Different timing for abdominal paracentesis catheter placement and drainage in severe acute pancreatitis complicated by intraabdominal fluid accumulation

BACKGROUND Non-surgical methods such as percutaneous drainage are crucial for the treatment of patients with severe acute pancreatitis(SAP).However,there is still an ongoing debate regarding the optimal timing for abdominal paracentesis catheter place-ment and drainage.AIM To explore the influence of different timing for abdominal paracentesis catheter placement and drainage in SAP complicated by intra-abdominal fluid accumu-lation.METHODS Using a retrospective approach,184 cases of SAP complicated by intra-abdominal fluid accumulation were enrolled and categorized into three groups based on the timing of catheter placement:group A(catheter placement within 2 d of symptom onset,n=89),group B(catheter placement between days 3 and 5 after symptom onset,n=55),and group C(catheter placement between days 6 and 7 after symptom onset,n=40).The differences in progression rate,mortality rate,and the number of cases with organ dysfunction were compared among the three groups.RESULTS The progression rate of group A was significantly lower than those in groups B and groups C(2.25%vs 21.82%and 32.50%,P<0.05).Further,the proportion of patients with at least one organ dysfunction in group A was significantly lower than those in groups B and groups C(41.57%vs 70.91%and 75.00%,P<0.05).The mortality rates in group A,group B,and group C were similar(P>0.05).At postoperative day 3,the levels of C-reactive protein(55.41±19.32 mg/L vs 82.25±20.41 mg/L and 88.65±19.14 mg/L,P<0.05),procalcitonin(1.36±0.51 ng/mL vs 3.20±0.97 ng/mL and 3.41±0.98 ng/mL,P<0.05),tumor necrosis factor-alpha(15.12±6.63 pg/L vs 22.26±9.96 pg/L and 23.39±9.12 pg/L,P<0.05),interleukin-6(332.14±90.16 ng/L vs 412.20±88.50 ng/L and 420.08±87.65ng/L,P<0.05),interleukin-8(415.54±68.43 ng/L vs 505.80±66.90 ng/L and 510.43±68.23ng/L,P<0.05)and serum amyloid A(270.06±78.49 mg/L vs 344.41±81.96 mg/L and 350.60±80.42 mg/L,P<0.05)were significantly lower in group A compared to those in groups B and group C.The length of hospital stay in group A was significantly lower than those in groups B and group C(24.50±4.16 d vs 35.54±6.62 d and 38.89±7.10 d,P<0.05).The hospitalization expenses in group A were also significantly lower than those in groups B and groups C[2.70(1.20,3.55)ten-thousand-yuan vs 5.50(2.98,7.12)ten-thousand-yuan and 6.00(3.10,8.05)ten-thousand-yuan,P<0.05).The incidence of complications in group A was markedly lower than that in group C(5.62%vs 25.00%,P<0.05),and similar to group B(P>0.05).CONCLUSION Percutaneous catheter drainage for the treatment of SAP complicated by intra-abdominal fluid accumulation is most effective when performed within 2 d of onset.

Timing of paracentesis and outcomes in hospitalized patients with decompensated cirrhosis

BACKGROUND Ascites is one of the most common complications of cirrhosis,placing a significant burden on the healthcare system.Data regarding the optimal time of paracentesis and outcomes among patients with cirrhosis and ascites are scarce.AIM To assess the outcomes of patients who underwent paracentesis within 12 h after admission compared to patients who underwent paracentesis later than 12 h.METHODS The study included 185 patients with cirrhosis and ascites who underwent paracentesis.The early paracentesis group was defined as paracentesis performed<12 h after admission(65 patients)and the delayed paracentesis group was defined as paracentesis performed>12 h after admission(120 patients).Newonset complications of cirrhosis,length of hospital stay,weekday or weekend admission,in-hospital mortality rate,and 90-d readmission rates were assessed and compared between the groups.RESULTS Significantly more patients in the delayed paracentesis group than in the early paracentesis group developed hepatic encephalopathy(45%vs 21.5%,P<0.01),hepato-renal syndrome(21.6%vs 9.2%,P=0.03)and infections(25%vs 10.7%,P=0.02)during hospitalization.There were no statistically significant differences in the occurrence of spontaneous bacterial peritonitis and upper gastrointestinal bleeding between the two groups.Length of stay was shorter in the early paracentesis group than in the delayed paracentesis group(6.7 d vs 12.2 d)and inhospital mortality was lower among patients in the early paracentesis group.Patients in the delayed paracentesis group had a higher risk of developing complications during hospitalization.CONCLUSION Early paracentesis(within 12 h after admission)could be a new inpatient quality metric among patients hospitalized with cirrhosis and ascites as it is associated with fewer complications of cirrhosis,lower in-hospital mortality and shorter length of stay.

