Paracentesis Research Articles

Safety and feasibility of a nurse-led ambulatory abdominal paracentesis service.

63 Background: Ascites is a common complication of cancer. Symptomatic ascites contributes to cancer-related morbidity and is distressing for patients (pts). Therapeutic abdominal paracentesis (TAP) provides symptom relief but requires specialized procedural knowledge and is usually performed in the inpatient setting with several days of hospitalization. Additionally, high hospital bed occupancy during the COVID-19 pandemic prevented timely admission for TAP. An Advanced Practice Nurse (APN)-led ambulatory TAP service was introduced at our center, with the aim of improving access to TAP and reducing hospital bed occupancy. Methods: A multidisciplinary team developed workflows and safety guidelines for TAP to enable right-siting of pts in a cancer day care unit. Pts were scheduled for radiologically guided insertion of abdominal drains in the morning before 10am to allow adequate time for drainage. Pre-procedure clinical examination and safety checks were performed by APNs in the day unit. Following the procedure, abdominal fluid was drained with concurrent administration of 20% IV albumin. Drains were removed by the APN and pts were examined before discharge on the same day. Data for all cancer pts requiring TAP in the day unit and hospital from 1 Jan to 30 Nov 2020 were extracted from the electronic medical record system. The primary outcome was length-of-stay (LOS). The primary safety outcome was adverse events in the day unit. Continuous data were compared using the t-test. Data analysis was done in SPSS version 22. Results: The number of TAPs performed in the day unit and general ward requiring hospitalization were 102 and 133, respectively. There was a significant reduction in average LOS with TAPs performed in the day unit vs. hospitalization (1.48 vs. 5.82 days, p<0.001) (Table). The mean difference was 4.34 (95% confidence interval 3.33 - 5.34) days saved per pt, or a saving of 443 inpatient bed days. The TAP day unit service encountered 10 adverse events (AEs) requiring admission to the ward for continued drainage. AEs were borderline baseline blood pressure, pt frailty and inability to care for an indwelling catheter. There were no infective or bleeding complications. The majority of TAPs (86.8%) were performed in one day, with the remainder over 2-days with the abdominal drain left in-situ and reattendance at the day unit the next day for further drainage. Differences in average length-of-stay with TAP in the hospital vs. day unit. Conclusions: An APN-led ambulatory abdominal paracentesis service is a safe alternative to inpatient paracentesis. Optimal utilization of a day unit enabled reduced LOS for pts with advanced cancer. This reduction in LOS was critical during a pandemic where bed demand was high. This was possible from advanced scheduling and control over the day unit capacity.[Table: see text]

S3631 The Milky Way

Introduction: Chylous ascites is a rare clinical finding indicative of peritoneal fluid containing lymphatic drainage. It is characterized by having a milky appearance that is rich in triglycerides, surpassing 110 mg/dL. This condition develops after disruption of the lymphatic system, usually secondary to trauma after abdominal surgery, malignancy, or cirrhosis. Chylous ascites accounts for less than 0.5% of cases of ascites in cirrhotic patients, presenting as progressive and painless abdominal distention. Case Description/Methods: Case of a 71 year-old male with history of cirrhosis due to hepatitis C on remission treated with elbasvir/grazoprevir, hypertension and end stage renal disease (ESRD) on hemodialysis (HD) who came to our institution after developing worsening abdominal distention with associated shortness of breath since 2 weeks prior. He denied fever, chills, cough, palpitations, chest pain, abdominal pain, hematemesis, hematochezia, or melena. Vitals signs were stable and physical exam was remarkable for a distended, tense and painless abdomen. Laboratories showed leukocytes in 7.8 x 103/uL, normocytic-normochromic anemia of 9.0 g/dL and platelets in 262 x103/ uL. Chemistry showed renal function consistent with his ESRD, without electrolyte disturbances. SGPT at 13 U/L and SGOT at 22 U/L. Anti-HBS, HBS ag and HIV ag/ab combo is nonreactive. Abd/pelvic CT scan revealed a nodular liver contour with hypertrophic changes of the left lobe compatible with chronic hepatocellular disease. The patient’s symptoms and findings were consistent with decompensated liver disease with tension ascites, for which a large-volume paracentesis was performed, removing 9L of white-milky fluid with subsequent placement of 50 g of IV albumin. The calculated serum-ascites albumin gradient (SAAG) was 2.4 g/dL consistent with portal hypertension. Ascitic fluid analysis revealed 40 cell count, 2 neutrophils, 916 mg/dL triglycerides and 90 mg/dL cholesterol, indicative of chylous ascites. Discussion: Abdominal paracentesis and analysis of the ascitic fluid are essential for the evaluation and management of chylous ascites. Management should focus on treatment of the underlying disease; however supportive measures may alleviate symptoms. These measures may include repeated paracentesis, diuretic therapy, salt and water restriction and dietary measures. It is imperative to be aware of this unusual manifestation, requiring prompt evaluation and appropriate management of the underlying pathology.Figure 1.: Ascitic fluid obtained after performing abdominal paracentesis.

