Abdominal Ascites Research Articles

Follow-up on new marker confirming the optimal status in the treatment of heart failure with reduced ejection fraction

Abstract Background At the present time, there is no strong criterion to guarantee the optimal management for patients with heart failure and reduced ejection fraction (HFrEF). In the past, our group suggested the use of the size of the femoral vein (FV), measured by ultrasound as a marker of the fluid status in the venous compartment. Is this criterion still the best marker of optimal treatment of HFrEF at 3 years follow-up, especially for patients with significant co-morbidities (chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD) on hemodialysis (HD), cirrhosis of liver or sepsis? Methods Patients with HFrEF and co-morbidities as above were enrolled. All patients had echocardiography to confirm EF <45% and underwent the ultrasound test to assess the size and expansibility of the femoral vein (SEFV). The SEFV is the ultrasound study of the FV examining its size and expansibility with cough. The location of the femoral artery (FA) and FV to be checked is the coronal plane immediately proximal to the bifurcation of the superficial and deep femoral artery. The normal size of FV is a little larger than of the FA. If the size of the FV is twice larger than the FA, the patient has fluid overload in the venous compartment (Figure 1). Then the patient was asked to cough in order to measure the size of the FV. If the FV did not increase its size with cough, the venous compartment was full. If the FV increased its size, the venous compartment was not full and could accommodate more fluid. In physical exam, the fluid overload is proved by the presence of extravascular fluid in the abdominal wall, ascites or leg edema or in the intravascular compartment by the presence of the jugular venous distention. During the 3 years of follow-up, the patients were seen in the office and had the SEFV at regular 6 months intervals. A small group of patients also underwent right heart catheterization to measure to the pulmonary capillary wedge pressure (PCWP). Results 180 patients with HFrEF and significant comorbidities were enrolled. All patients were taught to follow a low Na diet, <2000cc of fluid restriction and the guideline directed medical therapy. After about 3 years, 75% patients in the study group were asymptomatic, was not readmitted to the hospital for HF, and the size of the FV was within normal range. Their physical exam showed no fluid in the extravascular compartment. The PCWP became lower than 24mmHg in 18/20 who underwent the RHC. There was significant weight loss (15 lbs). In the control group, 60% of patients were asymptomatic and 50% were not readmitted for HF (p<0.05). Conclusions With the SEFV test, the patients with HFrEF and significant comorbidities were accurately estimated for presence or absence of fluid overload. This SEFV test was especially sensitive to detect fluid overload in patients with multiple co-morbidities. Further randomized trials are needed to confirm the above preliminary results. Funding Acknowledgement Type of funding sources: None. Figure 1. Enlarged size of femoral vein

BILATERAL CHYLOTHORAX AND ANASARCA CAUSED BY DASATINIB IN A PATIENT WITH CHRONIC MYELOGENOUS LEUKEMIA

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dasatinib is one of the tyrosine kinase inhibitors that is used in the treatment for Philadelphia positive Chronic Myeloid Leukemia (CML). Pleural effusion can occur in 10% of patients on dasatinib, but chylothorax was rarely reported as a side effect of dasatinib (1,2). CASE PRESENTATION: A 52 year-old male with medical history of CML presented with shortness of breath over the past 4months. Patient was diagnosed with CML 10 years ago. Initially he was started on imatinib which he did not tolerate secondary to headache and he was switched to dasatinib 100mg daily which he tolerated for 5 years. Bone marrow biopsy showed complete cytogenetic remission in 6-months and he achieved major molecular remission. Physical exam was remarkable for reduced air entry to both lungs, abdominal ascites, and lower extremities pitting edema up to the groins. Basic labs were within normal limits. Chest X-ray showed bilateral pleural effusions and confluent bibasilar infiltrates. Computed topography of the chest showed large bilateral effusions with passive atelectasis in the lower lobes (figure-1A and 1B). CT scan of the abdomen and pelvis showed diffuse body edema in the lower abdomen extending to both lower extremities. Large right hydrocele and moderate left hydrocele were also noticed (figure-1C). Imaging guided thoracentesis was performed on the right side and 1900 ml of milky fluid was drained. Pleural fluid analysis showed total protein of 4.6 g/dL (serum total protein:7.3 g/dL), glucose of 97 mg/dL (serum glucose: 84 mg/dL), elevated lactate dehydrogenase (116 U/L), elevated triglyceride (485 mg/dL), and elevated cholesterol (83 mg/dL). Based on that, Diagnosis of chylothorax was made and dasatinib was discontinued. Patient was started on short course of diuretics and oral prednisone. After one month of dasatinib discontinuation, patients SOB improved significantly. Abdominal and lower extremities swelling has improved too. Repeated CXR showed improved bilateral pleural effusion (figure-1D). We kept patient off dasatinib with monthly check of BCR/ABL by PCR with plan to restart dasatinib at 50 mg daily or switching to another treatment if he relapses. DISCUSSION: Pleural effusion is a known side effect of dasatinib and few reports of unilateral chylothorax have been reported. Bilateral chylothorax and anasarca are very rare side effects of dasatinib. In most of the cases, discontinuation of dasatinib can improve symptoms. In a previous case report, 63 year-old female presented with right sided dasatinib induced chylothorax which totally resolved after switching dasatinib to nilotinib (2). In another case report, the 71 year-old patient presented with dasatinib induced chylothorax that initially resolved and then recurred after re-initiation of dasatininb (3). CONCLUSIONS: Bilateral chylothorax after dasatinib is very rare. Most cases resolve completely with dasatinib discontinuation. REFERENCE #1: Kantarjian H, Shah NP, Hochhaus A, et al. Dasatinib versus imatinib in newly diagnosed chronic-phase chronic myeloid leukemia. N Engl J Med. 2010 Jun 17;362(24):2260-70. doi: 10.1056/NEJMoa1002315. Epub 2010 Jun 5. PMID: 20525995. REFERENCE #2: Al-Abcha A, Iftikhar MH, Abu Rous F, et al. Chylothorax: complication attributed to dasatinib use. BMJ Case Rep. 2019 Dec 16;12(12):e231653. doi: 10.1136/bcr-2019-231653. PMID: 31848139; PMCID: PMC6936595. REFERENCE #3: Chen B, Wu Z, Wang Q, et al. Dasatinib-induced chylothorax: report of a case and review of the literature. Invest New Drugs. 2020 Oct;38(5):1627-1632. doi: 10.1007/s10637-020-00932-3. Epub 2020 Apr 4. PMID: 32248338. DISCLOSURES: No relevant relationships by hamed daw, source=Web Response No relevant relationships by Christopher Haddad, source=Web Response No relevant relationships by Tariq Kewan, source=Web Response No relevant relationships by Talha Saleem, source=Web Response