Abdominal paracentesis drainage ameliorates severe acute pancreatitis in rats by regulating the polarization of peritoneal macrophages

AIM To investigate the role of peritoneal macrophage(PM) polarization in the therapeutic effect of abdominal paracentesis drainage(APD) on severe acute pancreatitis(SAP).METHODS SAP was induced by 5% Na-taurocholate retrograde injection in Sprague-Dawley rats. APD was performed by inserting a drainage tube with a vacuum ball into the lower right abdomen of the rats immediately after the induction of SAP. To verify the effect of APD on macrophages, PMs were isolated and cultured in an environment, with the peritoneal inflammatory environment simulated by the addition of peritoneal lavage in complete RPMI 1640 medium. Hematoxylin and eosin staining was performed. The levels of pancreatitis biomarkers amylase and lipase as well as the levels of inflammatory mediators in the blood and peritoneal lavage were determined. The polarization phenotypes of the PMs were identified by detecting the marker expression of M1/M2 macrophages via flow cytometry, qPCR and immunohistochemical staining. The protein expression in macrophages that had infiltrated the pancreas was determined by Western blot.RESULTS APD treatment significantly reduced the histopathological scores and levels of amylase, lipase, tumor necrosis factor-α and interleukin(IL)-1β, indicating that APD ameliorates the severity of SAP. Importantly, we found that APD treatment polarized PMs towards the M2 phenotype, as evidenced by the reduced number of M1 macrophages and the reduced levels of proinflammatory mediators, such as IL-1β and L-selectin, as well as the increased number of M2 macrophages and increased levels of anti-inflammatory mediators, such as IL-4 and IL-10. Furthermore, in an in vitro study wherein peritoneal lavage from the APD group was added to the cultured PMs to simulate the peritoneal inflammatory environment, PMs also exhibited a dominant M2 phenotype, resulting in a significantly lower level of inflammation. Finally, APD treatment increased the proportion of M2 macrophages and upregulated the expression of the anti-inflammatory protein Arg-1 in the pancreas of SAP model rats.CONCLUSION These findings suggest that APD treatment exerts antiinflammatory effects by regulating the M2 polarization of PMs, providing novel insights into the mechanism underlying its therapeutic effect.

Abdominal paracentesis drainage ameliorates myocardial injury in severe experimental pancreatitis rats through suppressing oxidative stress

BACKGROUND Abdominal paracentesis drainage(APD)is a safe and effective strategy for severe acute pancreatitis(SAP)patients.However,the effects of APD treatment on SAPassociated cardiac injury remain unknown.AIM To investigate the protective effects of APD on SAP-associated cardiac injury and the underlying mechanisms.METHODS SAP was induced by 5%sodium taurocholate retrograde injection in Sprague-Dawley rats.APD was performed by inserting a drainage tube with a vacuum ball into the lower right abdomen of the rats immediately after SAP induction.Morphological staining,serum amylase and inflammatory mediators,serum and ascites high mobility group box(HMGB)1,cardiac-related enzymes indexes and cardiac function,oxidative stress markers and apoptosis and associated proteins were assessed in the myocardium in SAP rats.Nicotinamide adenine dinucleotide phosphate oxidase activity and mRNA and protein expression were also examined.RESULTS APD treatment improved cardiac morphological changes,inhibited cardiac dysfunction,decreased cardiac enzymes and reduced cardiomyocyte apoptosis,proapoptotic Bax and cleaved caspase-3 protein levels.APD significantly decreased serum levels of HMGB1,inhibited nicotinamide adenine dinucleotide phosphate oxidase expression and ultimately alleviated cardiac oxidative injury.Furthermore,the activation of cardiac nicotinamide adenine dinucleotide phosphate oxidase by pancreatitis-associated ascitic fluid intraperitoneal injection was effectively inhibited by adding anti-HMGB1 neutralizing antibody in rats with mild acute pancreatitis.CONCLUSION APD treatment could exert cardioprotective effects on SAP-associated cardiac injury through suppressing HMGB1-mediated oxidative stress,which may be a novel mechanism behind the effectiveness of APD on SAP.

