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Fertility and Sterility Nov 2016To report the medical and surgical management of a rare case of recurrent moss-like endometriosis and associated hemorrhagic ascites. (Review)
Review
OBJECTIVE
To report the medical and surgical management of a rare case of recurrent moss-like endometriosis and associated hemorrhagic ascites.
DESIGN
Video description of the case, demonstration of the surgical technique, discussion of the histology, and review of endometriosis-associated ascites.
SETTING
Tertiary referral center.
PATIENT(S)
A 26-year-old nulliparous woman of Nigerian heritage with recurrent hemorrhagic ascites due to endometriosis. Three years previously she underwent an exploratory laparotomy for similar symptoms, and 7 L of hemorrhagic ascites were evacuated from her abdomen. Friable lesions covering the peritoneum of the uterus, bladder, and pouch of Douglas were biopsied and consistent with endometriosis. After her initial surgery, the patient was hormonally suppressed with goserelin for 3 months and oral medroxyprogesterone for 1 year. She then stopped the medications to attempt pregnancy but was unsuccessful. She used clomiphene for 3 months, and the ascites reaccumulated. The patient was started on depot leuprolide and oral norethindrone, but the ascites persisted.
INTERVENTION(S)
The patient underwent small-diameter laparoscopy using a multipuncture technique, evacuation of 7.8 L of hemorrhagic ascites, enterolysis, appendectomy, chromopertubation, and treatment of the endometriosis.
MAIN OUTCOME MEASURE(S)
Diffuse olive-green "mossy" endometriosis lesions blanketed the pelvic and abdominal peritoneum. The endometriosis was surgically resected with a combination of peritoneal stripping, excision with carbon dioxide laser, and ablation with neutral argon plasma. Examination of the ascites showed scattered hemosiderin-laden macrophages in a background of red blood cells. Histology of the olive-green mossy lesions revealed dense sheets of hemosiderin-laden macrophages and rare foci of endometriosis. Surgical reports in deidentified patients are exempted from Institutional Review Board approval. The patient gave consent to use photography and images for the video article.
RESULT(S)
No postoperative hormone suppression was given to the patient because she desired pregnancy. At 6 months after her second surgery, the patient had not achieved pregnancy, but the ascites had not reaccumulated. She was referred for further infertility care.
CONCLUSION(S)
This rare form of mossy endometriosis often mimics ovarian cancer, pelvic tuberculosis, and other gynecologic conditions, but when identified, the endometriosis can be treated and symptoms can subside with drainage of the ascites, thorough ablation of the diffuse, superficial lesions, and restoration of anatomy.
Topics: Adult; Ascites; Diagnosis, Differential; Drainage; Endometriosis; Female; Humans; Laparoscopy; Predictive Value of Tests; Recurrence; Treatment Outcome
PubMed: 27542707
DOI: 10.1016/j.fertnstert.2016.07.1119 -
Journal of Cardiothoracic Surgery Oct 2023Mild or moderate liver cirrhosis increases the risk of complications after cardiac surgery. Ascites is the most common complication associated with liver cirrhosis....
INTRODUCTION
Mild or moderate liver cirrhosis increases the risk of complications after cardiac surgery. Ascites is the most common complication associated with liver cirrhosis. However, the prognostic value of ascites on postoperative morbidity and mortality after cardiac surgery remains uninvestigated.
METHODS
A retrospective study included 69 patients with preoperatively diagnosed liver cirrhosis who underwent cardiac surgery between January 2009 and January 2018 at the Department of Cardiothoracic Surgery, University Hospital of Cologne, Germany. The patients were divided into ascites and non-ascites groups based on preoperatively diagnosed ascites. Thirty-day mortality, postoperative complications, length of stay, and blood transfusions were analyzed postoperatively.
RESULTS
Out of the total of 69 patients, 14 (21%) had preoperatively diagnosed ascites. Ascites group had more postoperative complications such as blood transfusions (packed red blood cells: 78.6% vs. 40.0%, p = 0.010; fresh frozen plasma: 57.1% vs. 29.1%, p = 0.049), acute kidney injury (78.6% vs. 45.5%, p = 0.027), longer ICU stay (8 vs. 3 days, p = 0.044) with prolonged mechanical ventilation (57.1% vs. 23.6%, p = 0.015) and tracheotomy (28.6% vs. 3.6%, p = 0.003). The 30-day mortality rate was significantly higher in the ascites group than in the non-ascites group (35.7% vs. 5.5%, p = 0.002).