HEART FAILURE AS INITIAL PRESENTATION OF A DEVIOUS METASTATIC CARCINOID DISEASE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Common presentations of carcinoid syndrome include flushing, palpitations, secretory diarrhea, bronchospasm and hypotension. In 20% of patients, symptoms may present initially with progressive exertional dyspnea indicating possible carcinoid heart disease (CHD). CASE PRESENTATION: A 74 y/o AA F with history T2DM, HTN, dyslipidemia, COPD, asthma presented with progressive exertional dyspnea for 6 month and 1 month history of diarrhea. Her physical exam was pertinent for T 36.2°C, BP 136/86, HR/80, RR/18 saturating 95%, loud blowing holosystolic murmur, bilateral LE pitting edema and abdominal ascites. Laboratory were significant for Na 147 mmol/L, K 2.9 mmol/L, creatinine at 1.65 mg/dL, BUN at 23 mg/dL and elevated NT-proBNP 4,866 pg/mL. A TTE showed normal LV systolic function with EF of 50-55% and severe RV and atrial dilatation, severe TR and dyssynergia with a flattened septum and PA of 50-55 mmHg. She underwent RHC which showed elevated right-sided filling pressures and low CO/CI. She was admitted to the hospital and was treated with aggressive diuresis and started on dobutamine. Further work up looking for infiltrative diseases were performed including ANA w/ reflex, RF, SPEP/UPEP, and Kappa/Lambda ratio and were all normal. CT scan showed an incidental hypodense lesion in the right hepatic dome. Serum serotonin was elevated at 930 ng/mL, 24 hr for 5-HIAA at 177mg/d and chromogranin A 3,257 ng/mL. She was started on octreotide and FNA of the right liver lesion was positive for a low-grade/well-differentiated neuroendocrine tumor. The patient was maintained on octreotide therapy for symptomatic relief and no further management was pursued due to critical health condition. DISCUSSION: CHD has an insidious presentation. Patients may be asymptomatic until the tumor metastasizes to the liver. A high suspicion coupled with serologic and imaging tests is crucial for earlier diagnosis. The left side of the heart is usually spared because the lungs metabolize the vasoactive substances before reaching the left-sided heart valves. Rarely, when the disease is found on the left side of the heart usually a right-to-left shunt is present. Typical TTE findings show a pattern of RV volume overload with enlarged RV and TV leaflet thickening. CONCLUSIONS: Early detection of carcinoid heart disease can improve prognosis and symptoms in patients with heart valve involvement. Treatment is aimed for symptomatic relief with somatostatin-analogs, telotristat therapy and temporary diuretic therapy with definitive surgical valve replacement. REFERENCE #1: Ram P et al, Carcinoid Heart Disease: Review of Current Knowledge. Tex Heart Inst J. 2019 Feb; 46(1): 21–27. REFERENCE #2: Fox DJ and Khattar RS. Carcinoid heart disease: presentation, diagnosis, and management. Heart. 2004 Oct; 90(10): 1224–1228. REFERENCE #3: Agha AM, Lopez-Mattei J, Donisan T, et alMultimodality imaging in carcinoid heart diseaseOpen Heart 2019;6:e001060. doi: 10.1136/openhrt-2019-001060 DISCLOSURES: No relevant relationships by Katherine Orengo Gomez, source=Web Response