Comparison of Simulation-Only vs. Simulation + Live Training in Paracentesis

Background Several studies have examined the effects of simulation and live training experiences on abdominal paracentesis skills, but no study has examined the durability of such training or compared skills retention between the simulation-only and hybrid training approaches. Methods A subset of internal medicine residents who participated in simulation-based training in abdominal paracentesis were assigned to an additional, live training experience. Procedural knowledge and skill were assessed following initial training and at six months, and compared between groups. Results Complete data was available for 29 out of 37 residents who received simulation-only training and 18 out of 23 who received simulation plus live training. There were no statistical differences in procedural skills scores at either point in time. The simulation plus live training group achieved a higher mean score on the knowledge test at six months (p=0.006). Conclusions Simulation-based training is sufficient for achieving initial mastery in abdominal paracentesis, but not for maintaining paracentesis skills at six months in the absence of structured, maintenance training. The addition of a live training experience to complement the simulation training was not sufficient to prevent skills decline.

Circulatory collapse after sheath removal in transfemoral transcatheter aortic valve implantation

An 87-year-old woman (146 cm, 42.2 kg) underwent transfemoral transcatheter aortic valve implantation (TF-TAVI) uneventfully. Following the removal of the delivery sheath and achieving access-site haemostasis, hemodynamic instability became gradually obvious. Contrast-enhanced computed tomography (CT) revealed free fluid in the retroperitoneal and intraabdominal cavities, suggestive of retroperitoneal haemorrhage (RPH), which perforated the abdominal cavity with extravasation of the contrast material (arrow), thus indicating an ongoing haemorrhage. The damaged site of the external iliac artery (arrow) was confirmed using digital subtraction angiography. The patient successfully underwent emergency endovascular aortic repair using a covered stent to seal the vascular rupture. In order to treat the abdominal compartment syndrome, approximately 2,700 ml of haemorrhagic fluid was evacuated using ultrasound-guided abdominal paracentesis. Eventually, she was discharged in a stable condition. RPH is a rare, although severe, complication of TF-TAVI, and has been reported in 0%–2.2% of cases. It is associated with a damage to iliofemoral artery, and constitutes the most frequent complication associated with vascular access, with the main predictive factors being the dimensions of small vessels, moderate or severe calcification, and centre experience. The diagnosis of RPH is often delayed due to the non-specific clinical presentations, such as flank, abdominal, back pain, and/or progressive hemodynamic instability. Although the best management protocol for RPH remains controversial, conservative management should only be applied in stable patients. In cases of uncontrollable, ongoing bleeding, endovascular treatment or embolization should be the method of choice. Open surgical intervention is rarely require. Nevertheless, if treated inappropriately, the mortality rates remain high.

Culture negative neutrocytic ascites versus culture positive spontaneous bacterial peritonitis; Is there a Difference; A Multi-Centric Study

Background: There are two variants of spontaneous bacterial peritonitis (SBP) include, culture negative neutrocytic ascites (CNNA) and culture positive SBP. Some suggested that, the clinical presentation of two variants is nearly similar, however, other reported that, patients with culture positive have a more severe course and higher mortality than CNNA. The aim of this study is to determine the clinical characteristics and predictors of CNNA in comparison to culture positive SBP. Materials and methods: This study included 300 consecutive patients with HCV related cirrhotic ascites. All patients underwent abdominal paracentesis and the ascitic fluid was processed for cell count and culture. Clinical and laboratory parameters of these patients were recorded at index admission.. Results: Out of 300 patients included in the study, 150 patients had SBP. Among the 150 patients with SBP, 100 patients were culture positive SBP (culture positive SBP with ascitic fluid PMNL ≥250 cells/m3) and 50 patients were CNNA (culture negative SBP with ascitic fluid PMNL ≥250 cells/m3). Compared to patients with culture positive SBP, patients with CNNA showed, a significant decrease as regards, fever, prevalence of DM, hepatic encephalopathy, platelets, blood PMNL and ascetic PMNL. Logistic regression analysis demonstrated that, decreased platelets count, blood PMNL and ascetic PMNL were independent predictor factors for CNNA. Conclusion: Patients with CNNA have a lower incidence of fever, prevalence of diabetes mellitus, hepatic encephalopathy, blood PMNL and ascetic PMNL versus culture positive SBP. Independent predictors of culture negative SBP are decreased platelets, blood PMNL and ascetic PMNL.