CONCLUSION
Ascites should be implemented in preoperative risk score assessments in cirrhotic patients undergoing cardiac surgery. Preoperative treatment of ascites could reduce the negative impact of ascites on postoperative complications after cardiac surgery. However, this needs to be thoroughly investigated in prospective randomized clinical trials.
Topics: Humans; Ascites; Cardiac Surgical Procedures; Liver Cirrhosis; Postoperative Complications; Prognosis; Retrospective Studies
PubMed: 37898812
DOI: 10.1186/s13019-023-02393-0 -
Hepatology Communications Dec 2022The aim of this study was to evaluate potential criteria for defining hyperdynamic circulation in patients with cirrhosis according to the severity of ascites and its...
The aim of this study was to evaluate potential criteria for defining hyperdynamic circulation in patients with cirrhosis according to the severity of ascites and its association with the activation of vasoactive systems and markers of systemic inflammation. Cross-sectional study of patients with cirrhosis and right heart catheter measurement from two different academic centers. We evaluated systemic vascular resistance (SVR)/cardiac output (CO) according to ascites severity. The first substudy evaluated the possible definition, the second validated the findings, and the third evaluated the possible mechanisms. Comparisons were performed by means of t test, Mann-Whitney U test, and analysis of variance. Finally, linear regression curves were adjusted to evaluate the relationship between CO and SVR according to the severity of ascites and compensated or decompensated stage of cirrhosis. The study included 721 patients (substudy 1, n = 437; substudy 2, n = 197; substudy 3, n = 87). Hyperdynamic circulation (HC), defined by absolute cutoffs, had no association with the presence or severity of ascites in the first two cohorts. No association was observed between HC with renin, aldosterone, or markers of bacterial translocation. Comparison of linear regression curves showed a shift of the CO-SVR relationship to the left in patients with refractory ascites (p < 0.001) compared to patients without ascites as well as to patients with decompensated cirrhosis (p = 0.002). Conclusion: HC according to the traditional concept of high CO and low SVR is not always present in ascites. Evaluation of the CO-SVR relationship according to the severity of ascites shows a shift to the left, suggesting that the presence of HC would be defined by this shift, independent of absolute values.
Topics: Humans; Ascites; Cross-Sectional Studies; Hemodynamics; Liver Cirrhosis; Vascular Resistance; Biomarkers
PubMed: 36221228
DOI: 10.1002/hep4.2102 -
World Journal of Gastroenterology Nov 2015Hyponatremia is a frequent complication of advanced cirrhosis with ascites associated with increased morbidity and mortality. It is caused by an impairment in the renal... (Review)
Review
Hyponatremia is a frequent complication of advanced cirrhosis with ascites associated with increased morbidity and mortality. It is caused by an impairment in the renal capacity to eliminate solute-free water and is considered to be related to persistent secretion of vasopressin despite low serum osmolality. This nonosmotic release of vasopressin is mediated by the autonomic nervous system, which senses the underfilling of arterial vascular component. This reduction of effective arterial blood volume is closely related to the development of ascites. Although the short-time effects of vasopressin V2 receptor antagonists (vaptans) on hyponatremia and ascites have been repeatedly reported, their effects on the long-term management of cirrhotic ascites have not been established yet. Considering that their effects on water diuresis and their safety are limited by severe underfilling state of patients, cautious approaches with adequate monitoring are needed to advanced cirrhosis. Proper indication, adequate doses and new possibility of combination therapy should be explored in the future controlled study. As hyponatremia is frequent obstacle to ascites management, judicious combination with low-dose diuretics may decrease the incidence of refractory ascites. Although vaptans show much promise in the treatment of advanced cirrhosis, the problem of high cost should be solved for the future.