THE HIDING HEPATIC HYDROTHORAX

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Hepatic Hydrothorax is excessive accumulation of pleural fluid in patients with decompensated liver cirrhosis without pulmonary or cardiac disease. Radioisotope diagnostic techniques are used to confirm doubtful cases of hepatic hydrothorax. [1] Here we describe an unusual case of pleural chylothorax secondary to hepatic hydrothorax(HH). CASE PRESENTATION: 68 yr-old-female with history of NASH liver cirrhosis, portal hypertension, RCC of the kidney s/p right partial nephrectomy, chronic kidney disease and MGUS presented with shortness of breath and abdominal distention. On examination she had diminished breath sounds and abdominal ascites with fluid thrill. Initial CT chest, abdomen and pelvis showed moderate right pleural effusion with liver cirrhosis and moderate ascites. During the course of her hospitalization, she underwent multiple diagnostic and therapeutic paracentesis and thoracentesis. Analysis of the pleural fluid was consistent with chylothorax, ascitic fluid had elevated triglycerides however was not diagnostic of chylous ascites. Microbiological work up was negative. No malignant cells were identified. She was started on optimal diuretic therapy. A peritoneum shunting study with SPECT/CT using technetium 99m MAA was performed with evidence of hepatic hydrothorax, following which she underwent a Transjugular intrahepatic portosystemic shun (TIPS) procedure. DISCUSSION: Spontaneous chylothorax after liver cirrhosis is a known entity. Triglyceride levels >200 mg/dl in ascitic fluid [2] and >110 mg/dl in pleural fluid is consistent with a chylous effusion. Migration of intraperitoneally infused 99mTc-labeled microspheres of human serum albumin or a sulfur colloid into the pleural cavity confirms the diagnosis of hepatic hydrothorax in unequivocal cases. The rate of isotope movement indicates the size of defects in the diaphragm. Ditah et al provided a systematic review and meta-analysis of a total of 198 patients suffering from HH where TIPS successfully eliminated the symptoms of refractory HH in 73% of cases. [3] CONCLUSIONS: In conclusion patient developed chylothorax from her ascites which was not evident on initial pleural and ascetic analysis. REFERENCE #1: [1] Dmitry Victorovich Garbuzenko, Nikolay Olegovich Arefyev, Hepatic hydrothorax: An update and review of the literature, World J Hepatol 2017 November 8; 9(31): 1197-1204 REFERENCE #2: [2] Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment Richa Bhardwaj*1, Haleh Vaziri1, Arun Gautam1, Enrique Ballesteros2, David Karimeddini3 and George Y. Wu1 1 Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT, USA; 2 Department of Pathology and Lab Medicine, UCONN Health, Farmington, CT, USA; 3 Department of Diagnostic Imaging and Therapeutics, UCONN Health, Farmington, CT, USA REFERENCE #3: [3]Ditah IC, Al Bawardy BF, Saberi B, Ditah C, Kamath PS. Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis. World J Hepatol 2015; 7: 1797-1806 [PMID: 26167253 DOI: 10.4254/wjh.v7.i13.1797] DISCLOSURES: No relevant relationships by Bharat Bhandari, source=Web Response No relevant relationships by Saadia Faiz, source=Web Response No relevant relationships by Carlos Jimenez, source=Web Response

