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World Journal of Gastroenterology Jul 2019This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed... (Review)
Review
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.
Topics: Adrenergic alpha-1 Receptor Agonists; Ascites; Clinical Trials as Topic; Diuretics; End Stage Liver Disease; Humans; Hypertension, Portal; Liver Cirrhosis; Liver Transplantation; Paracentesis; Portasystemic Shunt, Transjugular Intrahepatic; Prognosis; Quality of Life; Risk Assessment; Severity of Illness Index; Survival Rate; Treatment Outcome
PubMed: 31391769
DOI: 10.3748/wjg.v25.i28.3738 -
ESMO Open Apr 2023Malignant ascites is common in metastatic pancreatic cancer (mPC) and its management still remains a clinical challenge. Early identification of patients at risk for...
BACKGROUND
Malignant ascites is common in metastatic pancreatic cancer (mPC) and its management still remains a clinical challenge. Early identification of patients at risk for ascites development may support and guide treatment decisions.
MATERIALS AND METHODS
Data of patients treated for mPC at the Medical University of Vienna between 2010 and 2019 were collected by retrospective chart review. Ascites was defined as clinically relevant accumulation of intraperitoneal fluid diagnosed by ultrasound or computer tomography scan of the abdomen. We investigated the association between general risk factors, metastatic sites, liver function, systemic inflammation as well as portal vein obstruction (PVO) and ascites development.
RESULTS
Among 581 patients with mPC included in this study, 122 (21.0%) developed ascites after a median of 8.7 months after diagnosis of metastatic disease. The occurrence of ascites led to an 8.9-fold increased risk of death [confidence interval (CI) 7.2-11, P < 0.001] with a median overall survival of 1 month thereafter. Clinical risk factors for ascites were male sex [hazard ratio (HR) 1.71, CI 1.00-2.90, P = 0.048], peritoneal carcinomatosis (HR 6.79, CI 4.09-11.3, P < 0.001), liver metastases (HR 2.16, CI 1.19-3.91, P = 0.011), an albumin-bilirubin (ALBI) score grade 3 (HR 6.79, CI 2.11-21.8, P = 0.001), PVO (HR 2.28, CI 1.15-4.52, P = 0.019), and an elevated C-reactive protein (CRP) (HR 4.19, CI 1.58-11.1, P = 0.004).
CONCLUSIONS
Survival after diagnosis of ascites is very limited in mPC patients. Male sex, liver and peritoneal metastases, impaired liver function, PVO, as well as systemic inflammation were identified as independent risk factors for ascites development in this uniquely large real-life patient cohort.
Topics: Humans; Male; Female; Retrospective Studies; Ascites; Risk Factors; Inflammation; Pancreatic Neoplasms
PubMed: 36989885
DOI: 10.1016/j.esmoop.2023.101200 -
World Journal of Surgical Oncology Dec 2020To fully assess the quality of the guidelines for the management of malignant pleural effusions (MPE) and ascites and reveal the heterogeneity of recommendations and... (Review)
Review
OBJECTIVES
To fully assess the quality of the guidelines for the management of malignant pleural effusions (MPE) and ascites and reveal the heterogeneity of recommendations and possible reasons among guidelines.
METHODS
A systematic search was performed in the database to obtain guidelines for the management of MPE and ascites. The AGREE IIGtool was used to assess the quality of these guidelines. The Measurement Scale of Rate of Agreement (MSRA) was introduced to assess the scientific agreement of formulated recommendations for the management of MPE and ascites among guidelines, and evidence supporting these recommendations was extracted and analyzed.
RESULTS
Nine guidelines were identified. Only 4 guidelines scored more than 60% and are worth recommending. Recommendations were also heterogeneous among guidelines for the management of MPE, and the main reasons were the different emphases of the recommendations for the treatment of MPE, the contradictions in recommendations, and the unreasonably cited evidence for MPE.
CONCLUSIONS
The quality of the management guidelines for patients with MPE and malignant ascites was highly variable. Specific improvement of the factors leading to the heterogeneity of recommendations will be a reasonable and effective way for developers to upgrade the recommendations in the guidelines for MPE.
Topics: Ascites; Humans; Pleural Effusion, Malignant; Prognosis
PubMed: 33308239
DOI: 10.1186/s12957-020-02097-y -
Journal of Applied Clinical Medical... Jul 2022The detection of abdominal free fluid or hemoperitoneum can provide critical information for clinical diagnosis and treatment, particularly in emergencies. This study...
