Refractory ascites after laparoscopic cholecystectomy: a case report

BACKGROUND

Laparoscopic cholecystectomy is a common surgical option for gallstone disease with minimal trauma and rapid recovery. Ascites is a relatively uncommon complication after laparoscopic cholecystectomy and is more frequently observed in patients with preoperative abnormal liver function. However, patients without underlying liver disease develop refractory ascites after laparoscopic cholecystectomy are rare. We report a case of massive ascites caused by lymphatic injury after laparoscopic cholecystectomy.

CASE PRESENTATION

A 63-year-old woman complained of abdominal discomfort and distension at the twelfth day after a laparoscopic cholecystectomy for gallbladder stones. Subsequently, the patient developed spontaneous bacterial peritonitis and a decreased output of urine. Abdominal computed tomography (CT) identified abdominal effusion. The patient received abdominocentesis and the volume of slightly turbid yellow ascites averaged 1500-2000 ml per day. The results of laboratory analysis of ascitic fluid showed the following: serum-ascites albumin-gradient (SAAG), 11-12 g/L; albumin, 11-14 g/L; triglycerides, 0.91 mmol/L. After the diuretic therapy, repeated large-volume paracentesis with albumin supplementation, administration of antibiotics and renal vasodilating medications, the patient's symptoms did not relieve. Lymphoscintigraphy found a small amount of radioactive filling in the abdominal cavity. The patient finally received surgery with detection and ligation of the lymphatic leak. The ascites disappeared and the patient recovered well.

CONCLUSIONS

For patients with atypical characteristics of chylous ascites, lymphoscintigraphy could help to localize and qualify the diagnosis. Surgical treatment could be considered when conservative treatment fails.

Qi Sui Zhu Shui Plaster Inhibits AQP1 and MAPK Signaling Reduces Liver Damage Induced by Cirrhotic Ascites

Objective

At present, there is no special treatment for cirrhotic ascites in modern medicine. Qi Sui Zhu Shui plaster (QSZSP) has been used in ascites. The purpose of this study was to investigate the mechanism of action of QSZSP in the treatment of cirrhotic ascites and its relationship with aquaporin 1 (AQP1).

Methods

Twenty-four rats were divided into four groups, six rats in each group. Carbon tetrachloride-olive oil is injected into modeling. The control and model groups are treated with blank gel plaster (2 cm × 2 cm), QSZSP low-dose group is treated with Qi Sui Zhu Shui plaster (1 cm × 1 cm), and QSZSP high-dose group is treated with Qi Sui Zhu Shui plaster (2 cm × 2 cm). The changes in body weight and abdominal circumference were measured, the histopathological changes in liver, kidney, and peritoneum were observed in HE staining, the biochemical indexes related to liver function were detected, and the changes in AQP1 expression and the activation of MAPK pathway in the liver, kidney, and peritoneal tissues were evaluated in IHC staining and Western blot.

Results

After one week of injection of carbon tetrachloride-olive oil, the rats in the model group increased their body weight slowly, the abdominal circumference of the model rats continued to increase with time. After 16 weeks of construction of the cirrhotic ascites model, the liver, kidney, and peritoneum were significantly damaged, and the serum levels of TBiL, AST, ALT, Cr, BUN, K, Na, and Ca in the rats were significantly higher (P < 0.001) and ALB levels were significantly lower (P < 0.001) than those in the control group. After 4 weeks of treatment, the liver, kidney, and peritoneal injury were improved. TBiL, AST, ALT, Cr, BUN, K, Na, and Ca levels were significantly lower (P < 0.001) and ALB levels were significantly higher (P < 0.001) than those in the model group. The protein expression of AQP1, p-ERK, p-JNK, and p-p38 was found to be inhibited in the liver, kidney, and peritoneum.

Conclusion

QSZSP inhibits the protein expression of AQP1 and MAPK signaling pathway in the liver, peritoneum, and kidney to alleviate liver, kidney, and peritoneal injury caused by cirrhotic ascites, thus reducing the abnormal growth of abdominal circumference.

Paracentesis-induced circulatory dysfunction: are there albumin alternatives?

Background

Ascites is one of the main complications of advanced liver cirrhosis. It is defined as a pathological accumulation if free fluid in the peritoneal cavity.