Abdominal paracentesis drainage attenuates intestinal inflammation in rats with severe acute pancreatitis by inhibiting the HMGB1-mediated TLR4 signaling pathway

BACKGROUND Our previous studies confirmed that abdominal paracentesis drainage(APD)attenuates intestinal mucosal injury in rats with severe acute pancreatitis(SAP),and improves administration of enteral nutrition in patients with acute pancreatitis(AP).However,the underlying mechanisms of the beneficial effects of APD remain poorly understood.AIM To evaluate the effect of APD on intestinal inflammation and accompanying apoptosis induced by SAP in rats,and its potential mechanisms.METHODS SAP was induced in male adult Sprague-Dawley rats by 5%sodium taurocholate.Mild AP was induced by intraperitoneal injections of cerulein(20μg/kg body weight,six consecutive injections).Following SAP induction,a drainage tube connected to a vacuum ball was placed into the lower right abdomen of the rats to build APD.Morphological changes,serum inflammatory mediators,serum and ascites high mobility group box protein 1(HMGB1),intestinal barrier function indices,apoptosis and associated proteins,and toll-like receptor 4(TLR4)signaling molecules in intestinal tissue were assessed.RESULTS APD significantly alleviated intestinal mucosal injury induced by SAP,as demonstrated by decreased pathological scores,serum levels of D-lactate,diamine oxidase and endotoxin.APD reduced intestinal inflammation and accompanying apoptosis of mucosal cells,and normalized the expression of apoptosis-associated proteins in intestinal tissues.APD significantly suppressed activation of the intestinal TLR4 signaling pathway mediated by HMGB1,thus exerting protective effects against SAP-associated intestinal injury.CONCLUSION APD improved intestinal barrier function,intestinal inflammatory response and accompanying mucosal cell apoptosis in SAP rats.The beneficial effects are potentially due to inhibition of HMGB1-mediated TLR4 signaling.

An automated spring-loaded needle for endoscopic ultrasound-guided abdominal paracentesis in cancer patients

AIM: To evaluate the feasibility of using an automatedspring-loaded needle device for endoscopic ultrasound(EUS)-guided abdominal paracentesis(EUS-P) to see if this would make it easier to puncture the mobile and lax gastric wall for EUS-P.METHODS: The EUS database and electronic medical records at Fukushima Medical University Hospital were searched from January 2001 to April 2011. Patients with a history of cancer and who underwent EUS-P using an automated spring-loaded needle device with a 22-gauge puncture needle were included. The needle was passed through the instrument channel and advanced through the gastrointestinal wall under EUS guidance into the echo-free space in the abdominal cavity and ascitic fluid was collected. The confirmed diagnosis of malignant ascites included positive cytology and results from careful clinical observation for at least 6 mo in patients with negative cytology. The technical success rate, cytology results and complications were evaluated.RESULTS: We found 11 patients who underwent EUS-P with an automated spring-loaded needle device. In 4 cases, ascites was revealed only with EUS but not in other imaging modalities. EUS-P was done in 7 other cases because there was minimal ascitic fluid and no safe window for percutaneous abdominal aspiration. Ascitic fluid was obtained in all cases by EUS-P. The average amount aspirated was 14.1 mL(range 0.5-38 mL) and that was sent for cytological exam. The etiology of ascitic fluid was benign in 5 patients and malignant in 6. In all cases, ascitic fluid was obtained with the first needle pass. No procedure-related adverse effects occurred.CONCLUSION: EUS-P with an automated springloaded needle device is a feasible and safe method for ascites evaluation.