PURPOSE
The detection of abdominal free fluid or hemoperitoneum can provide critical information for clinical diagnosis and treatment, particularly in emergencies. This study investigates the use of deep learning (DL) for identifying peritoneal free fluid in ultrasonography (US) images of the abdominal cavity, which can help inexperienced physicians or non-professional people in diagnosis. It focuses specifically on first-response scenarios involving focused assessment with sonography for trauma (FAST) technique.
METHODS
A total of 2985 US images were collected from ascites patients treated from 1 January 2016 to 31 December 2017 at the Shenzhen Second People's Hospital. The data were categorized as Ascites-1, Ascites-2, or Ascites-3, based on the surrounding anatomy. A uniform standard for regions of interest (ROIs) and the lack of obstruction from acoustic shadow was used to classify positive samples. These images were then divided into training (90%) and test (10%) datasets to evaluate the performance of a U-net model, utilizing an encoder-decoder architecture and contracting and expansive paths, developed as part of the study.
RESULTS
Test results produced sensitivity and specificity values of 94.38% and 68.13%, respectively, in the diagnosis of Ascites-1 US images, with an average Dice coefficient of 0.65 (standard deviation [SD] = 0.21). Similarly, the sensitivity and specificity for Ascites-2 were 97.12% and 86.33%, respectively, with an average Dice coefficient of 0.79 (SD = 0.14). The accuracy and area under the curve (AUC) were 81.25% and 0.76 for Ascites-1 and 91.73% and 0.91 for Ascites-2.
CONCLUSION
The results produced by the U-net demonstrate the viability of DL for automated ascites diagnosis. This suggests the proposed technique could be highly valuable for improving FAST-based preliminary diagnoses, particularly in emergency scenarios.
Topics: Abdomen; Ascites; Deep Learning; Humans; Sensitivity and Specificity; Ultrasonography
PubMed: 35723875
DOI: 10.1002/acm2.13695 -
Journal of the American Heart... Apr 2023Background Congestive heart failure is a leading cause of morbidity and mortality worldwide. One of the signs of congestive heart failure is fluid overload including...
Background Congestive heart failure is a leading cause of morbidity and mortality worldwide. One of the signs of congestive heart failure is fluid overload including pulmonary edema, peripheral edema, and ascites. The cause of fluid overload remains incompletely understood, and management of these patients continues to be a challenge. The role of lymphatic circulation abnormalities in the cause and pathophysiology of fluid overload also remains unclear. Here we report on a study in a large animal model of right heart failure caused by severe tricuspid regurgitation comparing cardiovascular and lymphatic findings in a group of animals that did not develop ascites with a group of animals that developed ascites. Methods and Results Thirteen Yorkshire pigs were included in this study divided into 2 groups. Group 1 included 6 animals that did not develop ascites, and Group 2 included 7 animals that had developed ascites. The groups were compared on hemodynamic parameters as well as comparison of the animal's lymphatic anatomy and function. There was no difference between the groups in degree of tricuspid regurgitation and central venous pressure, with inferior vena cava pressure measuring 11.6±1.6 versus 13.2±3.7 (=0.534) and superior vena cava pressure measuring 12.0±2.3 versus 13.7±3.2 (=0.366). There was also no difference between the groups in all measured hemodynamic parameters, including right ventricular pressure, pulmonary artery pressure, and left ventricular function. The weighted liver size in the ascites group was significantly larger than in the nonascites group (30.3±12.4 versus 63.3±14.0 mL/kg, respectively; =0.001). The 2 groups also differed in the number of animals with regurgitant thoracic duct flow (Group 1: 1/6,17% versus Group 2: 6/7, 86%; =0.029) and the minimal thoracic duct diameter (Group 1: 2.3±0.3 versus Group 2: 4.2±2.2; =0.035). Conclusions In animals with right heart failure caused by severe tricuspid regurgitation, fluid overload did not correlate with hemodynamic parameters but rather with changes in the lymphatic system, including regurgitant lymphatic flow, minimal thoracic duct diameter, and liver size. This study is consistent with lymphatic dysfunction and not cardiovascular function playing a significant role in the cause of fluid overload. Further studies are needed to confirm these findings.
