and other clinical findings, such as the hyperdynamic circulation of cirrhosis. However, recent data in pre-ascites and in early ascites do not seem to conform to the peripheral arterial vasodilatation hypothesis. Sodium handling abnormalities can be demonstrated in pre-ascitic cirrhosis when patients are challenged with a sodium load, in the absence of systemic vasodilatation or arterial underfilling. Therefore, an alternative hypothesis with a direct hepatorenal interaction, acting via sinusoidal portal hypertension and/or hepatic dysfunction as the affector mechanism, is proposed to be the initiating event in renal sodium retention in cirrhosis. The second and later process is the development of systemic arterial vasodilatation, possibly due to the presence of excess systemic vasodilators and/or decreased responsiveness of the vasculature to endogenous vasoconstrictors. This, in turn, will lead to a relatively underfilled circulation with consequent activation of neurohumoral systems, promoting further renal sodium retention as described by the peripheral arterial vasodilatation hypothesis and ultimately leading to ascites. When compensatory natriuretic mechanisms fail, refractory ascites develops and hepatorenal syndrome sets in. Thus, renal sodium retention in cirrhosis is the result of interplay of many factors, with direct hepatorenal interaction predominating in earlier stages of the cirrhotic process, while systemic vasodilatation becomes a more important pathogenetic factor as the disease progresses.

Ascites↗
PubMed1985

Treatment of refractory ascites in patients with liver disease.

In conclusion, an understanding of the pathophysiology of ascitic fluid formation and clearance in patients with liver disease has resulted in the development of new approaches to the treatment of refractory ascites. Although these techniques have been very successful in controlling ascites they have been associated with a number of complications which can contribute to both short and long term morbidity and mortality. An approach to the individual patient must be based on detailed evaluation of the associated liver disease, its potential reversibility, and documentation that the ascites is truly refractory. If ascites reaccumulates rapidly following ultrafiltration and reinfusion of ascitic fluid then careful consideration may be given to insertion of a peritoneovenous shunt. Careful pre- and postoperative monitoring is necessary if significant complications are to be avoided.

Ascites↗
PubMed1998

Transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites.

BACKGROUND: The Transjugular Intrahepatic Portosystemic Shunt (TIPS) corrects portal hypertension and has proven to be effective in controlling variceal bleeding in patients with cirrhosis. Several reports have now appeared suggesting a possible role in patients with refractory ascites. AIMS: To examine the outcome of TIPS for the treatment of refractory ascites in patients with cirrhosis. METHODS: Fifteen patients underwent TIPS for ascites between April 1992 and December 1996. The clinical findings, response to treatment, complications, shunt patency and survival of these patients were analysed. RESULTS: TIPS was successfully placed in all patients. The mean period of follow-up was 375 days (range: 14-1165 days). In eight patients (53%) there was a reduction in the degree of ascites after shunt insertion, with six patients (40%) having complete resolution. Age, Child-Pugh class or portal pressure gradient, before or after the procedure, were not predictive of response. Of five patients with renal insufficiency (serum creatinine > 130 umol/L), only one had improvement in ascites control. Six patients (40%) required shunt revision during follow-up, either for acute thrombotic occlusion (two) or stent stenosis (four). New or worsening encephalopathy developed in ten patients (67%). Two patients (13%) died of liver failure within 30 days. Cumulative survival was 46% at one year and 18% at two years. Treatment response was associated with increased survival (p = 0.02), with median survival of 658 days as compared with 71 days for treatment failure. CONCLUSIONS: TIPS can be effective in the treatment of refractory ascites in patients with cirrhosis. Our experience suggests the benefit may be less for patients with advanced liver disease and renal impairment. Controlled trials are needed to compare TIPS with other treatment modalities such as large volume paracentesis or peritoneovenous shunting.

Aged↗
PubMed2006

Ascites in infants with severe sepsis - treatment with peritoneal drainage.