Ultrasound for Detection of Ascites and for Guidance of the Paracentesis Procedure: Technique and Review of the Literature

Objective: To review the use of ultrasound (US) for the detection of free intraperitoneal fluid (ascites) and for the procedural guidance of the paracentesis procedure. Methods: Two clinical vignettes are presented to review the pertinent diagnostic, management and safety considerations associated with paracentesis. First, US techniques used for the identification of ascites and in the quantification of fluid pockets amenable to aspiration will be discussed. Next, the actual steps required for the performance of US-guided paracentesis will be covered. A review and analysis of the most current literature regarding US and paracentesis then follows. Conclusion: Current literature favors US-guided paracentesis over the traditional blind technique with a significant reduction in both the rate of unsuccessful aspiration of fluid and in the bleeding complications related to this procedure. Use of US for both the diagnostic and therapeutic management of ascites should be advocated as an essential skill for physicians and other health care providers caring for these patients.

Paracentesis in cirrhotics is associated with increased risk of 30-day readmission

AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites.METHODS A retrospective analysis of the nationwide readmission database(NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites,spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission.RESULTS Of the 59597 patients included in this study, 18319(31%) were readmitted within 30 d. Majority(58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832(50%) patients on index admission. Independent predictors of 30-d readmission included age < 40(OR: 1.39; CI: 1.19-1.64), age 40-64(OR: 1.19; CI: 1.09-1.30), Medicaid(OR: 1.21; CI: 1.04-1.41) and Medicare coverage(OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity(OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis(OR: 1.16; CI: 1.10-1.23), paracentesis on index admission(OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma(OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted(P-value: 0.34); however cost of care was significantly more on 30 d readmission($30959 ± 762) as compared to index admission($12403 ± 378), P-value: < 0.001.CONCLUSION Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.

Paracentesis following intravitreal drug injections in maintaining physiologic ocular perfusion pressure

A retrospective analysis was performed of patients who received a paracentesis immediately following an intravitreal injection of bevacizumab or triamcinolone acetonide.These patients were previously diagnosed as having glaucoma,ocular hypertension,or had responded previously with sustained elevated intraocular pressure.Of 1661 procedures were performed.Totally 219（13%） of the injections were on phakic patients.A median（SD） of 210 μL（40 μL） of aqueous was removed during each paracentesis.There were no reported incidences of any complications.We propose performing a paracentesis immediately following intravitreal injections for patients at risk for ocular hypertension,glaucoma,and retinal vein or artery occlusion.

Covered transjugular intrahepatic portosystemic stent-shunt vs large volume paracentesis in patients with cirrhosis: A real-world propensity score-matched study

BACKGROUND Refractory ascites has a 1-year survival rate of 50%.In selected patients,treatment options include liver transplantation(LT)or transjugular intrahepatic portosystemic stent shunt(TIPSS).AIM To assess the outcomes of patients who underwent a TIPSS compared to large volume paracentesis(LVP).METHODS Retrospective study of patients who underwent a covered TIPSS or LVP for refractory or recurrent ascites over 7 years.Primary outcome was transplant-free survival(TFS).Further analysis was done with propensity score matching(PSM).RESULTS There were 150 patients[TIPSS group(n=75),LVP group(n=75)].Seven patients in the TIPSS group underwent LT vs 22 patients in the LVP group.Overall median follow up,20(0.47-179.53)mo.In the whole cohort,there was no difference in TFS[hazard ratio(HR):0.80,95%confidence interval(CI):0.54-1.21];but lower de novo hepatic encephalopathy with LVP(HR:95%CI:0.20-0.96).These findings were confirmed following PSM analysis.On multivariate analysis albumin and hepatocellular carcinoma at baseline were associated with TFS.CONCLUSION Covered TIPSS results in similar TFS compared to LVP in cirrhotic patients with advanced liver failure.Liver transplant assessment should be considered in all potential candidates for TIPSS.Further controlled studies are recommended to select appropriate patients for TIPSS.

Large-Volume Paracentesis in Patients with Cirrhotic Ascites: Does It Increase the Risk of Serious Bleeding and the Need for Transfusion?