Main body of the abstract

Ascites is a sign of decompensation in patients with liver cirrhosis and is associated with decreased survival. Ascites is associated with bad cosmetic figure and poor quality of life. Ascites is a predisposing factor for developing hydrothorax, hernias, diastolic dysfunction, spontaneous bacterial peritonitis, and renal impairment especially hepatorenal syndrome. The main treatment is salt restriction and diuretics. By the time the patient become non-responder and develop tense ascites, abdominal large volume paracentesis is the treatment of choice. Its advantages are rapid, cheap, and 1 day hospitalization. The main drawback is the development of paracentesis-induced circulatory dysfunction (PICD) if no volume expanding drugs are used. PICD is associated with dilutional hyponatremia, renal impairment, so it is considered the silent killer. Albumin infusion is the standard preventive measure but since costly to other alternatives such as colloids, vasoconstrictors or lowering the standard doses of the albumin was studied and is promising.

Conclusions

This review summarized the effectiveness of other alternative drugs.

Current approaches to the management of patients with cirrhotic ascites

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.

[A case of lateral abdominal wall hematoma treated with transcatheter arterial embolization]

Paracentesis is a diagnostic, therapeutic procedure performed in patients with ascites. It is generally thought to be a safe procedure and transfusion of platelet concentrate or fresh frozen plasma is not recommended before the procedure, because the incidence of clinically significant bleeding is very low. We report a case of lateral abdominal wall hematoma due to the injury of the deep circumflex iliac artery after paracentesis in patient with alcoholic liver cirrhosis who was treated with transcatheter arterial embolization.

Pathophysiology and treatment of significant bleeding oesophageal varices

Acute oesophageal variceal haemorrhage is a major cause of death associated with cirrhotic liver disease. Whilst surgical procedures can decrease the risk of recurrent bleeds, pharmacological aids are often used to treat the cause of the varices: portal hypertension. Insertion of a Sengstaken Blakemore tube or Minnesota tube can temporarily halt the haemorrhage by exerting pressure on the varices. This pressure decreases the blood supply to the oesophagus, thereby decreasing the amount of blood lost through a ruptured vessel. The use of these tubes is based on individual hospital policy. Other techniques such as band ligation, are also being introduced for the management of oesophageal varices to decrease haemorrhaging. Once the bleeding has been controlled surgical procedures such as sclerotherapy can attempt to permanently stop the rupture. However, these procedures do not treat the cause of the varices. Adjunctive medications, transplants and shunts attempt to permanently decrease the portal hypertension in order to decrease the risk of recurrent haemorrhage.

A systematic review: endometriosis presenting with ascites

BACKGROUND

The present review aims to increase the awareness of the gynecologists by analyzing all the case reports which refer to endometriosis presenting either with only ascites or with massive ascites with pleural effusion.

METHODS

To conduct the present review, the CENTRAL (in the Cochrane Library, current issue), MEDLINE (Silver Platter, from 1950 to 2010), and EMBASE (from 1950 to 2010) electronic databases were searched. As a result, all the publications based on the keywords relating to the review topic were acquired.

RESULTS

Since the description of first case in 1954, endometriosis-related ascites was reported to occur in a total of 63 women who were aged between 19 and 51 years. Approximately 63.0% of the recruited women for whom ethnicity was specified were of African origin (29 out of 46). Of the 50 subjects with known obstetric history, 41 (82.0%) were nulliparous. Abdominal distention, anorexia/weight loss, abdominal pain, and menometrorrhagia were the most frequently encountered clinical symptoms, whereas pelvic mass was the most common physical finding. The serum concentrations of CA 125 were between 20 and 3,504 IU/ml for 19 women whose CA 125 levels were determined. Pleural effusion was also present in 38.1% of the reviewed subjects (24 out of 63). The clinical features of the women with endometriosis-related ascites and pleural effusion were similar to those of the women who had only endometriosis-related ascites.

CONCLUSION

Endometriosis-related ascites and/or pleural effusion refers to extensive disease with a high risk for recurrence which usually affects non-Caucasian, nulliparous women of reproductive age and leads to clinical symptoms resembling those of an ovarian malignancy. Therefore, clinicians should consider endometriosis in differential diagnosis of pelvic masses and also include endometriosis in diagnostic workup of ascites or pleural effusion.