LEFT-SIDED PLEURAL EFFUSION, ASCITES AND LEIOMYOMATA: AN UNUSUAL CASE OF PSEUDO-MEIGS' SYNDROME

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Meigs' Syndrome has been described as the development of ovarian fibroma or fibroma-like mass with pleural effusion and ascitic fluid. It is present in approximately 1% of all ovarian fibroma, thecoma and granulosa cell tumors. Pseudo-Meigs' Syndrome is secondary to benign etiologies and reported to be more uncommon. These syndromes should be considered in women with the clinical triad of pleural effusion, ascites and a pelvic mass and can mimic more serious malignant tumors [1]. A thorough evaluation including biopsy and peritoneal and pleural fluid analyses need to be performed. CASE PRESENTATION: A G0P0 29-year-old female presents with chills and fatigue since the start of her menstrual cycle. She was found to be tachycardic, tachypneic and hypoxemic to 85% with moderate abdominal distention. CT of the chest, abdomen and pelvis showed a large left-sided pleural effusion, multiple abdominal masses with compressive effect and large-volume abdominal ascites. CA-125 level was elevated at 295 U/ml. Biopsy showed small muscle proliferation with bland spindle cells and no malignant features. Thoracentesis was consistent with exudative effusion and negative cytology. Left-sided pleural effusion continued to reaccumulate requiring multiple thoracenteses. Patient underwent left pleuroscopy with pleural biopsies showing fibrotic pleura and reactive mesothelial proliferation, negative for malignancy. There was an active ascitic fluid leak into the left hemithorax through a small, thinned-out region in the dome of the left hemidiaphragm. She underwent abdominal myomectomy several months later with resolution of symptoms. Final pathology was consistent with leiomyomata. DISCUSSION: We describe a case of abdominal leiomyomatosis resulting in ascites and leak into the left hemithorax with recurrent exudative pleural effusions and resolution after surgical myomectomy, consistent with Pseudo-Meigs' Syndrome [2]. Right-sided pleural effusions are most common as pleural fluid collects due to fluid leakage from edematous tumor resulting in translocation via diaphragmatic pores into the right hemidiaphragm [3]. Effusions are exudative in nature, although in previous studies only 1.6% of patients underwent pleural fluid analysis [4]. CA-125 are typically found to be elevated, with normalization post-surgery [5]. CA-125 levels were not re-checked post-myomectomy in our case. Surgical tumor removal results in resolution of ascites and pleural effusion [5]. Therefore, in patients presenting with pleural effusion and ascites in the setting of abdominal leiomyomata, Pseudo-Meigs' Syndrome should be suspected, and pleural fluid analysis and cytology play an important role in aiding diagnosis and further management. CONCLUSIONS: The prompt evaluation of patients with leiomyomatosis presenting with ascites and large pleural effusion can be vital in guiding future interventional management. REFERENCE #1: 1. Cowan M, Crantz J, Welsh S, Nahhas W, Lindheim SR. A rare case of acute pseudo-Meigs' Syndrome presenting with pleural effusion and ascites and a ruptured leiomyoma and hemorrhagic shock. Obstet Gynecol Cases Rev. 2016. 3:070. REFERENCE #2: 2. Peparini N, Chirletti P. Ovarian malignancies with cytologically negative pleural and peritoneal effusions: demons' or meigs' pseudo-syndromes? Int J Surg Pathol. 2009 Oct; 15(5):396-7.3. Meyers MA. The spread and localization of acute intraperitoneal effusions. Radiology. 1970 Jun;95(3):547-54. REFERENCE #3: 4. Krenke R, Maskey-Warzechowska M, Korczynski P et al. Pleural effusion in Meig's syndrome - transudate or exudate? Systematic review of the literature. Medicine (Baltimore). 2015 Dec; 94(49): e2114.5. Nguyen P, Yazdanpanah O, Schumaker B. Meigs' versus Pseudo-Meigs' Syndrome: A case of pleural effusion, ascites, and ovarian mass. Cureus. 2020 Aug; 12(8): e9704. DISCLOSURES: No relevant relationships by Sally Askar, source=Web Response No relevant relationships by Patrick Bradley, source=Web Response No relevant relationships by Labib Debiane, source=Web Response No relevant relationships by Shaikh Husnain, source=Web Response

DEATH BY CHYLOTHORAX

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Chylothorax is a rare entity that is typically associated with significant morbidity and mortality. A majority of cases of chylothorax are secondary to trauma; however, a significant number of chylous effusions are due to non-traumatic causes. This case report describes a recurrent, non-surgical chylous pleural effusion in an elderly male from presumed minimal neck trauma. CASE PRESENTATION: An elderly Caucasian male with a history significant for chronic HErEF, coronary artery disease, and cirrhosis secondary to amiodarone use who presented with progressive dyspnea on exertion after sustaining blunt injury to his R shoulder. Initial chest film demonstrated a large right sided pleural effusion, which was new compared to a prior chest film obtained two weeks earlier. Pulmonary medicine was consulted to perform right sided thoracentesis. 3 liters of chylous fluid was removed. Chemistry findings of the pleural fluid were transudative based on Light's criteria; however, pleural triglyceride level was elevated at 283 mg/dL with a pleural cholesterol level less than 50 mg/dL. Flow cytometry obtained on the pleural fluid was negative for malignant cells. A bedside ultrasound was completed at the time of initial thoracentesis, which did not demonstrate any abdominal ascites. A CT chest/abdomen was obtained, which was negative for evidence of malignancy. Patient developed worsening dyspnea, which prompted repeat thoracentesis two days following his initial thoracentesis with pleural studies again consistent with chylothorax. Patient was then referred for lymphangiography to assess the thoracic duct; however, access was unsuccessful despite two attempts. The chylous effusion reaccumulated every 48 hours and required repeat large volume thoracentesis. Patient developed progressive renal failure and was ultimately transitioned to hospice care. DISCUSSION: It is thought that approximately 50% of chylothorax cases are secondary to trauma. Non-traumatic causes of chylothorax comprise about 40% cases with a majority being secondary to lymphoproliferative malignancies. Transdiaphragmatic fluid migration of chylous ascites and thoracic duct obstruction from increased portal venous pressure have also been seen in patients with underlying cirrhosis. Lymphangiography remains the gold standard for visualization of the thoracic duct; however, this is a protracted procedure with an approximate 80% success rate. There are currently no evidence based guidelines for the evaluation or management of a chylothorax. CONCLUSIONS: This case report reaffirms the notion that chylothorax continues to have a significant morbidity and mortality despite aggressive clinical evaluation. It also demonstrates that minimal trauma can potential result in a thoracic duct injury leading to recurrent chylothorax. It also highlights that there are no current evidence-based guidelines for the evaluation and management of a chylothorax. REFERENCE #1: Riley LE, Ataya A. Clinical approach and review of causes of a chylothorax. Respiratory Medicine. 2019;157:7-13. doi:10.1016/j.rmed.2019.08.014 REFERENCE #2: Guermazi A, Brice P, Hennequin C, Sarfati E. Lymphography: An Old Technique Retains Its Usefulness. RadioGraphics. 2003;23(6):1541-1558. doi:10.1148/rg.236035704 REFERENCE #3: Alejandre-Lafont E, Krompiec C, Rau WS, Krombach GA. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol. 2011;52(3):305-311. doi:10.1258/ar.2010.090356 DISCLOSURES: No relevant relationships by Jared Dyer, source=Web Response no disclosure submitted for Rebecca Potfay