Background: Liver cirrhosis is the most common cause of ascites. For cirrhotic ascites that does not respond to diuretics and salt restriction, large-volume paracentesis is an alternative option. Methods: A retrospective cohort study of patients admitted to the Day care unit at King Abdulaziz University Hospital for therapeutic paracentesis of cirrhotic ascites was performed from March 2013-April 2014. The demographic data and results, including the platelet count, hemoglobin level, prothrombin time (PT), international normalized ratio (INR), serum creatinine, serum albumin, and bilirubin levels, were recorded. We recorded all of the bleeding episodes. Results: We recorded 118 admissions for 13 patients. Nine of them were male (69.2%), and the mean age was 58.6 ± 15.8 years. All patients had a Child-Pugh score of C. The platelet count was lower than normal for 78 admissions (66.1%), and the PT was prolonged for 99 admissions (84%). Three episodes of bleeding occurred in our cohort, all of which were mild and controlled by the local application of pressure. One patient required a platelet transfusion for severe thrombocytopenia, low platelets count was associated with elevated creatinine and low albumin levels (P = 0.014 and 0.003, respectively). Similarly, a prolonged PT was associated with low albumin, high bilirubin, low platelet, and high creatinine levels (P = 0.013, < 0.001, = 0.006, and < 0.001, respectively). Conclusions: Large-volume paracentesis is associated with only a small risk of bleeding in patients with cirrhotic ascites, and a transfusion of fresh frozen plasma (FFP) and platelets is not needed for the majority of patients.

Pathophysiology and Prevention of Paracentesis-induced Circulatory Dysfunction:A Concise Review

Annually,10%of cirrhotic patients with ascites develop refractory ascites for which large-volume paracentesis(LVP)is a frequently used therapeutic procedure.LVP,although a safe method,is associated with circulatory dysfunction in a significant percentage of patients,which is termed para-centesis-induced circulatory dysfunction(PICD).PICD results in faster reaccumulation of ascites,hyponatremia,renal impairment,and shorter survival.PICD is diagnosed through laboratory results,with increases of>50%of baseline plasma renin activity to a value≥4 ng/mL/h on the fifth to sixth day after paracentesis.In this review,we discuss the pathophysi-ology and prevention of PICD.

Mannitolum infusion on cirrhotic patients with tense ascites treated by paracentesis

OBJECTIVE: To investigate whether albumin can be substituted by mannitolum in cirrhotic patients with tense ascites treated by paracentesis. METHODS: Sixty-eight patients admitted to this therapeutic procedure were randomly assigned to receive intravenous albumin (36 patients) and mannitolum (32 patients) infusion. In repeated large-volume paracentesis (3-6 L/day), intravenous albumin 20 g or intravenous 20% mannitolum 250 ml were added. RESULTS: In 24 and 48 hours after paracentesis the mean value of electrolytes, liver and renal functions and various indicators of systemic circulation either in Group 1 or in Group 2 cases were found without changes (P > 0.05). As compared with that before paracentesis, the diameter of spleen vein was increased significantly (P

恶意的腹水: 预示的因素， pathophysiology 和治疗学的措施的评论

Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, quality of life can be improved through palliative procedures. Selecting the appropriate treatment modality remains a careful process, which should take into account potential risks and benefits and the life expectancy of the patient. Traditional therapies, including paracentesis, peritoneovenous shunt placement and diuretics, are successful and effective in varying degrees. After careful review of the patient’s primary tumor origin, tumor biology, tumor stage, patient performance status and comorbidities, surgical debulking and intraperitoneal chemotherapy should be considered if the benefit of therapy outweighs the risk of operation because survival curves can be extended and palliation of symptomatic malignant ascites can be achieved in select patients. In patients with peritoneal carcinomatosis who do not qualify for surgical cytoreduction but suffer from the effects of malignant ascites, intraperitoneal chemotherapy can be safely and effectively administered via laparoscopic techniques. Short operative times, short hospital stays, low complication rates and ultimately symptomatic relief are the advantages of laparoscopically administering heated intraperitoneal chemotherapy, making it not only a valuable treatment modality but also the most successful treatment modality for achieving palliative cure of malignant ascites.

