Ascites

Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND AND AIM

For those with a centrally located HCC, the two types of liver sectionectomy that can be performed are extended hepatectomy (EH) and central hepatectomy (CH). This meta-analysis aimed to compare the short- and long-term outcomes between patients treated with CH and patients treated with EH for those with centrally located HCC.

METHOD

We searched PubMed, Scopus, Web of Science, and Cochrane library for eligible studies from inception to 1 April 2022 and a systematic review and meta-analysis were done to compare the outcomes between the two groups.

RESULTS

we included 9 studies with a total of 1674 patients in this study. The pooled results in this meta-analysis showed equal long-term overall survival, Disease-free survival, recurrence and mortality between the two groups (5-year OS, RR = 1.14, 95% CI = 0.96-1.35, P = 0.12; I2 = 56%), (5-year DFS, RR = 0.81, 95% CI = 0.61-1.08, P = 0.15; I2 = 60%), (Recurrence, RR = 1.04, 95% CI = 0.94-1.15, P = 0.45; I2 = 27%), and (Mortality, RR = 0.55, 95% CI = 0.26-1.15, P = 0.11; I2 = 0%). In addition to that, no significant difference could be detected in the overall incidence of complications between the two groups (Complications, RR = 0.94, 95% CI = 0.76-1.16, P = 0.57; I2 = 0%). However, CH is associated with a remarkable increase in the rate of biliary fistula (Biliary fistula, RR = 1.90, 95% CI = 1.07-3.40, P = 0.03; I2 = 0%). And Liver cell failure was higher in the case of EH (LCF, RR = 0.47, 95% CI = 0.30-0.76, P = 0.002; I2 = 0%). Regarding the operative details, CH is associated with longer operative time (Time of the operation, Mean difference = 0.82, 95% CI = 0.36, 1.27, P = 0.0004; I2 = 57%).

CONCLUSION

No significant difference in the short and long-term survival and recurrence between CH and MH for CL-HCC. However, CH is associated with greater future remnant liver volume that decreases the incidence of LCF and provides more opportunities for a repeat hepatectomy after tumour recurrence.

Liver cirrhosis and immune dysfunction

Cirrhosis is end-stage liver disease resulting from various etiologies and is a common cause of death worldwide. The progression from compensated to decompensated cirrhosis to acute-on-chronic liver failure (ACLF) is due to multiple factors, including continuation of alcohol use or continued exposure to other toxins, an imbalance of the gut microbiota (dysbiosis), increased gut permeability and a disrupted immune response. This disrupted immune response is also named cirrhosis-associated immune dysfunction, which is characterized by worsening systemic inflammation with concomitant immune paralysis, as liver disease deteriorates. This review highlights central immunologic events during the exacerbation of cirrhosis and characterizes the different immune cell populations involved therein.

Belly fat or bloating? New insights into the physical appearance of St Anthony of Padua

Over the centuries, iconographic representations of St Anthony of Padua, one of the most revered saints in the Catholic world, have been inspired by literary sources, which described the Saint as either naturally corpulent or with a swollen abdomen due to dropsy (i.e. fluid accumulation in the body cavities). Even recent attempts to reconstruct the face of the Saint have yielded discordant results regarding his outward appearance. To address questions about the real appearance of St Anthony, we applied body mass estimation equations to the osteometric measurements taken in 1981, during the public recognition of the Saint's skeletal remains. Both the biomechanical and the morphometric approach were employed to solve some intrinsic limitations in the equations for body mass estimation from skeletal remains. The estimated body mass was used to assess the physique of the Saint with the body mass index. The outcomes of this investigation reveal interesting information about the body type of the Saint throughout his lifetime.

Current management of refractory ascites in patients with cirrhosis

Liver cirrhosis is a health problem worldwide, and ascites is its principal symptom. Refractory ascites is intractable and occurs in 5%-10% of all patients with ascites due to cirrhosis. Refractory ascites leads to a poor quality of life and high mortality rate. Ascites develops as a result of portal hypertension, which leads to water-sodium retention and renal failure. Various therapeutic measures can be used for refractory ascites, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, vasoconstrictive drugs, and an automated low-flow ascites pump system. However, ascites generally can be resolved only by liver transplantation. Because not all patients can undergo liver transplantation, traditional approaches are still used to treat refractory ascites. The choice of treatment modality for refractory ascites depends, among other factors, on the condition of the patient.