S2918 Ovarian Hyper-Stimulation Syndrome as a Cause for Large Volume Abdominal Ascites

S2918 Ovarian Hyper-Stimulation Syndrome as a Cause for Large Volume Abdominal Ascites

S2591 Hepatitis C-Induced Hepatocellular Carcinoma and Direct-Acting Antivirals

Introduction: Hepatitis C virus (HCV) is a major cause of hepatocellular carcinoma (HCC). Early cure with direct-acting antiviral agents (DAAs) reduces the risk of progression to HCC and reverses the severity of fibrosis. However, there has been ongoing debate regarding whether or not the use of DAAs causes an increased risk of HCC development after achieving sustained virological response (SVR) compared to patients who do not achieve SVR. This case adds to the debate about DAAs contributing to the occurrence/ progression of HCC in patients with HCV despite achieving SVR. Case Description/Methods: A 55-year-old man with history of alcohol abuse, HCV and decompensated liver cirrhosis presented for initiation of HCV treatment. The patient endorsed 20-pound unintentional weight loss. Ultrasound (US) of the abdomen revealed hepatosplenomegaly and large abdominal ascites without any hepatic lesions (Figure 1). Alpha fetoprotein (AFP) level was 5.7 ng/mL and HCV RNA load was 25,313 IU/mL. After completion of Sofosbuvir/Velpatasvir 400-100 mg daily for 24 weeks, HCV RNA load was undetectable but AFP level was 11,728 ng/mL and abdominal US showed three solid lesions with increased vascularity (Figure 2) concerning for de novo HCC occurrence versus accelerated development of occult HCC despite achieving SVR. Triple phase CT scan of the abdomen confirmed the presence of HCC, and a right portal vein tumor thrombus (Figure 3). The patient was a poor surgical/transarterial chemoembolization candidate and relocated to another state to continue his care. Discussion: Untreated HCV poses a huge morbidity and mortality burden due to its risk of progression to HCC. The advent of DAAs has made HCV treatment available to larger patient population. Earlier literature supported the increased risk of HCC in patients with HCV who were treated with DAAs. Following this, a large French study refuted the increased risk of recurrence rate of HCV-related HCC after DAAs. However, more studies are needed, especially in decompensated patients, to extrapolate data regarding the incidence of de novo HCV-related HCC in patients who received DAA therapy and achieve SVR compared to those who did not achieve SVR. In our case, the possibility of occult HCC prior to HCV treatment cannot be ignored, but did DAAs make it more aggressive? Cases like this necessitate further research about this controversial topic especially in patients with decompensated cirrhosis and possible occult HCC at presentation.Figure 1.: US Image Of The Liver Prior To Initiation of Direct-Acting Antiviral Agents. 2: US Image of Solid Heterogenous Hepatic Lesion. 3. CT Abdomen/Pelvis with Heterogenous Enhancement in the Right Lobe of the Liver.

B-PO02-204 EVIDENCE OF TWIN ATRIOVENTRICULAR NODES IN A PATIENT WITH AN SCN5A MUTATION AND STRUCTURALLY NORMAL HEART

Twin atrioventricular (AV) nodes are known to exist in association with complex congenital cardiac lesions. Genetic determinants of AV conduction are poorly understood, although reports have implicated a role of both SCN5A and MYH6 genes. Existence of twin AV nodes in a patient with a structurally normal heart has not previously been reported. We describe a patient with normal cardiac structure demonstrating evidence of twin AV nodes, later found to harbor an SCN5A mutation (D1595N). N/A Evaluation of a 21 week fetus revealed tachycardia, abdominal ascites, and pericardial effusion. Maternal history was significant for pacemaker placement due to intermittent complete heart block. Fetal echocardiogram confirmed supraventricular tachycardia (SVT), which resolved with maternal flecainide therapy. Delivered at term, the infant had a wide-complex bradycardic rhythm with ventricular ectopy concerning for flecainide toxicity. Echocardiogram revealed severely depressed biventricular function with normal intracardiac anatomy and normal abdominal/atrial situs. The rhythm developed into a regular wide-complex tachycardia with no discernable P-waves. Amiodarone resulted in slowing and narrowing of the QRS and emergence of sinus rhythm. By 2 weeks of age, biventricular function normalized. Telemetry revealed sinus rhythm with two distinct QRS morphologies and axes, but with consistent PR intervals and QRS durations. With sinus slowing, accelerated junctional rhythms matching both QRS morphologies were observed suggesting the presence of 2 distinct AV nodes (as opposed to aberrant AV conduction). A single junctional morphology became dominant but with widening of the QRS at higher sinus and junctional rates. Sotalol was initiated with subsequent Holters showing a dominant QRS morphology and a second junctional QRS morphology during sinus pauses. Genetic testing revealed an SCN5A mutation (p.D1595N), later confirmed in the patient’s mother. The presence of twin AV nodes in a living patient with normal cardiac anatomy has not been previously described. Discovery of an SCN5A mutation is an interesting finding, although a mechanistic explanation for its role in AV node formation remains elusive.