BACKGROUND: Ascites in neonates and infants is usually caused by cardiac failure and urinary or biliary tract obstruction. The objective of this study was to characterize our experience with ascites as a complication of sepsis. METHODS: We retrospectively collected and analyzed data of patients treated in the intensive care unit (ICU) of the university-based children's hospital, in whom ascites developed during nosocomial sepsis. Ten infants admitted to the ICU in the first 2 days of life developed sepsis on the mean 31.5 (+/-21.9) postnatal day. Gram-negative bacteria were the causative organism in nine cases, and Staphylococcus hemolyticus in one. Because of sepsis, reintubation and mechanical ventilation were necessary. All patients received broad spectrum antibiotics (including meropenem and ciprofloxacin), blood transfusions, catecholamines and intravenous immunoglobulin preparations. Ascites was observed on the median 13.5 day of sepsis (range 3-36), and severely compromised gas exchange. Continuous peritoneal drainage was applied by means of an intravascular catheter placed in the right lower abdominal quadrant. RESULTS: The mean drained fluid volume was 44.7 (+/-20.4) ml.kg(-1).day(-1), drainage was continued for a median of 5.5 (range 1-56) day, and enabled significant reduction of ventilator settings 24 h after its implementation. No severe complications related to drainage occurred; six of 10 babies survived. CONCLUSIONS: Ascites can develop in infants with sepsis and cause respiratory compromise. Continuous drainage of ascitic fluid by means of an intravenous catheter is relatively safe and can improve gas exchange.

Anti-Bacterial Agents↗
PubMed2005

Cyclic AMP-phosphodiesterases inhibitor improves sodium excretion in rats with cirrhosis and ascites.

BACKGROUND: The mechanisms responsible for renal dysfunction and sodium retention in cirrhosis remain unclear. Cyclic AMP (cAMP) regulates sodium reabsorption in the proximal nephron. This study investigates the role of cAMP metabolism in renal dysfunction in cirrhosis. METHODS: Renal function was studied by the clearance technique in anesthetized control and cirrhotic rats with or without ascites. cAMP phosphodiesterase (PDE) activity was measured in the renal cortex in vitro. Moroever, the effects on renal function of the intravenous administration of cAMP and rolipram, a powerful and specific cAMP-PDE4 inhibitor, were evaluated. RESULTS: In control and in non-ascitic cirrhotic rats, cAMP administration significantly increased sodium and phosphate excretions, but did not change these excretions in cirrhotic rats with ascites. cAMP-PDE activity was higher in ascitic than in control rats (P < 0.05). Rolipram infusion significantly increased sodium and phosphate excretion only in cirrhotic rats with ascites. CONCLUSION: These results suggest that increased renal cAMP-PDE activity is responsible for resistance to the natriuretic effects of cAMP in cirrhosis and plays a role in the development of ascites.

Analysis of Variance↗
PubMed1997

Usefulness of a nonmachinery based system for the reinfusion of cell-free and concentrated autogenous ascitic fluid.

A nonmachinery based system using gravity dependent flow for the treatment and reinfusion of ascitic fluid was developed, and its usefulness was assessed. In a preliminary study using bovine plasma, samples with protein concentrations below 5.0 g/dl were found to be treatable with this system. Bovine plasma containing blood, prepared to 0.5% hematocrit and with a protein concentration of 3.0 g/dl, was also treatable. We conducted a clinical study of 1,799 treatment sessions (1,495 using a machinery based system and 304 using a nonmachinery based system) of 343 patients with ascites refractory to various treatments. The recovery ratio of protein from the original ascitic fluid was 96% using the nonmachinery based system and 77% with the machinery based system (p < 0.01). Of 253 continuous reinfusions of ascitic fluid using the nonmachinery based system, the original ascitic fluid at protein concentrations below 2.5 g/dl was treatable. Original ascitic fluid below a hematocrit of 0.7% (protein concentration, 1.4 g/dl) was also treatable. This new procedure was simple and time and labor saving; the high recovery ratio of protein also demonstrated the usefulness of the new system.