The Circulatory System in Liver Disease

In the cirrhotic liver, distortion of the normal liver architecture is caused by structural and vascular changes. Portal hypertension is often associated with a hyperdynamic circulatory syndrome in which cardiac output and heart rate are increased and systemic vascular resistance is decreased. The release of several vasoactive substances is the primary factor involved in the reduction of mesenteric arterial resistance, resulting in sodium and water retention with eventual formation of ascites. Management of these patients with acute cardiac dysfunction often requires invasive hemodynamic monitoring in an intensive care unit setting to tailor decisions regarding use of fluids and vasopressors.

The Palliative Management of Refractory Cirrhotic Ascites Using the PleurX (©) Catheter

Background. Treatment options are limited for patients with refractory cirrhotic ascites (RCA). As such, we assessed the safety and effectiveness of the PleurX catheter for RCA. Methods. A retrospective analysis was performed on all patients with RCA who have undergone insertion of the PleurX catheter between 2007 and 2014 at our clinic. Results. Thirty-three patients with RCA were included in the study; 4 patients were lost to follow-up. All patients were still symptomatic despite bimonthly large volume paracentesis and were not candidates for TIPS or PV shunt. Technical success was achieved in 100% of patients. The median duration the catheter remained in situ was 117.5 days, with 95% CI of 48-182 days. Drain patency was maintained in 90% of patients. Microorganisms consistent with spontaneous bacterial peritonitis (SBP) from a catheter source were isolated in 38% of patients. The median time to infection was 105 days, with 95% CI of 34-233 days. All patients were treated for SBP successfully with antibiotics. Conclusion. Use of the PleurX catheter for the management of RCA carries a high risk for infection when the catheter remains in situ for more than 3 months but has an excellent patency rate and did not result in significant renal injury.

Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. Because many diseases can cause ascites, in particular cirrhosis, samples of ascitic fluid are commonly analyzed in order to develop a differential diagnosis. The concept of transudate versus exudate, as determined by total protein measurements, is outdated and the use of serum-ascites albumin gradient as an indicator of portal hypertension is more accurate. Lactate dehydrogenase (LDH), vascular endothelial growth factor (VEGF), and other tumor markers can be helpful in distinguishing between malignant and benign conditions. Glucose and adenosine deaminase levels may support a diagnosis of tuberculous disease, and amylase level may indicate a diagnosis of pancreatitis. Given the specificity and sensitivity of laboratory results, accurate diagnosis should be based on both laboratory data and clinical judgment.

Use of (18)F-FDG PET/CT to locate primary malignancies in patients with hepatic cirrhosis and malignant ascites

OBJECTIVE

Ascites in patients with hepatic cirrhosis is caused by cirrhosis in most cases. For most malignant ascites, the primary malignancy could be readily identified using conventional imaging methods, e.g., computed tomography (CT) and magnetic resonance imaging (MRI). However, in a small fraction of the patients, the primary malignancy remains occult even with these examinations. In this retrospective study, we assessed the usefulness of (18)F-FDG PET/CT in patients with hepatic cirrhosis and malignant ascites of otherwise unknown origin.

METHODS

Twenty-eight patients with malignant ascites of unknown primary sites after CT, MRI and ultrasound during the period of five years between January 2008 and December 2012 had received (18)F-FDG PET/CT. Medical records of these patients were reviewed and analyzed.

RESULTS

Elevated (18)F-FDG absorption was found in 23 of 28 cases in the following sites: gastrointestinal tract (n=10, 43.5%), prostate (n=5, 21.7%), peritoneum (n=4, 13.3%), and ovary (n=4, 13.3%). Cancer was confirmed by pathology in 20 cases after open or laparoscopic surgeries. Five patients were found to have benign ascites, among which, 3 were found to be false positive due to tuberculosis. SUV values were significantly higher for tumors than for benign lesions (mean values, 6.95 vs. 2.94; P=0.005).

CONCLUSIONS

The (18)F-FDG PET/CT can be as a powerful imaging tool in identifying tissue origin in liver cirrhosis patients suspected of cancers or with cancers of unknown primary sites.

Refractory ascites - a rare presentation of severe aortic regurgitation

A 47 year-old male with a history of refractory ascites presented to our centre complaining of dyspnoea, abdominal distention, and weight gain. He was admitted under a medical team for investigation and management. Work-up excluded all common aetiologies of ascites. Echocardiography revealed severe aortic regurgitation (AR) with a dilated left ventricle but no right heart pathology or pulmonary hypertension. He underwent mechanical aortic valve replacement. Intra-operatively, a prolapsing left coronary leaflet of the aortic valve with frayed edges raised suspicion of resolved infective endocarditis. Postoperative course was uneventful. Following replacement of the aortic valve, the patient was completely free of ascites. This case demonstrates that ascites can be an unusual clinical presentation of severe aortic regurgitation, which may respond to aortic valve replacement.