Topics: Animals; Antidiuretic Hormone Receptor Antagonists; Aquaporin 2; Ascites; Biomarkers; Humans; Liver Cirrhosis; Neurophysins; Patient Selection; Protein Precursors; Receptors, Vasopressin; Risk Factors; Treatment Outcome; Vasopressins; Water-Electrolyte Balance
PubMed: 26556988
DOI: 10.3748/wjg.v21.i41.11584 -
Medical Science Monitor : International... Nov 2021BACKGROUND Complications are the most important outcome determinants for acute pancreatitis (AP). We designed this single-center retrospective study to evaluate the...
BACKGROUND Complications are the most important outcome determinants for acute pancreatitis (AP). We designed this single-center retrospective study to evaluate the clinical findings (complications, disease severity, and outcomes) of 218 patients with AP and to identify variables associated with ascites. MATERIAL AND METHODS We extracted clinical data from consecutive patients with AP and divided them into 2 groups based on presence or absence of ascites. We compared disease severity, complications, and outcomes between groups. RESULTS We analyzed data from 218 patients with AP (43 with ascites and 175 without it). The patients with ascites had a more severe disease (higher incidence of pancreatic inflammation [90.70% vs 68.57%; P=0.003], higher modified computed tomography severity index score [2.00 (0.00-2.00) vs 4.00 (4.00-6.00); P<0.001], higher incidence of moderate/severe AP [53.49% vs 13.14%; P<0.001]) and poorer outcomes (higher incidence of ventilation [6.98% vs 0.57%; P=0.025] and vasopressor use [4.65% vs 0%; P=0.038], and longer hospital stays [10.00 (7.00-13.00) vs 8.00 (5.00-10.00); P=0.007]) than those without ascites. Moreover, patients with ascites also displayed a higher risk for pancreatic fluid collection (odds ratio [OR]=9.206; 95% confidence interval [CI], 2.613-32.447; P<0.001), renal failure (OR=5.732; 95% CI, 1.025-32.041; P=0.024), respiratory failure (OR=6.242; 95% CI, 1.034-37.654; P=0.029), and pleural effusion (OR=5.186; 95% CI, 1.381-19.483; P<0.001) than those without ascites. CONCLUSIONS The findings from the experience of a single center of patients with AP showed that pancreatic fluid collections, renal failure, respiratory failure, and pleural effusion were associated with the development of ascites.
Topics: Ascites; China; Comorbidity; Female; Humans; Male; Middle Aged; Pancreatitis; Retrospective Studies; Severity of Illness Index
PubMed: 34737257
DOI: 10.12659/MSM.933196 -
Antimicrobial Agents and Chemotherapy Jun 2021The pharmacokinetics and antifungal activity of the echinocandins anidulafungin (AFG), micafungin (MFG), and caspofungin (CAS) were assessed in ascites fluid and plasma...
The pharmacokinetics and antifungal activity of the echinocandins anidulafungin (AFG), micafungin (MFG), and caspofungin (CAS) were assessed in ascites fluid and plasma of critically ill adults treated for suspected or proven invasive candidiasis. Ascites fluid was obtained from ascites drains or during paracentesis. The antifungal activity of the echinocandins in ascites fluid was assessed by incubation of Candida albicans and Candida glabrata at concentrations of 0.03 to 16.00 μg/ml. In addition, ascites fluid samples obtained from our study patients were inoculated with the same isolates and evaluated for fungal growth. These patient samples had to be spiked with echinocandins to restore the original concentrations because echinocandins had been lost during sterile filtration. In ascites fluid specimens of 29 patients, echinocandin concentrations were below the simultaneous plasma levels. Serial sampling in 20 patients revealed a slower rise and decline of echinocandin concentrations in ascites fluid than in plasma. Proliferation of C. albicans in ascites fluid was slower than in culture medium and growth of C. glabrata was lacking, even in the absence of antifungals. In CAS-spiked ascites fluid samples, fungal CFU counts moderately declined, whereas spiking with AFG or MFG had no relevant effect. In ascites fluid of our study patients, echinocandin concentrations achieved by therapeutic doses did not result in a consistent eradication of C. albicans or C. glabrata. Thus, therapeutic doses of AFG, MFG, or CAS may result in ascites fluid concentrations preventing relevant proliferation of C. albicans and C. glabrata, but do not warrant reliable eradication.
