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Cureus Apr 2024Abdominal paracentesis is a commonly performed bedside procedure. It serves as a therapeutic and diagnostic tool for a variety of conditions. It is regarded as a safe...
Abdominal paracentesis is a commonly performed bedside procedure. It serves as a therapeutic and diagnostic tool for a variety of conditions. It is regarded as a safe procedure with a low risk of complications. Rarely, iatrogenic complications such as peritonitis, haemorrhage, and bowel perforation may occur. Intraperitoneal haemorrhage is rare and usually occurs due to bleeding from the intraabdominal venous collateral vessels or mesenteric varices. However, intraperitoneal haemorrhage secondary to injury to the abdominal wall arteries, such as the inferior epigastric artery or deep circumflex iliac artery (DCIA), is very uncommon. We report on a 64-year-old man with decompensated cardiac failure who underwent paracentesis due to gross ascites. Twenty-four hours post-procedure, he became progressively hypotensive and lethargic. An ecchymosis measuring 3 cm × 2 cm was seen over the puncture site. An urgent CT angiography of the abdomen showed a large left-sided intraperitoneal haematoma with active contrast extravasation from the left DCIA. We performed a successful angioembolisation of the left DCIA. It is important to note that intraperitoneal haemorrhages secondary to DCIA injury may present as occult intraperitoneal haemorrhage. Angioembolisation is a useful tool in the management of uncontrolled intraperitoneal haemorrhage. The recommended puncture site is in the left lower quadrant, 2-4 cm superior and medial to the anterior superior iliac spine (ASIS). This case report serves to emphasise the rare but potentially lethal complication of a commonly performed procedure. A high index of suspicion of intraperitoneal haemorrhage is required for patients with unexplained hypotension post-paracentesis, even if overt abdominal signs are absent. The use of ultrasound guidance will aid in reducing the risk of severe complications and increasing the overall success rate.
PubMed: 38826601
DOI: 10.7759/cureus.59428 -
Respiratory Medicine Case Reports 2024Medical thoracoscopy with chemical pleurodesis is a last resort for managing patients who suffer. from recurrent hepatic hydrothorax. However, despite pleurodesis, the...
Medical thoracoscopy with chemical pleurodesis is a last resort for managing patients who suffer. from recurrent hepatic hydrothorax. However, despite pleurodesis, the rapid fluid build-up can hinder the successful apposition of the pleural surfaces. To improve the chances of success, we investigated the effectiveness of abdominal paracentesis before chemical pleurodesis via medical thoracoscopy to reduce significant fluid shifts from the peritoneal to the pleural cavity. We present a series of three patients with liver cirrhosis complicated by hepatic hydrothorax who underwent medical thoracoscopy with talc pleurodesis. Before the procedure, we optimised medical treatment, and if needed, we performed large-volume paracentesis to prevent rapid reaccumulation of pleural fluid. All study subjects achieved treatment success, defined as relief of breathlessness and absence of pleural effusion at 12 months. Complications related to the treatment included hepatic encephalopathy and acute kidney injury, which were managed conservatively. To manage symptomatic and recurrent hepatic hydrothorax, medical thoracoscopy with talc pleurodesis, preceded by the evacuation of ascites, can be considered as a treatment option. This procedure should be considered early for those who do not respond to medical management and are not suitable candidates for TIPS or liver transplantation.
PubMed: 38817846
DOI: 10.1016/j.rmcr.2024.102039 -
ACG Case Reports Journal May 2024A 59-year-old woman with polycythemia vera-related portal hypertension requiring frequent paracentesis was admitted for asymptomatic recurrent spontaneous bacterial...