PELVIC ORGAN PROLAPSE AND INGUINAL HERNIA AGGRAVATED BY OVARIAN FIBROTHECOMA WITH ASCITES

We present a case of pelvic organ prolapse and inguinal hernia worsened by a benign ovarian tumor with ascites. A 61-year-old woman was referred to us complaining of feeling of something protruding from her vagina. She was diagnosed with Stage III cystocele. Behavioral therapy was administered as she had only slight subjective symptoms. She visited us eight months later due to a rapid aggravation of cystocele and voiding difficulty. She subsequently developed acute abdominal pain caused by incarcerated inguinal hernia. Abdominal ultrasound, MRI and CT showed a 10.6×9.0 cm pelvic mass with ascites. As an ovarian cancer with peritoneal dissemination was suspected, she immediately underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and colposuspension. Pathological diagnosis was fibrothecoma, a benign ovarian tumor. Postoperative course was uneventful, and ascites quickly disappeared in a manner similar to Meigs syndrome. Although no procedure was done to manage inguinal hernia, it was unproblematic for 18 months, after that it worsened, necessitating hernial repair. She had no recurrence of prolapse or ascites.Increased intra-abdominal pressure due to abdominal mass or ascites can worsen prolapse and hernial diseases such as inguinal, umbilical, and abdominal hernia. In this case, ovarian fibrothecoma with ascites seemed to be responsible for worsening of the prolapse and inguinal hernia. To conclude, it is important to consider background diseases when examining patients with prolapse and coexisting hernial diseases.

P55-10 A case of peritoneal mesothelioma that recurred 27 years later

Peritoneal mesothelioma is one of the rare cancers for no effective treatment has been developed. This time, the patient was diagnosed with fallopian tube cancer at the first onset and did surgery and chemotherapy, but 27 years later, she had abdominal mass, peritoneal mesothelioma and ascites. We report including a review of the literature. A 64-year-old woman. No medical history. Onset in X-27 with a right abdominal mass. A diagnosis was right fallopian tube tumor, and laparotomy and total hysterectomy were performed. Pathological diagnosis was low to moderately differentiated adenocarcinoma. Five courses of CEP therapy were performed, and then with remission in X-27. In year X, she had a right abdominal mass, peritoneal dissemination, and ascites. Diagnosis of moderately differentiated adenocarcinoma by biopsy. Six courses of TC (+ BV) therapy were performed, and a remission was obtained on CT. Year X biopsy added immunostaining to diagnose mesothelioma. Reexamination of histopathological specimens from X-27, immunostaining could not be added, but HE staining did not show proliferation of epithelial cells. The main tumor was the mesothelium, which was re-diagnosed as mesothelioma. The tissue specimens of X-27 and X were very similar. Unlike peritoneal cancer, peritoneal mesothelioma is a malignant tumor derived from mesothelial cells and is a rare cancer, and difficult to treatment. The effects of surgery and radiation therapy are limited. CDDP + PEM therapy is often selected as the drug therapy according to pleural mesothelioma, but there is currently no treatment indicated or approved for. This time, we experienced a case in which both initial and recurrence were effective by ovarian cancer regimen, and we believe that it could be considered as one of the active treatments for peritoneal mesothelioma.

Clinical Features and Overall Survival of Females with Hepatocellular Carcinoma: A Retrospective Study and Review of the Literature in the Association of Southeast Asian Nations

IntroductionHepatocellular carcinoma (HCC) causes more than 200,000 women deaths annually. This study aimed to investigate the clinical features, provide prognostic factors for female patients with HCC, and performed a literature review on them in the Association of Southeast Asian Nations (ASEAN).Materials and MethodsWe conducted a retrospective cohort study of female patients with HCC at Thammasat University Hospital, Thailand between January 2009 and January 2019. Furthermore, important aspects of female patients with HCC in the ASEAN published in PubMed and Scopus up to October 2020 were extensively reviewed.ResultsA total of 187 female patients with HCC were included (mean age 65.7±11.9 years). Elderly females were diagnosed with HCC at a more advanced stage than younger individuals (37.0% vs 23.2%, p=0.049, OR 1.94, 95% CI 1.00–3.78) and the younger group had a significantly higher overall 2-year survival rate than the elderly group (65.0% vs 45.5%, p=0.03, OR 2.23, 95% CI 1.09–4.57). Abdominal pain (HR 9.89, 95% CI 2.85–34.38, p<0.001), ascites at presentation (HR 2.77, 95% CI 1.11–6.92, p=0.03), ruptured hepatoma (HR 14.68, 95% CI 12.60–83.09, p=0.002), advanced-stage HCC (HR 9.74, 95% CI 1.89–50.26; p=0.007), and serum hypoalbuminemia (HR 4.67, 95% CI 1.62–13.50, p=0.004) were significantly associated with poor survival rate. From the ASEAN, a total of 543 females HCC patients from 6 studies were extensively reviewed. Chronic hepatitis B infection was among the pre-existing liver disease leading to HCC in ASEAN. HCC in females of the ASEAN occurred most often at an advanced age and had a grave prognosis.ConclusionHCC affects a large number of females, especially in Thailand and the ASEAN, is diagnosed at an advanced stage and had a grave prognosis. Abdominal pain, ascites, ruptured HCC, advanced-stage HCC, and serum hypoalbuminemia are associated with poor prognosis. Early detection of HCC and prompt treatment in patients at risk could result in better survival outcomes.

