Ascites: its correction by peritoneovenous shunting

Rivaroxaban-calibrated chromogenic anti-Xa assay in cirrhosis: Use to rule out disseminated intravascular coagulation

Peritoneovenous shunts (PVSs) are used to relieve ascites in cirrhosis. Disseminated intervascular coagulation (DIC) is a complication of PVSs requiring immediate PVS removal. We report a patient who developed new elevations of prothrombin time (PT) and activated partial thromboplastin time (aPTT) 6 hours after PVS placement, concerning for new-onset DIC. We address the key clinical question of distinguishing DIC from rivaroxaban effect on labs. The patient took rivaroxaban 3 hours after PVS placement, suggesting rivaroxaban effect. Rivaroxaban-calibrated anti-Xa level was in the expected treatment range. Over 12 hours, coagulation labs and rivaroxaban levels declined, with no evidence of DIC. The sudden PT/aPTT increase was attributed to rivaroxaban, however, the distinction between DIC and rivaroxaban effect was possible only with the rapid availability of rivaroxaban levels. While there are no US Food and Drug Administration-approved tests for rivaroxaban levels in the United States, this case demonstrates they can have significant clinical impact, encouraging more widespread adaptation of these assays.

Implantation of a skin graft tube to create a saphenoperitoneal shunt for refractory ascites

PURPOSE

We evaluated the effectiveness of placing a skin tube in the subcutaneous plane to manage refractory ascites by draining the ascitic fluid from the peritoneal cavity into the long saphenous vein.

METHODS

Twenty patients with refractory ascites underwent this technique which was performed in two stages. In the first stage, a thin piece of partial thickness skin graft was rolled into a tube and implanted in the subcutaneous plane of the lower abdomen and the upper thigh near and parallel to the upper segment of the long saphenous vein. In the second stage, which was done 3 months later, we anastomosed the upper end of the skin tube to the peritoneal cavity and the lower end of the skin tube to the long saphenous vein. The follow-up period was 4 years.

RESULTS

There was no mortality. The complications consisted of hematoma formation in two patients, wound infection in three, and ascitic fluid leakage from the upper anastomosis in three. All these complications were managed conservatively.

CONCLUSION

These findings show that creating a saphenoperitoneal shunt with a skin graft tube interposition is a novel, safe, and cost-effective technique of resolving the problem of refractory ascites.

Current medical management of cirrhotic ascites

The presence of ascites may indicate a number of hepatic and extra-hepatic disorders. This situation requires comprehensive evaluation to determine the underlying cause. The evaluation and management of ascites in patients with known cirrhosis is very important since this manifestation of portal hypertension has a detrimental effect on the prognosis for such patients.

The anaesthetic and perioperative management of the patient undergoing insertion of a peritoneo-venous shunt

The infusion of ascitic fluid from the peritoneal cavity into the central venous circulation may relieve massive intractible ascites, and improve renal function when hepatorenal syndrome is present. preoperative preparation of these patients includes investigation of hepatic, renal, pulmonary, cardiac and neurological function, correction of electrolyte and coagulation abnormalities, restoration of normal fluid balance and the provision of supplemental vitamins and calories. Premedication is achieved with an oral benzodiazepine or an intramuscular injection of a narcotic agent. General anaesthesia is provided by thiopentone, suxamethonium, nitrous oxide, oxygen, pancuronium and a narcotic, with intermittent positive pressure ventilation. Close monitoring of cardiac, respiratory and renal function is imperative perioperatively. Postoperatively, supervision in an Intensive Care Unit is advised as complications such as cardiac failure, septicaemia and disseminated intravascular coagulation may occur.

Use of Denver shunt in recurrent hepatic hydrothorax

A 49-year-old woman with alcoholic cirrhosis was hospitalized for severe respiratory distress. A moderate amount of ascites was noted on physical examination, and the right hemithorax was completely opacified on the chest x-ray film. Thoracentesis was performed, and a follow-up chest x-ray film showed marked reduction of pleural effusion. Two days later the patient again was in respiratory distress, and a chest tube was inserted. On the tenth hospital day, a peritoneovenous (Denver) shunt was inserted and the chest tube was removed. Follow-up chest x-ray films showed almost complete resolution of pleural effusion, and the patient has remained free of symptoms. When hepatic hydrothorax does not respond to conventional therapy, we believe aggressive treatment with a Denver shunt may be successful. To our knowledge this procedure has been performed successfully in only one other patient. Further study is needed to assess its value as a possible alternative method of treatment.

Peritonitis in cirrhotic patients with LeVeen shunts

Six cirrhotic patients are described in whom peritonitis developed from 10 days to 15 months after the insertion of a LeVeen shunt. The presenting clinical features of fever, increasing ascites and deterioration in mental status resembled these previously reported for cirrhotic patients but with spontaneous peritonitis without shunts. Important differences were observed, however, in microbiology, incidence of bacteremia and therapy. Staphylococcus aureus, a rare cause of spontaneous peritonitis, was found in one half of our cases, suggesting that perioperative contamination during shunt placement was an important etiologic factor. All six had concomitant bacteremia which may be attributable to the direct peritoneal-venous connection. Appropriate systemic antimicrobial therapy without shunt removal failed to eradicate the infection irrespective of the patency of the shunt or absence of inflammation at the sites of insertion. Recommended treatment for suspected peritonitis in patients with shunts is systemic antimicrobial therapy with an agent active against staphylococci plus an aminoglycoside, followed by removal of the shunt if the diagnosis is confirmed.

Fatal pulmonary tumor embolization following peritoneovenous shunting for malignant ascites

A 44-year-old white male with pseudomyxoma peritonei and intractable malignant ascites is described. This patient underwent three peritoneovenous shunt procedures utilizing first the LeVeen shunt and finally the Denver shunt in a surgical attempt at palliative decompression of his malignant ascites. The peritoneovenous shunts resulted in massive tumor embolization to the pulmonary vasculature, clinically asymptomatic disseminated intravascular coagulation, and partial thrombosis of the superior vena cava. The pulmonary tumor embolization was manifest clinically as moderate pulmonary hypertension with increased pulmonary vascular resistance and persistent hypoxia.

Complications after peritoneovenous shunting for ascites

The results and complications in our first 23 consecutive patients receiving the peritoneovenous shunt for intractiable hepatic ascites are presented. A good initial diuretic effect was obtained in 20 of the 23 patients, with reversal of hepatorenal failure in 3 of 5 patients. The postoperative complication rate was high (74 percent). Infection, coagulopathy and complication of the underlying liver disease contributed to a mortality rate of 26 percent. Late complications were related to the primary liver disease. The 6 month survival rate was 58 percent and the 1 hear survival rate 52 percent with five patients followed up for more than 2 years. Because of the significant morbidity and mortality associated with the peritoneovenous shunt, we recommend it only for patients with massive intractable hepatic ascites whose condition is refractory to maximal medical therapy.

Posttraumatic Budd-Chiari syndrome with late reversibility of hepatic venous obstruction

A peritoneo-venous shunt was inserted in a 15-mo-old infant with Budd-Chiari syndrome following hepatic trauma. Ascites resolved and late renewed patency of the right hepatic vein was demonstrated.