Deciphering the diagnostic dilemma of abdominopelvic tuberculosis and advanced ovarian cancer

Abdominopelvic tuberculosis often poses a diagnostic challenge due to its bizarre clinical features and inconclusive imaging features. Most such patients were categorized under advanced ovarian cancer and undergo radical cytoreductive surgery with its associated morbidity, which would otherwise resolve spontaneously with medical management. This is a retrospective study of ten patients referred to the Department of Surgical Oncology between November 2015 to October 2018 in a tertiary care centre at south Tamil Nadu, India as advanced ovarian cancer and later diagnosed to have tuberculosis.In 10 patients, the mean age was 34 years; mean CA125 was 496.6 IU/ml. abdominal pain and distension, loss of weight were seen in 70% of cases, respectively.Only one patient had a prior history of tuberculosis. The imaging findings were complex adnexal mass in 9 patients (90%), ascites in 6 patients (60%) and omental stranding in 6 patients (60%). Abdominal paracentesis was done in 6 patients (60%) and all had lymphocyte rich effusion. The diagnosis is established by laparotomy and biopsy in seven patients (70%), diagnostic laparoscopy in two patients (20%) and image-guided trucut biopsy in one patient (10%) with histopathology revealing caseating granulomas. With our patients' experience, a high index of suspicion is always needed whenever we encounter young women presenting with ascites, adnexal mass and elevated serum CA125 even when the routine investigations for tuberculosis reveal negative findings. The biopsy is the gold standard for establishing the diagnosis and to commence therapy.

Cohort study of hospitalists’ procedural skills: baseline competence and durability after simulation-based training

ObjectivesHospitalists are expected to be competent in performing bedside procedures, which are associated with significant morbidity and mortality. A national decline in procedures performed by hospitalists has prompted questions about...

Study of Ascitic Fluid Micro RNA-155 in Patients with Spontaneous Bacterial Peritonitis

Background: In patients with cirrhosis, spontaneous bacterial peritonitis is the most common bacterial infection. This research aims at studying the ascititc fluid Micro RNA-155 as a possible biomarker in spontaneous peritonitis. Method: 187 liver cirrhosis and ascites were chosen, 97 SBP patients and 90 SBP patients, all patients had historical history, thorough and local examination, comprehensive investigations, abdominal ultrasonography, diagnostic abdominal paracentesis and Micro RNA-155 evaluation. Results: in SBP, the average value of TLC, Polymorphene, and RNA-155 was considerably greater than non SBP, but in the SBP group the average value of ascetic albumin, glucose, and protein was considerably lower than in the non-SBP group. For MiR-155, the optimal balance of sensitivity and specificity was 0.022 for ROC as a marker with sensitivity 60 percent and specificity 62.0 percent and surface area under curve 0.639. No statistically significant link exists among SBP patients among Micro RNA-155 with TLC, polymorphs, MELD score and Child Pugh score values. Conclusion; Although MiR-155 was increased in the ascetic fluid of SBP patients, and is a predictor for SBP development, it cannot be employed as diagnostic marker in the SBP, according to this research.

Efficacy and safety of abdominal paracentesis drainage on patients with acute pancreatitis: a systematic review and meta-analysis

ObjectivesTo conduct a systematic review and meta-analysis of the efficacy and safety of abdominal paracentesis drainage (APD) in patients with acute pancreatitis (AP) when compared with conventional ‘step-up’ strategy based...