Peritoneal sarcoidosis presenting with acute abdominal pain and ascites: A case report

Peritoneal sarcoidosis presenting with acute abdominal pain and ascites: A case report

Preventive and Treatment Interventions for Abdominal Ascites of Patients with Liver Cirrhosis: A Systematic Review of Randomized Controlled Trials.

AIMThis systematic review aimed to evaluate the efficacy of preventive and therapeutic approaches used in the management of ascites in liver cirrhosis.METHODLiterature review was done in “Scopus, Web of Science, CINAHL, ScienceDirect, PubMed MEDLINE, Ulakbim National Database, and Cochrane Library” databases using the keywords, “ascites, refractory ascites, liver cirrhosis, intervention, prophylaxis, treatment, nursing management, prevention, ascites management, randomized controlled trials,” and 2,447 articles were obtained. The studies with low bias risk were included. This systematic review was planned by following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement.RESULTSA total of 11 randomized controlled trials were included. When the included studies were examined, ascites treatment approaches were evaluated in all of the studies; however, preventive approaches were not evaluated. It was found that mannitol, a diuretic drug, helps ascites management by contributing to weight loss, decrease in abdominal circumference, and urinary sodium excretion. The automatic low-flow ascites pump also reduced the need for large-volume paracentesis. There was a decrease in weight and abdominal circumference measurements when band compression was applied to the umbilicus.CONCLUSIONTherapeutic approaches were found to be effective. It was thought that the lack of nursing practices and the prevention of ascites formation in the abdomen was an important deficiency. Randomized controlled trials were recommended for the prevention of abdominal ascites formation and the side effects of treatment on the patient.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Correlation of gastrointestinal perforation location and amount of free air and ascites on CT imaging

PurposeTo analyze the amount of free abdominal gas and ascites on computed tomography (CT) images relative to the location of a perforation.MethodsWe retrospectively included 172 consecutive patients (93:79 = m:f) with GIT perforation, who underwent abdominal surgery (ground truth for perforation location). The volume of free air and ascites were quantified on CT images by 4 radiologists and a semiautomated software. The relation of the perforation location (upper/lower GIT) and amount of free air and ascites was analyzed by the Mann–Whitney test. Furthermore, best volume cutoff for upper and lower GIT perforation, areas under the curve (AUC), and interreader volume agreement were assessed.ResultsThere was significantly more abdominal ascites with upper GIT perforation (333 ml, range 5 to 2000 ml) than with lower GIT perforation (100 ml, range 5 to 2000 ml, p = 0.022). The highest volume of free air was found with perforations of the stomach, descending colon and sigmoid colon. Significantly less free air was found with perforations of the small bowel and ascending colon compared to the aforementioned. An ascites volume > 333 ml was associated with an upper GIT perforation demonstrating an AUC of 0.63 ± 0.04.ConclusionUsing a two-step process based on the volumes of free air and free fluid can help localizing the site of perforation to the upper, middle or lower GI tract.Graphic abstract

Atypical Case of Minoxidil-Induced Generalized Anasarca and Pleuropericardial Effusion

Minoxidil is an antihypertensive medication used to control blood pressure that is resistant to three or more antihypertensive medications including diuretics. There have only been a few reported cases of minoxidil-induced pleuropericardial effusion with anasarca. Here, we discuss the case of a 70-year-old male with a history of uncontrolled hypertension who presented to the hospital with swelling of the extremities. He was on minoxidil 10 mg twice a day and complained of generalized body swelling and extremity pain with symptoms of dyspnea on exertion, paroxysmal nocturnal dyspnea, weight gain, abdominal distention, and intermittent, throbbing extremity pain (8/10). The patient denied a history of cardiac disease, pulmonary embolism, deep vein thrombosis, and malignancy. His vitals were stable with a blood pressure of 152/67 mmHg. The physical examination findings were significant for positive jugular vein pressure, bilateral crackles at the lung bases with abdominal distention, fluid thrill, and flank edema. The extremities showed pitting edema in the upper and lower extremities that were tender to palpation. Laboratory results were only significant for uremia and elevated brain natriuretic peptide. Electrocardiography, echocardiography, and CT of the chest and abdomen exhibited findings consistent with pericardial effusion, pleural effusion, abdominal ascites, and anasarca in the soft tissues of the axilla and chest wall. After discontinuation of minoxidil and starting intravenous diuretics, the patient showed clinical improvement. This case report reviews and explains that minoxidil-induced anasarca should be considered as a differential diagnosis in patients taking minoxidil as knowledge of this rare finding may lead to early diagnosis and management.