Adult↗
PubMed1998

Hemorrhagic ascites due to congestive heart failure.

Ascites due to congestive heart failure (CHF) is characteristically serous in gross appearance. Although hemorrhage into ascites commonly indicates a malignant or inflammatory cause, cirrhosis of the liver is a well known cause of bloody ascites. We report a case of hemorrhagic ascites due to biventricular congestive heart failure in which workup for other causes was negative and hemorrhage cleared after 4 months. In as much as the mechanism of ascites is similar in both cirrhosis and CHF, we propose that a similar mechanism could cause bleeding into ascites in CHF.

Aged↗
PubMed1998

Transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory ascites: effect on body weight and Child-Pugh score.

OBJECTIVE: This study suggests that patients with medically refractory ascites treated with transjugular intrahepatic portosystemic shunt (TIPS) may have improved in overall clinical status. METHODS: We performed a retrospective study of 35 patients with medically refractory ascites treated with TIPS. Body weight, ascites, and Child-Pugh score were assessed at baseline, at 2 months, and after a mean 8.8-month follow-up interval. RESULTS: After TIPS, there was significant improvement in Child-Pugh score from 9.7+/-1.5 to 8.2+/-2.3. Ascites completely resolved or improved in 23 of 24 patients (96%) who had long term follow-up. Two months after TIPS, there was a significant decrease in weight of 6.1 kg corresponding to a loss of ascites. Between 2 and 8.8 months, there was a significant mean weight gain of 5.5 kg. CONCLUSION: This study suggests that patients treated with medically refractory ascites with TIPS may have improvement in overall clinical status, as measured by increase in lean body mass and improvement in Child-Pugh score.

Adult↗
PubMed1999

Predictors of clinical response to transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with refractory ascites.

OBJECTIVE: Transjugular intrahepatic portosystemic shunt (TIPS) is used increasingly as a treatment for refractory ascites. The aim of the present study was to determine the prognostic value of different parameters in predicting a favorable evolution following TIPS in a cohort of 53 cirrhotic patients without organic renal disease and with refractory ascites. METHODS: Patients were classified as good responders if they survived more than 6 months, without severe chronic hepatic encephalopathy and with good control of ascites. The prognostic value for a good outcome was evaluated using age, creatinine clearance, plasma renin activity, plasma aldosterone, and Pugh score. RESULTS: Good control of ascites was obtained in 90%. The cumulative survival rate was 54% at 6 months, 48% at 1 yr, and 39% at 2 yr. The vast majority of patients died of complications of hepatic insufficiency. Severe chronic hepatic encephalopathy developed in 26%. Overall, a good clinical response was observed in 47%. Creatinine clearance was identified as the only pre-TIPS factor to be significantly and independently associated with a good clinical response to TIPS for refractory ascites. A good clinical response was observed in 57% of patients with a creatinine clearance >36 ml/min compared to 9% of those with a clearance <36 ml/min (p < 0.01). This cutoff point in creatinine clearance had a sensitivity of 96% and a specificity of 36%; positive predictive and negative predictive values were 57% and 90%, respectively. CONCLUSIONS: TIPS might be useful for the treatment of refractory ascites in cirrhotic patients without severe renal function impairment. However, the TIPS usefulness still has to be demonstrated compared to large volume paracentesis or Leveen shunt. In patients with poor renal function or with liver failure after TIPS, liver transplantation should be considered.

Adult↗
PubMed1999

Successful treatment of chylous ascites secondary to Mycobacterium avium complex in a patient with the acquired immune deficiency syndrome.

Chylous ascites is a rare form of ascites, the presence of which generally denotes a very poor long term prognosis. We report the case of a patient with acquired immune deficiency syndrome (AIDS) and massive chylous ascites secondary to Mycobacterium avium complex (MAC) infection, identified in the ascitic fluid by a DNA probe assay. With multidrug anti-MAC therapy the ascites resolved completely, and the patient has survived for >21 months. Diagnosis and treatment of MAC-related chylous ascites are reviewed.