A 59-year-old woman with polycythemia vera-related portal hypertension requiring frequent paracentesis was admitted for asymptomatic recurrent spontaneous bacterial peritonitis, which was diagnosed based on elevated polymorphonuclear (PMN) count. She had multiple similar admissions during which she was treated with antibiotics. The patient had chronic baseline leukocytosis due to polycythemia vera. Repeat paracentesis after intravenous antibiotics demonstrated persistent elevation of PMN count without clinical symptoms. A multidisciplinary team concluded that the increased PMN count was secondary to polycythemia. The patient was diagnosed with omental extramedullary hematopoiesis, a rare condition causing elevated PMN count in the absence of bacterial contamination.
PubMed: 38784785
DOI: 10.14309/crj.0000000000001364 -
Clinical and Experimental Hepatology Mar 2024Early paracentesis before antibiotic administration reduces morbidity and mortality in patients with decompensated cirrhosis. We studied the association of variables...
AIM OF THE STUDY
Early paracentesis before antibiotic administration reduces morbidity and mortality in patients with decompensated cirrhosis. We studied the association of variables with antibiotic administration before or after performing paracentesis.
MATERIAL AND METHODS
This was a retrospective study of 137 patients with ascites secondary to cirrhosis admitted to a community hospital in New York City. Predictor variables were demographic, disease-related, admission timing, and serum measurement.
RESULTS
We found a significantly increased relative risk for performing paracentesis after antibiotic administration for those admitted at night (relative risk ratio [RRR] = 3.01, 95% CI: 1.02-8.85, = 0.046). Demographic, disease-related, and serum measurement variables were not significantly associated with performing paracentesis or order of antibiotic administration. Also, increased body mass index was significantly associated with decreased relative risk for paracentesis not done (RRR = 0.84, 95% CI: 0.74-0.96, = 0.01).
CONCLUSIONS
In conclusion, there was increased relative risk for performing paracentesis after antibiotic administration for patients admitted at night. We recommend ongoing resident and hospitalist training to maintain competency in bedside procedures such as paracentesis for patients with cirrhosis. Also, increased staffing or the presence of a resident/hospitalist led interventional team during night shifts may also help optimize the rates of timely paracentesis.
PubMed: 38765905
DOI: 10.5114/ceh.2024.136215 -
Cureus Apr 2024We present the case of a 62-year-old immunocompromised man with ulcerative colitis, primary sclerosing cholangitis, and cirrhosis treated with azathioprine and...
We present the case of a 62-year-old immunocompromised man with ulcerative colitis, primary sclerosing cholangitis, and cirrhosis treated with azathioprine and ustekinumab who quickly developed invasive infection after incidental identification on routine paracentesis. The infection rapidly progressed from bacterial peritonitis to bacteremia and meningitis within three days. Treatment with ampicillin and trimethoprim/sulfamethoxazole was successful. We highlight the increased risk of invasive listeriosis in immunocompromised individuals, including those on biologic therapies, and the importance of considering as a pathogen from sterile sites even in asymptomatic patients.
PubMed: 38738136
DOI: 10.7759/cureus.58116 -
Cureus Apr 2024Pseudomyxoma peritonei (PMP) is a rare intra-abdominal malignancy characterized by diffuse dissemination of mucinous tumor cells, leading to mucinous ascites. Accurate...
Pseudomyxoma peritonei (PMP) is a rare intra-abdominal malignancy characterized by diffuse dissemination of mucinous tumor cells, leading to mucinous ascites. Accurate diagnosis is crucial for appropriate management. This report presents a case of a 55-year-old Lebanese male farmer initially misdiagnosed with liver cirrhosis who presented with progressive abdominal distension refractory to diuretics and dietary modifications. Paracentesis revealed a mucinous exudate, with subsequent clinical and histopathological examination confirming PMP. The patient was referred for further evaluation at a specialized center equipped for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). This case highlights the diagnostic challenges of PMP due to its non-specific presentation, emphasizing the importance of prompt and accurate diagnosis to facilitate optimal therapeutic intervention.
PubMed: 38721212
DOI: 10.7759/cureus.57857 -
Annals of Hepatology May 2024Sarcopenia is a common complication of end-stage liver disease (ESLD), but its exact relationship to myosteatosis and frailty remains unclear. In this pilot study, we...