Biliary peritonitis due to liver cyst rupture in autosomal dominant polycystic kidney disease

BackgroundAutosomal dominant polycystic kidney disease (ADPKD) is the most frequent genetic kidney disease and polycystic liver disease is its major extrarenal manifestation, however biliary peritonitis due to a liver cyst rupture is extremely rare.Case presentationThe patient was a 71-year-old Japanese woman who was diagnosed with ADPKD 3 years previously and developed right abdominal pain suddenly 1 month previously. As abdominal computed tomography (CT) showed a ruptured liver cyst in the right lobe, she was admitted to our hospital. Her symptoms improved with conservative management and she was discharged from the hospital after 1 week. Although she was asymptomatic for a while, she noticed abdominal distension and general malaise at 1 month after hospital discharge. Since abdominal CT showed massive ascites, she was admitted to our hospital again. A physical examination revealed abdominal distention without tenderness. Her serum creatinine, alkaline phosphatase, γ-glutamyl transpeptidase, total bilirubin, and CA19-9 were elevated. Abdominal paracentesis revealed amber transparent ascites and the bilirubin and CA19-9 concentrations were high. She was diagnosed with biliary peritonitis due to a ruptured liver cyst. Hemodialysis treatment was initiated with drainage of the ascites. The outflow of the ascites was no tendency to decrease and drip infusion cholangiography (DIC)-CT revealed a communication between the ruptured cyst and an intrahepatic bile duct. On day 31, she was transferred to a university hospital and abdominal surgery was performed. After removing the necrotic roof of the ruptured cyst on the right liver lobe, the orifice of the bile leakage was sutured. Cholecystectomy was performed and cholangiography showed no stones in the common bile duct. Abdominal CT one month after the operation showed no recurrence of ascites and she was discharged on day 49. Hemodialysis treatment was discontinued immediately after discharge because urine volume increased and her creatinine level decreased. There has been no recurrence of ascites since then.ConclusionsWhile rare, biliary peritonitis can occur in association with the rupture of a liver cyst in ADPKD patients due to communication between the cyst and the intrahepatic bile duct, and DIC-CT should be recommended when biliary cyst rupture is suspected.

Abdominal paracentesis drainage attenuates intestinal mucosal barrier damage through macrophage polarization in severe acute pancreatitis.

Abdominal paracentesis drainage (APD), as an effective treatment of severe acute pancreatitis (SAP) in clinical settings, can ameliorate intestinal barrier damage and the overall severity of SAP. However, the mechanism underlying therapeutic effects of APD on damaged intestinal mucosal barrier during SAP is still unclear. Here, SAP was induced by injecting 5% Na-taurocholate retrograde into the biliopancreatic duct of rats to confirm the benefits of APD on enteral injury of SAP and further explore the possible mechanism. Abdominal catheter was placed after SAP was induced in APD group. As control group, the sham group received no operation except abdominal opening and closure. By comparing changes among control group, sham group, and APD group, APD treatment obviously lowered the intestinal damage and reduced the permeation of intestinal mucosal barrier, which was evidenced by intestinal H&E staining, enteral expression of tight junction proteins, intestinal apoptosis measurement and detection of serum diamine oxidase, intestinal fatty acid binding protein and D-lactic acid. Furthermore, we found that APD polarized intestinal macrophages toward M2 phenotype by the determination of immunofluorescence and western blotting, and this accounts for the benefits of APD for intestinal injury in SAP. Importantly, the protective effect against intestinal injury by APD treatment was mediated through the inhibited ASK1/JNK pathway. In summary, APD improved the intestinal mucosal barrier damage in rats with SAP through an increasing portion of M2 phenotype macrophages in intestine via inhibiting ASK1/JNK pathway.

Abdominal paracentesis drainage attenuates intestinal inflammation in rats with severe acute pancreatitis by inhibiting the HMGB1-mediated TLR4 signaling pathway.