Current approaches to the management of patients with cirrhotic ascites

This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords:“liver cirrhosis,”“portal hypertension,”“ascites,”“pathogenesis,”“diagnostics,” and “treatment.” Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.

Myxedema ascites with high CA-125:Case and a review of literature

Ascites appearing in a previously healthy female patient is usually ascribed to a variety of causes,among which,is a cancerous process,especially if it comes with a raised CA-125 level.Although the CA-125 antigen is present on more than 80% of malignant epithelial ovarian tissue of non-mucinous type,it is also found on both healthy and malignant cells of mesothelial and non-mesothelial origin.Myxedema ascites which is caused by hypothyroidism is a rare entity,but on the other hand is easy to treat.It is one of the differential diagnoses when the ascites is refractory to treatment and no other obvious cause can be identified.If the diagnosis is delayed,patients will frequently receive unnecessary procedures,while treatment has very good response rates and ascites resolve with serum CA-125 normalization after adequate hormonal treatment.

Management of refractory ascites in cirrhosis:Are we out of date?

Cirrhosis is a major cause of morbidity and mortality worldwide with liver transplantations as it only possible cure.In the face of a significant organ shortage many patients die waiting.A major complication of cirrhosis is the development of portal hypertension and ascites.The management of ascites has barely evolved over the last hundred years and includes only a few milestones in our treatment approach,but has overall significantly improved patient morbidity and survival.Our mainstay to ascites management includes changes in diet,diuretics,shunt procedures,and large volume paracentesis.The understanding of the pathophysiology of cirrhosis and portal hypertension has significantly improved in the last couple of decades but the changes in ascites management have not seemed to mirror this newer knowledge.We herein review the history of ascites management and discuss some its current limitations.

Efficacy of tolvaptan in patients with refractory ascites in a clinical setting

AIM: To elucidate the efficacies of tolvaptan(TLV) as a treatment for refractory ascites compared with conventional treatment. METHODS: We retrospectively enrolled 120 refractory ascites patients between January 1, 2009 and September 31, 2014. Sixty patients were treated with oral TLV at a starting dose of 3.75 mg/d in addition to sodium restriction(> 7 g/d), albumin infusion(10-20 g/wk), and standard diuretic therapy(20-60 mg/d furosemide and 25-50 mg/d spironolactone) and 60 patients with large volume paracentesis in addition to sodium restriction(less than 7 g/d), albumin infusion(10-20 g/wk), and standard diuretic therapy(20-120 mg/d furosemide and 25-150 mg/d spironolactone). Patient demographics and laboratory data, including liver function, were not matched due to the small number of patients. Continuous variables were analyzed by unpaired t-test or paired t-test. Fisher's exact test was applied in cases comparing two nominal variables. We analyzed factors affecting clinical outcomes using receiver operating characteristic curves and multivariate regression analysis. We also used multivariate Cox's proportional hazard regression analysis to elucidate the risk factors that contributed to the increased incidence of ascites.RESULTS: TLV was effective in 38(63.3%) patients. The best cut-off values for urine output and reduced urine osmolality as measures of refractory ascites improvement were > 1800 mL within the first 24 h and > 30%, respectively. Multivariate regression analysis indicated that > 25% reduced urine osmolality [odds ratio(OR) = 20.7; P < 0.01] and positive hepatitis C viral antibodies(OR = 5.93; P = 0.05) were positively correlated with an improvement of refractory ascites, while the total bilirubin level per 1.0 mg/dL(OR = 0.57;P = 0.02) was negatively correlated with improvement. In comparing the TLV group and controls, only the serum sodium level was significantly lower in the TLV group(133 mE q/L vs 136 mE q/L; P = 0.02). However, there were no significant differences in the other parameters between the two groups. The cumulative incidence rate was significantly higher in the control group with a median incidence time of 30 d in the TLV group and 20 d in the control group(P = 0.01). Cox hazard proportional multivariate analysis indicated that the use of TLV(OR = 0.58; P < 0.01), uncontrolled liver neoplasms(OR = 1.92; P < 0.01), total bilirubin level per 1.0 mg/dL(OR = 1.10; P < 0.01), and higher sodium level per 1.0 m Eq/L(OR = 0.94; P < 0.01) were independent factors that contributed to incidence. CONCLUSION: Administration of TLV results in better control of refractory ascites and reduced the incidence of additional invasive procedures or hospitalization compared with conventional ascites treatments.