INTRODUCTION AND OBJECTIVES
Sarcopenia is a common complication of end-stage liver disease (ESLD), but its exact relationship to myosteatosis and frailty remains unclear. In this pilot study, we tested the feasibility of a specialized MRI protocol and automated image analysis in patients with ESLD.
MATERIALS AND METHODS
In a single-center prospective study, adult liver transplant candidates with ESLD underwent assessment of muscle composition between 3/2022 and 6/2022 using the AMRA® MAsS Scan. The primary outcome of interest was feasibility of the novel MRI technique in patients with ESLD. We also tested if thigh muscle composition correlated with validated measures of frailty and sarcopenia.
RESULTS
Eighteen subjects (71 % male, mean age 59 years) were enrolled. The most common etiologies of cirrhosis were alcohol-related liver disease (44 %) and non-alcohol-associated fatty liver disease (33 %), with a mean MELD-Na of 13 (± 4). The mean time needed to complete the MRI protocol was 14.9 min and only one patient could not complete it due to metal hardware in both knees. Forty-one percent of patients had adverse muscle composition (high thigh fat infiltration and low-fat free muscle volume) and these patients were more likely to have undergone a recent large volume paracentesis (43 % vs. 0 %, p < 0.02). The adverse muscle composition group performed significantly worse on the 6-minute walk test compared to the remainder of the cohort (379 vs 470 m, p < 0.01).
CONCLUSIONS
The AMRA® MAsS Scan is feasible to perform in patients with ESLD and can be used to quantify myosteatosis, a marker of muscle quality and potentially muscle functionality in ESLD.
PubMed: 38719079
DOI: 10.1016/j.aohep.2024.101508 -
The Journal of Maternal-fetal &... Dec 2024To explore the prenatal clinical utility of chromosome microarray analysis (CMA) for polyhydramnios and evaluate the short and long-term prognosis of fetuses with...
OBJECTIVES
To explore the prenatal clinical utility of chromosome microarray analysis (CMA) for polyhydramnios and evaluate the short and long-term prognosis of fetuses with polyhydramnios.
METHODS
A total of 600 singleton pregnancies with persistent polyhydramnios from 2014 to 2020 were retrospectively enrolled in this study. All cases received amniocentesis and were subjected to CMA results. All cases were categorized into two groups: isolated polyhydramnios and non-isolated polyhydramnios [with soft marker(s) or with sonographic structural anomalies]. All fetuses were followed up from 6 months to five years after amniocentesis to acquire short and long-term prognosis.
RESULTS
The detection rates of either aneuploidy or pathogenic copy number variants in fetuses with non-isolated polyhydramnios were significantly higher than those with isolated polyhydramnios (5.0 1.5%, = 0.0243; 3.6 0.8%, = 0.0288). The detection rate of total chromosomal abnormalities in the structural abnormality group was significantly higher than that in the isolated group (10.0 2.3%, = 0.0003). In the CMA-negative cases, the incidence of termination of pregnancy, neonatal and childhood death, and non-neurodevelopmental disorders in fetuses combined with structural anomalies was significantly higher than that in fetuses with isolated polyhydramnios ( < 0.05). We did not observe any difference in the prognosis between the isolated group and the combined group of ultrasound soft markers. In addition, the risk of postnatal neurodevelopmental disorders was also consistent among the three groups (1.6 1.3 1.8%).
CONCLUSION
For low-risk pregnancies, invasive prenatal diagnosis of isolated polyhydramnios might be unnecessary. CMA should be considered for fetuses with structural anomalies. In CMA-negative cases, the prognosis of fetuses with isolated polyhydramnios was good, and polyhydramnios itself did not increase the risk of postnatal neurological development disorders. The worse prognosis mainly depends on the combination of polyhydramnios with structural abnormalities.