Topics: Animals; Swine; Ascites; Tricuspid Valve Insufficiency; Vena Cava, Superior; Heart Failure; Heart
PubMed: 36974748
DOI: 10.1161/JAHA.122.026984 -
Seminars in Cancer Biology Nov 2022The ascites ecosystem in ovarian cancer is inhabited by complex cell types and is bathed in an environment rich in cytokines, chemokines, and growth factors that... (Review)
Review
The ascites ecosystem in ovarian cancer is inhabited by complex cell types and is bathed in an environment rich in cytokines, chemokines, and growth factors that directly and indirectly impact metabolism of cancer cells and tumor associated cells. This milieu of malignant ascites, provides a 'rich' environment for the disease to thrive, contributing to every aspect of advanced ovarian cancer, a devastating gynecological cancer with a significant gap in targeted therapeutics. In this perspective we focus our discussions on the 'acellular' constituents of this liquid malignant tumor microenvironment, and how they influence metabolic pathways. Growth factors, chemokines and cytokines are known modulators of metabolism and have been shown to impact nutrient uptake and metabolic flexibility of tumors, yet few studies have explored how their enrichment in malignant ascites of ovarian cancer patients contributes to the metabolic requirements of ascites-resident cells. We focus here on TGF-βs, VEGF and ILs, which are frequently elevated in ovarian cancer ascites and have all been described to have direct or indirect effects on metabolism, often through gene regulation of metabolic enzymes. We summarize what is known, describe gaps in knowledge, and provide examples from other tumor types to infer potential unexplored roles and mechanisms for ovarian cancer. The distribution and variation in acellular ascites components between patients poses both a challenge and opportunity to further understand how the ascites may contribute to disease heterogeneity. The review also highlights opportunities for studies on ascites-derived factors in regulating the ascites metabolic environment that could act as a unique signature in aiding clinical decisions in the future.
Topics: Female; Humans; Ascites; Ecosystem; Carcinoma, Ovarian Epithelial; Ovarian Neoplasms; Intercellular Signaling Peptides and Proteins; Cytokines; Tumor Microenvironment
PubMed: 35259492
DOI: 10.1016/j.semcancer.2022.03.004 -
American Journal of Kidney Diseases :... Nov 2021The past few decades have seen steady increase in the prevalence of kidney failure needing kidney replacement therapy. Concomitantly, there has been progressive growth... (Review)
Review
The past few decades have seen steady increase in the prevalence of kidney failure needing kidney replacement therapy. Concomitantly, there has been progressive growth of heart failure and chronic liver disease, and many such patients develop ascites. Therefore, it is not uncommon to encounter patients with kidney failure who concurrently have ascites. The presence of ascites adds many challenges in the management of kidney failure. Poor hemodynamics make volume management difficult. The presence of coagulopathy, malnutrition, and encephalopathy compounds the complexity of the management. Such patients do not tolerate hemodialysis well. However, several concerns have limited the use of peritoneal dialysis (PD), so hemodialysis remains the predominant dialysis modality in these patients. However, observational studies have illustrated that PD provides hemodynamic stability and facilitates better volume management compared with hemodialysis. Moreover, PD obviates the need for therapeutic paracentesis by facilitating continuous drainage of ascites. PD potentially reduces hemorrhagic complications by avoiding routine anticoagulation use. Moreover, small studies have suggested that outcomes such as peritonitis and mechanical complications are comparable to those in PD patients without ascites. PD does not affect transplant candidacy, and these patients can successfully receive combined liver and kidney transplants. Hence, PD should be considered a viable dialysis option in kidney failure patients with ascites.
Topics: Ascites; Humans; Kidney Failure, Chronic; Liver Cirrhosis; Peritoneal Dialysis; Peritonitis
PubMed: 34144102
DOI: 10.1053/j.ajkd.2021.04.010 -
Saudi Journal of Gastroenterology :... 2022The impact of propranolol on patients with cirrhosis and refractory ascites is controversial. We conducted a nationwide longitudinal cohort study to compare the survival...
BACKGROUND
The impact of propranolol on patients with cirrhosis and refractory ascites is controversial. We conducted a nationwide longitudinal cohort study to compare the survival between patients with cirrhosis and refractory ascites, with and without using propranolol.
METHODS
Data of patients with cirrhosis and refractory ascites using propranolol, and controls matched by age and gender, were extracted from The National Health Insurance Research Database of Taiwan. The baseline demographic characteristics were compared between groups. Cox regression analysis was used to examine the predictors of mortality.