Acquired Immunodeficiency Syndrome↗
PubMed2004

Rapid diagnosis of infected ascitic fluid using leukocyte esterase dipstick testing.

OBJECTIVES: Ascitic fluid infection is presumptively diagnosed when the fluid polymorphonuclear leukocyte (PMN) concentration equals or exceeds 250 cells/microl. The leukocyte esterase (LE) test has been shown to be a good predictor of the presence of PMNs and bacteria in urine and other body fluids. This study examines the value of the Multistix 10 SG LE Dipstick test for the rapid diagnosis of infected ascitic fluid. METHODS: One hundred thirty-six ascitic fluid samples were evaluated by PMN count, culture, and LE Dipstick testing. LE dipstick values of "small" or greater were considered positive. For each sample, the LE test result was compared to the corresponding PMN count and culture result. RESULTS: Ten of the 11 LE-positive samples had PMN >/=250 cells/microl, while 10 of 12 samples with PMN >/=250 cells/microl were also LE-positive. Of the 125 LE-negative samples, 123 were also negative by PMN count. One hundred twenty-three of the 124 samples with PMN <250 cells/microl had negative LE tests. There was a less concordant relationship between the LE test and culture results. The sensitivity and specificity of the LE test for detecting ascitic fluid PMN >/=250 cells/microl were 83% and 99%, respectively, with a positive predictive value of 91% and a negative predictive value of 98%. CONCLUSIONS: The Multistix leukocyte esterase test is useful for the prompt detection of an elevated ascitic fluid PMN count, and represents a convenient new method for the rapid diagnosis of infected ascitic fluid.

Ascitic Fluid↗
PubMed2005

Accuracy of endoscopic ultrasonography in diagnosing ascites and predicting peritoneal metastases in gastric cancer patients.

BACKGROUND: Preoperative diagnosis of peritoneal metastases (PM) is difficult in patients with gastric cancer (GC). AIMS: To assess the accuracy of endoscopic ultrasonography (EUS) in diagnosing ascites and its predictability for the presence of PM in GC patients. SUBJECTS: Consecutive patients with newly diagnosed GC from 1998 to 2004 were studied. METHODS: All patients underwent EUS, ultrasound (US), and computed tomography (CT) scan for preoperative staging and the presence of ascites. The results were compared with operative findings. The diagnosis of PM was confirmed by histopathology or peritoneal fluid cytology. RESULTS: A total of 301 patients were recruited and in 250 patients the presence of ascites (n = 93) and PM (n = 71) were confirmed. EUS was more sensitive (87.1%) than combined US and CT scan examinations (16.1%) and operative findings (laparoscopy or laparotomy) (40.9%) in diagnosing ascites. Sensitivity, specificity, positive and negative predictive values, and accuracy for predicting the presence of PM were 73%, 84%, 64%, 89%, and 81% by EUS; 18%, 99%, 87%, 75%, and 76% by combining US and CT scan; and 77%, 94%, 83%, 91%, and 89% by operative findings, respectively. In multivariate logistic regression analysis, EUS detected ascites was the only significant independent predictor for the presence of PM (p<0.001; odds ratio 4.7 (95% confidence interval 2.0-11.2)). CONCLUSION: EUS is a sensitive method for diagnosing ascites which is an important predictive factor for the presence of PM in GC patients.

Adenocarcinoma↗
PubMed1988

Is ascites caused by impaired hepatic inactivation of blood borne endogenous opioid peptides?

Methionine enkephalin and catecholamines were measured in carefully collected plasma samples from 25 patients with cirrhosis and ascites, and 25 with cirrhosis without ascites, 15 disease and 15 healthy controls. Methionine enkephalin was invariably raised in the ascites group, the median value being 4.6-6.9 times that of the other three groups. Similarly, in the ascites group, median noradrenaline was increased 2.5-4.2 and median adrenaline 1.8-2.5 times that of the other groups. Plasma methionine enkephalin is considerably raised in patients with cirrhotic ascites and has actions which could enable it to be an initiating factor of ascites formation.