Topics: Adult; Antifungal Agents; Ascites; Critical Illness; Echinocandins; Humans; Lipopeptides; Microbial Sensitivity Tests
PubMed: 33972242
DOI: 10.1128/AAC.02565-20 -
Clinical Drug Investigation Jun 2022Portal hypertension is a major complication of cirrhosis characterized by a pathological hepatic venous pressure gradient (HVPG) ≥ 5 mmHg. The structural changes... (Review)
Review
Portal hypertension is a major complication of cirrhosis characterized by a pathological hepatic venous pressure gradient (HVPG) ≥ 5 mmHg. The structural changes observed in the liver leading to intrahepatic vascular resistance and, consequently, portal hypertension appear in the early stages of cirrhosis. Clinically significant portal hypertension (HVPG ≥ 10 mmHg) is associated with several clinical consequences, such as ascites, hyponatremia, gastroesophageal variceal bleeding, hepatorenal syndrome, cardiopulmonary complications, adrenal insufficiency, and hepatic encephalopathy. The diagnosis and management of these complications depend on their early identification and treatment. Regarding ascites, diuretics are a useful treatment, although plasma sodium levels must be properly controlled to avoid hyponatremia. The management of hypovolemic hyponatremia usually consists in stopping diuretics and the administration of volume. On the contrary, hypervolemic hyponatremia is managed with fluid and sodium restriction. Transjugular intrahepatic portosystemic shunt (TIPS) should be considered in patients with refractory ascites. Primary prophylaxis of variceal bleeding should be based mainly on non-selective beta-blockers. Management of acute gastroesophageal variceal bleeding includes vasoactive drugs and endoscopic band ligation and, in patients at high risk of failure and rebleeding, preemptive use of TIPS. Secondary prophylaxis with a combination of non-selective beta-blockers and endoscopic band ligation is the treatment of choice. This article focuses on the management of ascites, hyponatremia, and gastroesophageal variceal bleeding.
Topics: Adrenergic beta-Antagonists; Ascites; Diuretics; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Hyponatremia; Liver Cirrhosis; Portasystemic Shunt, Transjugular Intrahepatic; Sodium
PubMed: 35476218
DOI: 10.1007/s40261-022-01147-5 -
Liver International : Official Journal... Nov 2022Obeticholic acid (OCA) has recently been restricted in patients with primary biliary cholangitis (PBC) with "advanced cirrhosis" because of its narrow therapeutic index....
BACKGROUND & AIMS
Obeticholic acid (OCA) has recently been restricted in patients with primary biliary cholangitis (PBC) with "advanced cirrhosis" because of its narrow therapeutic index. We aimed to better define the predicting factors of hepatic serious adverse events (SAEs) and non-response in cirrhotic patients undergoing OCA therapy.
METHODS
Safety and efficacy of treatment were evaluated in a cohort of consecutive PBC cirrhotic patients started with OCA. OCA response was evaluated according to the Poise criteria. Risk factors for hepatic SAEs and non-response were reported as risk ratios (RR) with 95% confidence intervals (CIs).
RESULTS
One hundred PBC cirrhotics were included, 97 Child-Pugh class A and 3 class B. Thirty-one had oesophageal varices and 5 had a history of ascites. Thirty-three per cent and 32% of patients achieved a biochemical response at 6 and 12 months respectively. Male sex (adjusted-RR 1.75, 95%CI 1.42-2.12), INR (1.37, 1.00-1.87), Child-Pugh score (1.79, 1.28-2.50), MELD (1.17, 1.04-1.30) and bilirubin (1.83, 1.11-3.01) were independently associated with non-response to OCA. Twenty-two patients discontinued OCA within 12 months: 10 for pruritus, 9 for hepatic SAEs (5 for jaundice and/or ascitic decompensation; 4 for upper digestive bleeding). INR (adjusted-RR 1.91, 95%CI 1.10-3.36), lower albumin levels (0.18, 0.06-0.51), Child-Pugh score (2.43, 1.50-4.04), history of ascites (3.5, 1.85-6.5) and bilirubin (1.30, 1.05-1.56), were associated with hepatic SAEs. A total bilirubin≥1.4 mg/dl at baseline was the most accurate biochemical predictor of hepatic SAEs under OCA.