BACKGROUNDOur previous studies confirmed that abdominal paracentesis drainage (APD) attenuates intestinal mucosal injury in rats with severe acute pancreatitis (SAP), and improves administration of enteral nutrition in patients with acute pancreatitis (AP). However, the underlying mechanisms of the beneficial effects of APD remain poorly understood.AIMTo evaluate the effect of APD on intestinal inflammation and accompanying apoptosis induced by SAP in rats, and its potential mechanisms.METHODSSAP was induced in male adult Sprague-Dawley rats by 5% sodium taurocholate. Mild AP was induced by intraperitoneal injections of cerulein (20 μg/kg body weight, six consecutive injections). Following SAP induction, a drainage tube connected to a vacuum ball was placed into the lower right abdomen of the rats to build APD. Morphological changes, serum inflammatory mediators, serum and ascites high mobility group box protein 1 (HMGB1), intestinal barrier function indices, apoptosis and associated proteins, and toll-like receptor 4 (TLR4) signaling molecules in intestinal tissue were assessed.RESULTSAPD significantly alleviated intestinal mucosal injury induced by SAP, as demonstrated by decreased pathological scores, serum levels of D-lactate, diamine oxidase and endotoxin. APD reduced intestinal inflammation and accompanying apoptosis of mucosal cells, and normalized the expression of apoptosis-associated proteins in intestinal tissues. APD significantly suppressed activation of the intestinal TLR4 signaling pathway mediated by HMGB1, thus exerting protective effects against SAP-associated intestinal injury.CONCLUSIONAPD improved intestinal barrier function, intestinal inflammatory response and accompanying mucosal cell apoptosis in SAP rats. The beneficial effects are potentially due to inhibition of HMGB1-mediated TLR4 signaling.

Should Patients Hospitalized for Decompensated Cirrhosis Receive Intravenous Albumin

Guidelines recommend intravenous (IV) albumin for patients with cirrhosis after large-volume paracentesis and for patients with spontaneous bacterial

Development of a north-west London paracentesis simulation course for core medical trainees

We designed, implemented and evaluated a near-peer simulation training programme teaching diagnostic and therapeutic abdominal paracentesis to core medical trainees (CMTs). We taught diagnostic and therapeutic abdominal paracentesis to 77 north-west London CMTs over 8 training days over 4 years, 2015 to 2019. The programme was optimised by use of plan, do, study, act (PDSA) cycles and the content was evaluated by anonymous pre- and post-course questionnaires. There was a need for this training; 89% of participants reported inadequate training opportunities pre-course and only 28% felt 'confident' or 'very confident' to insert an ascitic drain. Simulation training appears effective when teaching these skills. Having been low in confidence before the course, all participants reported increased confidence after completing the course. Simulation training has been highlighted as a key aspect of the new internal medicine training programme, which replaces CMT. We would recommend using PDSA cycles to implement effective simulation programmes.

Comparative Accuracy of Ultrasound and Physical Examination Conducted by Clinical Year Medical Students in Diagnosing Ascites

Background: Accurate diagnosis of ascites is crucial before abdominal paracentesis can be performed. Physical examination alone can be inaccurate and lead to incorrect clinical decision making. Objective: We aimed to evaluate and compare the accuracy of physical examination and ultrasound conducted by clinical year medical students after short ultrasound training session. Materials and Methods: This was a prospective quasi experimental study conducted from January 2020 to April 2020. The sample consisted of 18 clinical-year medical students at Srinagarind Hospital Emergency Department. Ultrasound training (intervention) was provided by one specialist in emergency ultrasound. Five volunteer patients were evaluated for ascites using two modalities (physical examination [PE; pre-intervention] and ultrasound [post-intervention]). Participants then responded to a questionnaire constructed to evaluate the relative ease of use of each modality as well as students’ confidence and satisfaction. Data were compared using the McNemar test, and p<0.05 was considered statistically significant. Results: Eighteen medical students were included. Participants were able to diagnose ascites in the five patient volunteers using PE with a sensitivity of 74.2%, specificity of 94.4%, positive predictive value (PPV) of 95.2%, and negative predictive value (NPV) of 70.8%. Subsequent ultrasound examination yielded a sensitivity of 90.7%, specificity of 97.2%, PPV of 98%, and NPV of 87.5%. Use of ultrasound increased diagnostic accuracy from 82.2% to 93.3% and yielded higher mean ease and satisfaction scores. However, the average confidence score was lower and time required to perform the procedure was longer. Conclusion: Medical students were able learn to use an ultrasound device after a short training session with an expert. Ultrasound yielded higher diagnostic accuracy for ascites. Future studies should be conducted regarding the inclusion of ultrasound training programs in medical education curricula. Keywords: Ultrasound, Ascites, Emergency medicine, Medical curriculum