Value of combined detection of AFU and TCH in differential diagnosis between malignant and non-tuberculous benign ascites

The purpose of this study was to accurately evaluate the diagnostic efficacy of combined detection of ascitic fluid alpha-L-fucosidase (AFU) and cholesterol (TCH) compared with that of their individual detection. We assayed ascitic AFU activity by colorimetry and TCH level by CHOD-PAP method simultaneously in all 213 cases. Then, we assessed the value of combined detection of AFU and TCH activities with receiver operating characteristic curve (ROC curve), including diagnostic sensitivity, specificity, diagnostic accuracy, positive predict value(PV+), negative predict value(PV-) to see whether these two ascitic fluid biochemical examinations might help in differential diagnosis between malignant and non-tuberculous benign ascites. The mean values of AFU and TCH in malignant group [(164.96 ± 87.72) μmol/lh and (1.65 ± 1.00) mmol/l, respectively] were significantly higher than those in non-tuberculous benign group [(104.02 ± 62.08) μmol/lh and (0.69 ± 0.58) mmol/l, respectively] (P < 0.01). The optimal cutoff value of 101.95 μmol/lh for ascitic AFU and 1.04 mmol/l for ascitic TCH resulted in a diagnostic sensitivity of 82.3% and 70.8%, specificity of 63.2 and 83.8%, accuracy of 72.8 and 77.9%, PV+ of 65.3 and 78.2%, PV- of 83.1 and 77.8%, respectively. Combined detection of the two markers, the sensitivity, specificity, accuracy, PV+ and PV- were 86.5, 85.5, 85.9, 83.0, and 88.5%, respectively. Through comparison by Pearson Chi-square, the combined detection of AFU and TCH produced better diagnostic accuracy (85.9%) compared with the individual detection (P < 0.05). The combined detection of AFU and TCH produced better diagnostic accuracy in comparison with their individual detection, which is helpful to differential diagnosis between malignant and non-tuberculous benign ascites that may be relatively ideal markers to fit for clinical application in local hospitals.

Refractory ascites: pathogenesis, definition and therapy of a severe complication in patients with cirrhosis

Ascites is a frequent complication of cirrhosis and portal hypertension, because of the increase of the sinusoidal hydrostatic pressure. Cirrhosis accounts for over 75% of episodes of ascites. Cirrhotic patients with ascites have marked alterations in the splanchnic and systemic haemodynamics, causing central hypovolaemia and arterial hypotension with consequent activation of the vasoconstrictor systems, renin-angiotensin and sympathetic systems, and with increased renal sodium re-absorption. One of the most serious complications in cirrhotic patients with ascites is the occurrence of refractoriness, that is the inability to resolve ascites by the standard medical treatment with low sodium diet and diuretic doses up to 160 mg/day of furosemide and 400 mg/day of spironolactone. Many patients with refractory ascites also have a chronic renal insufficiency that is called hepatorenal syndrome type-2. In these patients ascites may be treated with periodic paracentesis or with transjugular intrahepatic portosystemic shunt. However, only liver transplantation may improve the survival of such patients.

Evaluation and management of patients with refractory ascites

Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis (LVP) and transjugular intrahepatic portasystemic stent-shunt (TIPS) are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morbidity and mortality (most surgical options) rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.

Palliation of malignant ascites

The management of recurrent, symptomatic malignant ascites can be problematic for physicians and patients. The most common, low-risk method is large-volume paracentesis. Patient disease progression often leads to rapid reaccumulation of ascites, which requires frequent return visits to the hospital for symptom management. Other techniques have been developed to achieve palliation of symptoms, including tunneled external drainage catheters, peritoneal ports, and peritoneovenous

Ovarian carcinoma in two patients with chronic liver disease

Ascites is a common and debilitating complication of cirrhosis. However, patients with chronic liver disease are not spared from other causes of ascites and physicians should be careful not to miss an underlying malignancy. Ovarian cancer is an insidious disease, which is difficult to diagnose and it ranks first in mortality among all gynecological cancers. Here, we present two cases of patients with chronic liver disease that developed ascites not simply because of cirrhosis but as a manifestation of ovarian cancer. We would like to emphasize that the causes of ascites, other than the liver itself, should not be overlooked in patients with chronic liver disease.