CONCLUSIONS
An accurate baseline assessment is crucial to select cirrhotic patients who can benefit from OCA. Although OCA is effective in one third of cirrhotics, bilirubin level ≥1.4 mg/dl should discourage from its use.
Topics: Albumins; Ascites; Bilirubin; Chenodeoxycholic Acid; Humans; Liver Cirrhosis; Liver Cirrhosis, Biliary; Male
PubMed: 35932095
DOI: 10.1111/liv.15386 -
The Turkish Journal of Pediatrics 2020Ascites is defined as abnormal fluid retention in the peritoneal cavity and it can be encountered at any age including fetal life. Ascites mostly results from cirrhosis,...
BACKGROUND
Ascites is defined as abnormal fluid retention in the peritoneal cavity and it can be encountered at any age including fetal life. Ascites mostly results from cirrhosis, chronic renal disease and heart failure in childhood. However, there are various reasons for cirrhotic and non-cirrhotic ascites in the pediatric age. Cerebrospinal fluid ascites is one of the rarest.
CASE
A 3.5- year- old Sudanese boy who underwent right-sided ventriculoperitoneal shunt surgery for hydrocephalus 10 months ago was admitted to the Neurosurgery Intensive Care Unit for intracranial tumor surgery. He had neurologic deterioration and ascites accumulation for the last 4 months. He was consulted with the pediatric gastroenterologist to exclude the reasons causing ascites after admission. No chronic liver, renal or heart disease was shown. The gross appearance of ascitic fluid was so clear that it resembled the cerebrospinal fluid and laboratory analysis results were compatible with transudate. The magnetic resonance imaging identified a mass in the left lateral ventricle. From the pediatrician`s perspective, overproduction of cerebrospinal fluid from a tumor was assumed and shunt exclusion was proposed to alleviate ascites. After the externalization of the stunt and external ventricular device implementation, no further ascites occurred. The patient had a successful tumor excision and discharged after gaining oral feeding ability and sufficient weight gain.
CONCLUSION
In case of intractable ascites occurrence after a ventriculoperitoneal shunt placement, a pediatrician should consider etiologies resulting in imbalance of absorption and secretion function of cerebrospinal fluid.
Topics: Ascites; Brain Neoplasms; Child; Child, Preschool; Humans; Hydrocephalus; Magnetic Resonance Imaging; Male; Ventriculoperitoneal Shunt
PubMed: 33108092
DOI: 10.24953/turkjped.2020.05.021 -
Medicine Aug 2022Heart failure leading to cardiac ascites is an extremely rare and underrecognized entity in clinical practice. Recognizing cardiac ascites can be difficult, especially... (Review)
Review
Heart failure leading to cardiac ascites is an extremely rare and underrecognized entity in clinical practice. Recognizing cardiac ascites can be difficult, especially since patients presenting with ascites may have more than 1 etiology. Various biomarkers are available to aid in the diagnosis of cardiac ascites, though with differing sensitivities and specificities. Such biomarkers include serum albumin, ascitic albumin and protein, as well as serum N-terminal pro-brain natriuretic peptide (NT-proBNP). While serum NT-proBNP is a powerful biomarker in distinguishing the etiology of ascites and monitoring treatment progression, its cost can be prohibitive in low-resource settings. Clinicians practicing under these circumstances may opt to rely on other parameters to manage their patients. We go on further to report a series of 3 patients with cardiac ascites to illustrate how these biomarkers may be employed in the management of this patient population. Clinicians should always keep in mind the differential diagnosis of cardiac failure as a cause of ascites. The resolution of cardiac ascites may serve as a surrogate clinical marker for response to antifailure therapy in lieu of NT-proBNP at resource-scarce centers.
Topics: Ascites; Biomarkers; Diagnosis, Differential; Heart; Heart Failure; Humans; Natriuretic Peptide, Brain; Peptide Fragments
PubMed: 35945724
DOI: 10.1097/MD.0000000000029951