Ascites in peripartum cardiomyopathy: case report

Ascites is the abnormal accumulation of excess fluid in peritoneal cavity.1 Normally, peritoneal cavity contains 25–50 mL of ascitic fluid, which allows for the movement of bowel loops past one other and helps hydrate serousal surfaces. Cirrhosis is the most common cause of ascites in the Western world (75%), followed by peritoneal malignancy (12%), heart failure (5%) (include peripartum cardiomyopathy), and peritoneal tuberculosis (2%). A 19-years-old woman diagnosed with peripartum cardiomyopathy. She came with chest pain and increased of her abdominal perimeter since 6 month ago, a month after she got cesarean delivery. She was given high protein and low sodium diet, water restriction, treated with furosemide 40 mg, spironolactone 25 mg, and abdominal paracentesis with total 1500 cc of yellowish ascites fluid was evacuated. Early detection is required in this case to ensure effective management without any complications. Treatment depends upon the cause of the ascites. Dietary sodium restriction and diuretics remains the first line therapy for its management. The use of diuretics needs close monitoring and follow up, including weight loss, electrolytes, and patient’s condition daily.

PERFORATIVE PERITONITIS IN NEWBORNS: INSTRUMENTAL AND MORPHOLOGICAL EXAMINATION FINDINGS

The aim: To study and analyze the results of instrumental diagnostic measures and morphological verification of perforations of abdominal viscera in peritonitis in newborns, their importance in timely diagnosis, as well as to present authors’ experience of examining newborns with PP, taking into account the complexity of diagnosis and treatment of these patients. Materials and methods: The study is based on the results of examining 59 newborns with PP of various etiologies. Instrumental methods that were used in the diagnosis of PP and differential diagnosis of other emergencies involved the following: radiological examination (plain abdominal radiography), abdominal and retroperitoneal ultrasound, neurosonography, echocardiography, diagnostic abdominal paracentesis. Morphological verification of hollow viscus perforations was performed by methods of histologic examination in 54 newborns who underwent surgery. Results: It is emphasized that perforations in NEC and spontaneous gastrointestinal perforations have clinical and morphological differences. The analysis of morphological data showed absence of intestinal musculature or muscular wall defect in spontaneous gastrointestinal perforations. Perforations in NEC had massive gastric or bowel wall necrosis. Morphogenesis of gastrointestinal perforations in newborns is crucial for developing correct treatment strategy and choosing surgical approach. Conclusions: Diagnosis of PP in newborns should be comprehensive and include modern instrumental studies that enable to reliably establish the cause of peritonitis and indications for surgical treatment. Differential diagnosis of PP in newborns with other diseases aims to differentiate PP from a number of similar clinical symptoms of urgent conditions in order to conduct adequate preoperative preparation and appropriate surgery. Diagnostic markers of PP involve the following: pneumoperitoneum, free fluid in the abdomen, sentinel loop (intestinal distention), fixed bowel loop, cloudy brown or greenish intra-abdominal fluid with a large number of leukocytes and bacteria.

Palliative Long-Term Abdominal Drains Versus Large Volume Paracentesis in Refractory Ascites Due to Cirrhosis (REDUCe Study): Qualitative Outcomes

ContextPalliative care remains suboptimal in end-stage liver disease (ESLD). ObjectivesWe report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomized to either palliative long-term abdominal drains (LTADs) (allow home drainage) vs. large volume paracentesis (LVP) (hospital drainage). MethodsConcurrent embedded qualitative study in a 12-week feasibility randomized controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim, and analyzed using applied thematic analysis, considered in terms of a pathway approach toward accessing health care. Quantitative outcomes were collected (integrated palliative outcome scale, short-form liver disease quality of life, EQ-5D-5 L, Zarit Burden Interview-12). ResultsFourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognizing the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient's journey by removing the need for hospital drainage. Additional benefits included personalized care, improved symptom control of ascites, being at home, and regular support from community nurses. Nurses also viewed the LTAD favorably, though expressed the need for additional support should this become standard of care. ConclusionPatients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible. Trial registrationISRCTN30697116, date assigned: 07/10/2015.