Topics: Humans; Female; Pregnancy; Polyhydramnios; Adult; Retrospective Studies; Chromosome Aberrations; Microarray Analysis; Pregnancy Outcome; Prenatal Diagnosis; Prognosis; Amniocentesis; Ultrasonography, Prenatal
PubMed: 38710614
DOI: 10.1080/14767058.2024.2344089 -
American Journal of Ophthalmology Case... Jun 2024To describe the presentation of lacrimal gland secretions mimicking a positive Seidel test following combined complex cataract surgery and endocyclophotocoagulation...
PURPOSE
To describe the presentation of lacrimal gland secretions mimicking a positive Seidel test following combined complex cataract surgery and endocyclophotocoagulation (ECP).
OBSERVATION
The patient presented with a posterior subcapsular cataract (PSC) most likely secondary to chronic steroid use for a history of chemical burns from a firework injury in 2019. This injury resulted in symblepharon formation and limbal stem cell deficiency. He also developed glaucoma secondary to steroid response and angle structure damage. On postoperative day 1 (POD 1) after combined cataract surgery and ECP, the patient's paracentesis was Seidel positive and aqueous suppression was started. On postoperative week 1 (POW 1), the paracentesis was Seidel negative; however, it was noted at this visit that there were 3 pinpoint areas in the superotemporal conjunctiva that were Seidel positive. Digital pressure did not worsen the leak. Ultrasound biomicroscopy (UBM) was performed at POW 2.5 and showed lacrimal gland ducts in the superotemporal conjunctiva. Given this, it is likely that the "Seidel positive" finding was not due to aqueous humor leakage, but secretions from lacrimal gland tissue that may have been dragged more anteriorly due to conjunctiva scarring, thus producing a false positive Seidel sign.
CONCLUSION & IMPORTANCE
This case highlights a false positive Seidel sign in the context of an eye with a complex ocular history and recent surgery. Clinicians should recognize that a false positive Seidel sign is possible if normal lacrimal gland anatomy has been disturbed.
PubMed: 38707948
DOI: 10.1016/j.ajoc.2024.102048 -
Drugs in Context 2024Human albumin (HA) is an effective adjuvant treatment for patients with cirrhosis developing spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and...
BACKGROUND
Human albumin (HA) is an effective adjuvant treatment for patients with cirrhosis developing spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and ascites requiring large-volume paracentesis (LVP). However, cost remains a barrier to use, particularly in resource-limited settings. This study aims to assess the cost-effectiveness of HA in patients with cirrhosis with SBP, HRS or ascites requiring LVP in the Indonesian healthcare system as a representative of a resource-limited setting.
METHODS
Three decision-tree models were developed to assess the cost-effectiveness of (1) antibiotics and HA antibiotics alone in patients with SBP, (2) terlipressin and HA terlipressin alone in patients with HRS, and (3) LVP and HA LVP and gelatine for patients with ascites. Clinical utility and economic inputs were pooled from the available literature. Time horizon was 3 months. Outcomes were expressed as incremental cost-effectiveness ratios (ICER) reported as 2021 IDR per quality-adjusted life year (QALY) (exchange rate June 30, 2021: 1 EUR = 17,245 IDR). Willingness-to-pay thresholds considered were: three times the GDP per capita (199,355,561 IDR/QALY; 11,560 EUR/QALY) and one time the GDP per capita (66,451,854 IDR/QALY; 3853 EUR/QALY).
RESULTS
The ICER for antibiotics and HA ( antibiotics alone) for SBP was 80,562,652 IDR per QALY gained (4672 EUR/QALY). The ICER for terlipressin and HA ( terlipressin) for HRS was 23,085,004 IDR per QALY gained (1339 EUR/QALY). The ICER for LVP and HA LVP and gelatine was 24,569,827 IDR per QALY gained (1425 EUR/QALY).
CONCLUSION
Adjunctive HA may be a cost-effective treatment for SBP, HRS and LVP in resource-limited settings.
PubMed: 38699066
DOI: 10.7573/dic.2024-1-1