Low incidence of spontaneous bacterial peritonitis in asymptomatic cirrhotic outpatients

AIM: To compare the incidence of spontaneous bacterial peritonitis in cirrhotic outpatients and inpatients undergoing therapeutic paracentesis METHODS: From January 1 to May 31, 2004, 1041 patients from 70 different hospitals underwent 2123 therapeutic abdominal paracentesis (AP) performed as a outpatient procedure in 355 and as inpatient procedure in 686 cases respectively. The following parameters were compared prospectively between outpatients and inpatients: spontaneous bacterial peritonitis (SBP) prevalence, age, gender, cause of cirrhosis, symptoms, score and grade according to Child-Pugh classification, cirrhosis complications, antibiotics treatment, serum creatinine, platelet count and ascitic protein concentration. RESULTS: SBP was observed in 91 patients. In the whole population the SBP prevalence was 8.7% (95%CI: 7.2-10.6) it was 11.7% (95%CI: 9.5-14.3) in inpatients and 3.1% (95%CI: 1.7-5.5) in outpatients (P < 0.00001). SBP prevalence was 8.3% (95%CI: 4.3-15.6) in symptomatic outpatients vs 1.2% (95%CI: 0.4-3.4) in asymptomatic outpatients (P < 0.002). Patients undergoing outpatient AP were significantly different from those undergoing inpatient AP; they were older (61.1 ± 11.1 years vs 59.4 ± 11.7 years; P = 0.028), cause of cirrhosis was less often alcohol (83 .7 vs 88.2%; P < 0.001), Child-Pugh score was lower (8.9 vs 10.1; P < 0.001) and more often B than C (63.7% vs 38%; P < 0.001). In addition, in outpatients the platelet count was higher (161 ± 93 Giga/L vs 143 ± 89 Giga/L; P = 0.003), serum total bilirubin concentration was lower (38.2 ± 60.7 μmol/L vs 96.3 ± 143.3 μmol/L; P < 0.0001), and ascitic protein concentration higher (17.9 ± 10.7 g/L vs 14.5 ± 10.9 g/L; P < 0.001) than in inpatients. CONCLUSION: In asymptomatic cirrhotic outpatients, the incidence of spontaneous bacterial peritonitis is low thus exploratory paracentesis could be avoided in these patients without significant risk.

Hemoperitoneum in cirrhotic patients without abdominal trauma or tumor

BACKGROUND:Hemoperitoneum is associated with several emergency conditions and is especially evident when it occurs in patients with liver cirrhosis.This study aimed to assess the clinical characteristics of cirrhotic patients who did not have abdominal trauma or tumor but who developed hemoperitoneum.METHODS:We reviewed the clinical records of 1276 consecutive cirrhotic patients with hemoperitoneum at our center between January 2007 and December 2009.Hemoperitoneum was confirmed by abdominal paracentesis.RESULTS:Of the 1276 cirrhotic patients,19 were found to have hemoperitoneum,but only 6 did not have abdominal trauma or tumor.The occurrence of spontaneous hemoperitoneum in the cirrhotic patients was therefore 0.5%.Hemoperitoneum can occur spontaneously in severely decompensated cirrhotic patients with intra-abdominal collateral vessels and high scores on the model for end-stage liver disease and Child-Pugh-Turcotte test.Most patients presented with abdominal distension,abdominal pain,increased abdominal girth and hemodynamic instability with a significant drop in the hemoglobin level.Three patients died of hemorrhagic shock within 24 hours,and the other 3 died of hepatic encephalopathy or spontaneous bacterial peritonitis after 5 to 10 days because of further decompensation of the liver.CONCLUSIONS:Hemoperitoneum can occur in cirrhotic patients who do not have abdominal trauma or tumor.It mainly occurs in severely decompensated end-stage cirrhotic patients.Cirrhotic patients with hemoperitoneum have a poor prognosis.