Unusual Case of Hepatic Sinusoidal Obstruction Syndrome Induced By Low Dose Oral Cyclophosphamide

Hepatic sinusoidal obstruction syndrome (SOS) has been reported in patients receiving high dose intravenous (IV) cyclophosphamide especially as a part of preparative regimen for hematopoietic stem cell transplantation. Hepatic SOS from low dose oral cyclophosphamide has not been reported. Here we present a rare case of hepatic SOS induced by low dose oral cyclophosphamide. A 78-year-old male with history of coronary artery disease status post coronary artery bypass graft (CABG) was initially seen in hematology clinic for evaluation of normocytic anemia. During workup, bone marrow biopsy revealed NK cell large granular lymphocytic leukemia (LGL). He was then started on low dose oral cyclophosphamide 50 mg daily. After 2 months, his dose was reduced to 25 mg daily due to severe neutropenia. He then tolerated cyclophosphamide well and his hemoglobin (Hb) improved from his baseline 8 gm/dl to 12 gm/dl in 4 months. After 6 months of treatment, he was admitted to the hospital for abdominal distension, ascites and 15 pounds weight gain over 3 weeks. Labs most prominent on admission were Hb of 12.5 gm/dL , WBC 5.3 x 103/µL, Platelets 197 x 103/µL, total bilirubin 1.6 mg/dL, aspartate aminotransferase (AST) 89 U/L , alanine aminotransferase (ALT) 35 U/L and alkaline phosphatase (ALP) 283 U/L. Workup of ascites included abdominal paracentesis which revealed serum ascites albumin gradient(SAAG) <1.1 and fluid cytology was negative for carcinoma. Ultrasound of abdomen showed diffuse parenchymal heterogeneity and increased echogenicity of liver with patent hepatic vessels with normal direction of blood flow. Echocardiogram revealed preserved left ventricular systolic function with estimated left ventricular ejection fraction of 60%. He then underwent transjugular liver biopsy which revealed chronic lymphoproliferative disorder of NK cells, prominent centrilobular sinusoidal dilatation and congestion, lobular disarray, cholestasis and sinusoidal fibrosis suggestive of veno-occlusive disease secondary to drug/toxin induced liver injury. The Naranjo adverse drug reaction probability scale indicated a probable relationship between hepatic SOS and cyclophosphamide. Cyclophosphamide was held. Bone marrow biopsy showed the patient was in remission. His liver enzymes are improving and hematologic counts continue to be stable while on observation. High dose of IV cyclophosphamide given as myeloablative therapy in combination of total body irradiation or busulfan (or other agents) in preparation for hematopoietic stem cell transplantation can induce hepatic SOS, which can be severe leading to acute liver failure and death. The diagnosis is usually based on clinical features of tender hepatomegaly, weight gain, ascites and jaundice. Liver biopsy is usually diagnostic. Mechanism of injury is related to direct toxic effects of cyclophosphamide on sinusoidal cells in the liver, causing their necrosis and release into the sinusoids, obstruction and obliteration of hepatic veins. This case demonstrates that hepatic SOS can also be caused by low dose oral cyclophosphamide. Given this rare occurrence, it is prudent for the clinicians to keep an open mind and consider hepatic SOS as a potential side effect even with oral cyclophosphamide. Disclosures Yacoub: Novartis: Speakers Bureau; Agios: Honoraria, Speakers Bureau; Incyte: Speakers Bureau; Hylapharm: Current equity holder in private company; Cara Therapeutics: Current equity holder in publicly-traded company; Ardelyx: Current equity holder in publicly-traded company; Dynavax: Current equity holder in publicly-traded company; Roche: Other: Support of parent study and funding of editorial support.

Clinical usage of serum albumin to ascitic fluid albumin gradient and ascitic fluid total protein in pediatric ascites

Abdominal paracentesis is performed as a diagnostic test in children with ascites. Serum albumin to ascitic fluid albumin gradient (SAAG) is frequently used in adults to distinguish types of portal hypertension. We aim to investigate the utilization of SAAG and other biomarkers in determining the etiology of significant ascites in children. In this retrospective study, children aged 0-21 years with significant ascites were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and medical records during the period 1983-2010. Medical records of children who had abdominal paracentesis were examined in detail. 207 children had significant ascites and of those children, 20 (9.6%) had abdominal paracentesis. Our data showed that high albumin gradient (SAAG ≥ 1.1 g/dL) differentiates causes of ascites secondary to portal hypertension (cirrhosis, hepatic vein outflow obstruction, or congestive hepatopathy) from other causes. In addition, ascitic fluid total protein (AFTP) may help in differential diagnosis of ascites. Children with high SAAG manifest clinical features of portal hypertension including esophageal varices or variceal hemorrhage. Among patients with initially unclear causes of ascites, SAAG and AFTP can provide guidance for appropriate investigations.