Ascites↗
PubMed2003

How valuable is ascitic cytology in the detection and management of malignancy?

INTRODUCTION: Ascitic cytology is often requested in the early stages of ascitic assessment. A review of this practice in a major English teaching hospital is presented. METHOD: Patients were retrospectively identified using the histopathology and patient administration system between January 1999 and May 2001. RESULTS: Of 276 samples sent for assessment 35 cases were found to be negative when on further review an intra-abdominal malignancy was present. The malignancy was diagnosed using a radiological modality. The sensitivity of ascitic cytology was found to be 60% with 100% specificity. A delay of up to five days could be incurred awaiting the cytology results before further radiological examinations were undertaken. CONCLUSION: Too much hope is placed on ascitic cytology to provide the diagnosis at the expense of other investigations. It is recommended that the initial assessment should concentrate on history, examination, and basic tests on ascitic fluid to assess the serum-ascites albumin gradient. Ovarian malignancy is the only tumour type yielding a significant rate of detection from cytology with some prognostic impact. Results should not be awaited before abdominal ultrasound is undertaken. This more directed practice would help reduce unnecessary workload for the pathologist and has resource implications.

Ascitic Fluid↗
PubMed1993

Refractory ascites: early experience in treatment with transjugular intrahepatic portosystemic shunt.

PURPOSE: To evaluate the transjugular intrahepatic portosystemic shunt (TIPS) in treatment of refractory ascites. MATERIALS AND METHODS: Fourteen patients with chronic liver disease and portal hypertension were included in a prospective study. Six patients had Child-Pugh class B disease; eight had class C disease. Indications for TIPS were three previous hospital admissions over 9 months for treatment of tense ascites, no response to diuretic therapy, or an occluded peritoneovenous shunt with tense ascites. The volume of ascitic fluid was sonographically evaluated before and after TIPS placement. RESULTS: The technical success rate for TIPS creation was 93%. Mean portosystemic gradient decreased from 22.8 mm Hg +/- 7.2 before TIPS placement to 11.3 mm Hg +/- 3.6 after TIPS (P = .005). Complete resolution of ascites was achieved in seven (50%) patients. Treatment failed in seven; five had Child-Pugh class C disease, and four of these had a Child-Pugh score greater than 11. CONCLUSION: These results are comparable to those for other forms of treatment of ascites. The authors do not, however, recommend TIPS in patients with a Child-Pugh score greater than 11.

Ascites↗
PubMed1997

Refractory ascites: midterm results of treatment with a transjugular intrahepatic portosystemic shunt.

PURPOSE: To assess midterm results and examine factors associated with successful treatment of refractory ascites with creation of a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: In 50 patients with refractory ascites, TIPS creation was performed. Clinical and ultrasound follow-up were performed. Success was defined as survival with no further therapeutic paracentesis and decreased ascites. RESULTS: Mean follow-up was 11.6 months after the TIPS procedure. Major complications occurred in 16% of patients including intraperitoneal hemorrhage, refractory encephalopathy, and progression of liver and renal failure. Overall mortality was 60% (30 patients). In 23 (62%) of 37 patients not lost to follow-up, ascites was controlled successfully at 1-3 months. A bilirubin level greater than 3.0 mg/dL (52 mumol/L) and creatinine level greater than 1.9 mg/dL (170 mumol/L) were associated with treatment failure (86% treatment failure at 3 months) and early mortality (P = .03). In all 14 patients alive at 1-year follow-up, ascites was controlled successfully. CONCLUSION: TIPS creation is often useful in treatment of severe ascites not controlled with medical therapy. In patients with advanced liver and renal failure, TIPS creation is not associated with a definite benefit and may hasten death.

Adolescent↗