Chylothorax in Henoch-Schonlein purpura: a case report and review of the literature

Henoch-Schonlein purpura (HSP) is the most common acute vasculitis in the pediatric population, with an incidence of 10-14 per 100,000. The classic presentation of this disorder includes erythematous papules followed by palpable purpura in the lower extremities, trunk, and face, arthralgia or arthritis, abdominal pain, gastrointestinal bleeding, and nephritis. While renal abnormalities in HSP are common, the classic pulmonary manifestations, such as hemorrhage and pneumonitis, are thought to be infrequent. Subclinical pulmonary manifestations, including diffusion defects and radiographic anomalies, seem to be quite frequent in patients with HSP but are not commonly reported. Other respiratory manifestations include pleural effusion and chylothorax, but these are rarely mentioned in the literature. Chylothorax was only reported once in an adult patient with HSP in whom the mechanism of formation was demonstrated to be secondary to transdiaphragmatic passage of chylous fluid from the peritoneal cavity. Here we describe an 8-year-old girl with HSP, nephrotic syndrome, and chylothorax, and we report the results of a review of the literature regarding respiratory complications in HSP. The present case is the first pediatric patient reported with HSP and chylothorax. The therapeutic measures utilized were effective in resolving her edema, ascites, and chylothorax, and we advocate the use of these measures as first-line therapy in future patients with similar complications from HSP.

The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club

Ascites is a common complication of cirrhosis, and heralds a new phase of hepatic decompensation in the progression of the cirrhotic process. The development of ascites carries a significant worsening of the prognosis. It is important to diagnose noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites since these occur with increased frequency in patients with liver disease. The International Ascites Club, representing the spectrum of clinical practice from North America to Europe, have developed guidelines by consensus in the management of cirrhotic ascites from the early ascitic stage to the stage of refractory ascites. Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance. Diuretics should be added in a stepwise fashion while maintaining sodium restriction. Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy. Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS). Successful placement of TIPS results in improved renal function, sodium excretion, and general well-being of the patient but without proven survival benefits. Clinicians caring for these patients should be aware of the potential complications of each treatment modality and be prepared to discontinue diuretics or not proceed with TIPS placement should complications or contraindications develop. Liver transplantation should be considered for all ascitic patients, and this should preferably be performed prior to the development of renal dysfunction to prevent further compromise of their prognosis.

Trace elements analysis of ascitic fluid in benign and malignant diseases

OBJECTIVES

To evaluate differences in ascitic fluid trace element concentrations which might be useful in discrimination between benign and malignant ascites.

DESIGN AND METHODS

The concentrations of copper, zinc, magnesium and iron in ascitic fluid and venous blood in 17 patients were investigated. The relationship between these trace elements and type of disease were examined. Investigations were carried out in a group of 5 males and 5 females aged 54 to 77 yr who had cirrhosis ascites and in a group of 7 females aged 41 to 76 yr with ascites due to gynecologic neoplasms.

RESULTS

The mean ascitic fluid and serum concentrations of copper were significantly higher in neoplastic diseases compared to benign disease states (118,43 vs. 97,50, 91,14 vs. 26.90) (p < 0,05 and p < 0,01 respectively). The zinc levels in ascitic fluid and serum were significantly different between the groups (p < 0,01). Neoplastic patients had significantly higher ascitic fluid magnesium levels than the benign disease group (2,17 vs. 1,55, p < 0,001). The serum levels of iron were significantly lower in the neoplastic diseases group (92, 28 vs. 255, p < 0, 01). In benign diseases the concentration of zinc in ascitic fluid correlated positively with ascitic fluid copper concentrations. The concentrations of zinc and iron in malignant ascites correlate positively with the magnesium concentrations. Statistically significant negative correlations were found between ascites zinc and magnesium and magnesium and copper in cirrhotic patients and magnesium and copper in malignant diseases.

CONCLUSIONS

The results showed that zinc, magnesium and iron levels were significantly different between cirrhotic and neoplastic illness. Analysis of serum and ascitic fluid trace element composition may be helpful in identifying and distinguishing the malignant and nonmalignant ascites and provides useful information on processes regulating passage of blood components into the peritoneal cavity.

Management of ascites

The evaluation of ascites includes a directed history, focused physical examination, and diagnostic paracentesis with ascitic fluid analysis. Dietary sodium restriction and oral diuretics are the mainstay of therapy for the majority of patients with cirrhotic ascites. Transjugular intrahepatic portocaval shunt has emerged as the treatment of choice for selected patients with refractory ascites, although serial large-volume paracenteses should be attempted first. Early diagnosis, broad-spectrum antibiotics, and albumin infusion contribute to the successful management of spontaneous bacterial peritonitis (SBP). Referral for liver transplant evaluation should be considered at the first sign of decompensation and should not be delayed until development of ominous clinical features, such as refractory ascites and SBP.