RESULTS
In this study, 1788 patients were enrolled in each group; 1304 patients (72.9%) in the propranolol group and 1445 patients (80.8%) in the control group died (P < 0.001). The mean survival was 34.3 ± 31.2 months in the propranolol group and 20.8 ± 26.6 months in the control group (P < 0.001). Propranolol (hazard ratio [HR]: 0.60, 95% confidence interval [CI]: 0.55-0.64, P < 0.001), statins (HR: 0.43, 95% CI: 0.34-0.56, P < 0.001), age (HR: 1.02, 95% CI: 1.01-1.02, P < 0.001), and diabetes mellitus (HR: 1.14, 95% CI: 1.05-1.24, P = 0.002) were the independent predictors for mortality.
CONCLUSIONS
Use of propanolol was associated with reduced mortality, compared with controls, in this nationwide cohort of patients with cirrhosis and refractory ascites.
Topics: Ascites; Humans; Liver Cirrhosis; Longitudinal Studies; Proportional Hazards Models; Propranolol
PubMed: 35295067
DOI: 10.4103/sjg.sjg_586_21 -
Chirurgia (Bucharest, Romania : 1990) 2020The risk of developing an abdominal wall hernia is high in the cirrhotic patient, due to the association of ascites, hypoalbuminemia and amyotrophy in connection with... (Review)
Review
The risk of developing an abdominal wall hernia is high in the cirrhotic patient, due to the association of ascites, hypoalbuminemia and amyotrophy in connection with undernutrition frequently associated with cirrhosis. Thus, almost 20% of cirrhotic patients develop an umbilical hernia. Parietal surgery is more at risk in cirrhotic patients and its indications must be discussed on a case-by-case basis. The objective of this work was to review the entire literature on wall surgery in order to best define the surgical indications and the specifics of their management. The bibliographic research was done on Pubmed over the period from January 1995 to December 2019, using French and English as publication languages. The keywords retained were "hernia" [Mesh] and "liver cirrhosis" [Mesh]. In an elective situation, preoperative ascites control is recommended. A parietal prosthesis can be used, even in the case of uninfected ascites, preferably in the retromuscular position. Laparoscopy should be used with caution, due to the bleeding risk. No recommendation can be made on the use of prophylactic intra-abdominal drainage. The literature data do not allow the trans-jugular route portosystemic shunt recommendation, nor the use of a peritoneal-vesical pump to decrease the volume of ascites before parietal surgery in cirrhotic patients.
Topics: Abdominal Wall; Ascites; Hernia, Umbilical; Hernia, Ventral; Herniorrhaphy; Humans; Liver Cirrhosis
PubMed: 32369717
DOI: 10.21614/chirurgia.115.2.140 -
International Journal of Medical... 2021The differential diagnosis of benign ascites and malignant ascites is incredibly challenging for clinicians. This research aimed to develop a user-friendly predictive... (Observational Study)
Observational Study
The differential diagnosis of benign ascites and malignant ascites is incredibly challenging for clinicians. This research aimed to develop a user-friendly predictive model to discriminate malignant ascites from non-malignant ascites through easy-to-obtain clinical parameters. All patients with new-onset ascites fluid were recruited from January 2014 to December 2018. The medical records of 317 patients with ascites for various reasons in Renmin Hospital of Wuhan University were collected and reviewed retrospectively. Thirty-six parameters were included and selected using univariate logistic regression, multivariate logistic regression, and receiver operating characteristic (ROC) curve analyses to establish a mathematical model for differential diagnosis, and its diagnostic performance was validated in the other groups. Age, cholesterol, hypersensitivity C-reactive protein (hs-CRP) in serum, ascitic fluid adenosine deaminase (AF ADA), ascitic fluid lactate dehydrogenase (AF LDH) involvement in a 5-marker model. With a cut-off level of 0.83, the sensitivity, specificity, accuracy, and area under the ROC of the model for identifying malignant ascites in the development dataset were 84.7%, 88.8%, 87.6%, and 0.874 (95% confidence interval [CI], 0.822-0.926), respectively, and 80.9%, 82.6%, 81.5%, and 0.863 (95% CI,0.817-0.913) in the validation dataset, respectively. The diagnostic model has a similar high diagnostic performance in both the development and validation datasets. The mathematical diagnostic model based on the five markers is a user-friendly method to differentiate malignant ascites from benign ascites with high efficiency.
Topics: Adenosine Deaminase; Adult; Aged; Ascites; Ascitic Fluid; C-Reactive Protein; Cholesterol; Diagnosis, Differential; Female; Humans; L-Lactate Dehydrogenase; Male; Middle Aged; Models, Statistical; Paracentesis; Peritoneal Neoplasms; ROC Curve; Retrospective Studies
PubMed: 33850466
DOI: 10.7150/ijms.53743