Childhood acute promyelocytic leukemia complicated with thrombosis: four cases and literatures review

Objective: To investigate the clinical characteristics and prognosis of children with acute promyelocytic leukemia (APL) complicated with thrombosis. Methods: The clinical profiles of four APL patients complicated with thrombosis treated at the First Affiliated Hospital of Zhengzhou University between January 2012 and December 2019 were reviewed. Literature search and review covered the China national knowledge infrastructure, Wanfang database, China biology medicine disc and PubMed using the key words of "acute promyelocytic leukemia" and "thrombosis" up to June 2020. Results: Four patients included one male and three females with an age range of 4-13 years. In two patients, thrombosis occurred intracranially, both patients presented with seizure and hemiplegia. In one patient, thrombosis occurred in spleen, the patient presented with severe abdominal pain. In the last patient, thrombosis occurred in liver, the patient presented with abdominal pain, distension and ascites. Thrombosis occurred during the course of retinoic acid treatment in three patients, it occurred before the initiation of the treatment in one patient. Thrombosis was confirmed by imaging examination in all four patients. After thrombolytic and anticoagulation treatment, the vessels were recanalized and the symptoms were alleviated in 3 cases, the fourth patient died of hepatic venous thrombosis. Literature search identified no similar reports in Chinese journals, 11 case reports were found in English journals. In these 15 patients, 9 were male and 6 females with an age range of 3-16 years. Thrombus located in brain in 6 cases, in lower limbs for 3 cases, in liver for 3 cases, in spleen in 2 cases and in coronary artery for 1 case. In 10 cases thrombosis occurred before the induce treatment and in 5 cases occurred during the induction treatment. After surgery, thrombolytic and anticoagulation treatment vascular recanalization was observed in 10 patients, and in those patients, the symptoms were relieved, death occurred in 5 patients, including three patients with hepatic venous thrombosis. Conclusions: Thrombosis may occur before or during the treatment for APL. Both arterial and venous thrombosis may occur in patients with APL. Imaging examination is a reliable method for its diagnosis. After treatment, most patients had good prognosis with recanalization of blood vessels, but the mortality rate was high for patients with hepatic venous thrombosis.

Peritoneal Lymphomatosis: The Great Mimicker

Peritoneal lymphomatosis (PL) is defined as intraperitoneal dissemination of lymphoma. Although rare, it is associated with high-grade lymphomas and can be easily mistaken for peritoneal carcinomatosis (PC) on imaging, which is a common condition associated with gastrointestinal and gynecological malignancies. Both PL and PC share similar radiographic features, however, they differ considerably in terms of prognosis and management. We present a case of a 58-year-old male with abdominal distention and ascites, initially reported as having PC on imaging. A subsequent peritoneal biopsy revealed PL secondary to a low-grade follicular lymphoma. Since PL responds well to chemotherapy, its prompt diagnosis and differentiation from PC helps avoid unnecessary surgery.

Abdominal complications in patients with a ventriculoperitoneal shunt: proposal for management recommendations from a single pediatric tertiary center.

The aim of this study was to describe our experience in the management of patients with ventriculoperitoneal shunt-related complications (abdominal pseudocyst, bowel-related complications, and ascites) and to propose treatment recommendations. A retrospective descriptive study was conducted in patients with ventriculoperitoneal shunt-related abdominal complications seen between 2009 and 2019 at a tertiary-care pediatric center. Patients were classified according to their diagnosis into the following: group A (abdominal pseudocyst), group B (bowel-related complications), and group C (ascites). The following variables were studied in all three groups: age, sex, etiology of hydrocephalus, history of pyogenic ventriculitis, history of abdominal surgery, clinical presentation, presence of ventricular enlargement on computed tomography scan, abdominal ultrasonography, shunt series X-ray, cerebrospinal fluid cultures, urgent as well as elective surgical interventions, antibiotic treatment, length of hospital stay, follow-up, and outcome. Overall, 48 patients were analyzed: group A, n=29; group B, n=15; and group C, n=4. In all cases, surgical decision-making was based on symptom severity at the time of diagnosis, presence of ventricular enlargement on computed tomography scan, and cerebrospinal fluid culture results. In patients with positive cultures, the shunt system was removed, and an external ventricular drain was placed. In oligosymptomatic patients, cerebrospinal fluid culture results were awaited to define long-term treatment and in patients with ventricular enlargement or clinically difficult-to-treat symptoms, the distal catheter was exteriorized at the thoracic level. In patients with shunt-related abdominal complications, surgical management depends on symptom severity and/or whether infection is present at the time of diagnosis.