Peritoneal Fluid Analysis Research Articles

Man With Abdominal Swelling

A 46-year-old man presented to the emergency department with abdominal swelling for 2 weeks. He had a history of hepatitis C that he treated with milk thistle for 20 years. He denied significant alcohol intake. His vital signs were normal and his examination revealed a distended abdomen that was tympanic to percussion with mild tenderness. Paracentesis was performed and milky white fluid was aspirated (Figure 1). Chylous ascites. The patient received intravenous antibiotics and was admitted for suspected spontaneous bacterial peritonitis. Peritoneal fluid analysis showed normal white cell counts and Gram stain results and triglyceride levels of 2,196 mg/dL. Computed tomography (CT) of the abdomen and pelvis showed a para-aortic mass with chylous ascites (Figure 2). Biopsy of the mass confirmed a diagnosis of lymphoma. Chylous ascites is an uncommon finding, typically caused by disturbance of the lymphatic system1Browse N.L. Wilson N.M. Russo F. et al.Etiology and treatment of chylous ascites.Br J Surg. 1992; 79: 1145Crossref PubMed Scopus (177) Google Scholar because of a mass or blunt trauma. Lymphomas are the malignancy responsible for most cases of chyloperitoneum.2Press O.W. Press N.O. Kaufman S.D. Evaluation and management of chylous ascites.Ann Intern Med. 1982; 96: 358-364Crossref PubMed Scopus (277) Google Scholar The grim prognosis of chylous ascites as a result of lymphoma makes prompt diagnosis with lymph node biopsy or laparotomy imperative.2Press O.W. Press N.O. Kaufman S.D. Evaluation and management of chylous ascites.Ann Intern Med. 1982; 96: 358-364Crossref PubMed Scopus (277) Google Scholar Surgery, chemotherapy, or radiation should soon follow.2Press O.W. Press N.O. Kaufman S.D. Evaluation and management of chylous ascites.Ann Intern Med. 1982; 96: 358-364Crossref PubMed Scopus (277) Google Scholar

Abstract CT055: Novel intraperitoneal treatment for peritoneal metastases: results from the Immunotoxin in Peritoneal Carcinomatosis (ImmunoPeCa) phase I clinical trial

Abstract Introduction: Peritoneal metastasis from colorectal cancer (PM-CRC) is a condition with poor prognosis, even in patients undergoing potentially curative treatment with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). The ImmunoPeCa trial explores the tolerability of combining intraperitoneally administered MOC31PE immunotoxin with CRS-HIPEC. MOC31PE, consisting of the monoclonal antibody MOC31, which recognizes the tumor associated cell surface antigen EpCAM, and Pseudomonas exotoxin (PE), has shown excellent anti-cancer efficacy in preclinical studies. The immunotoxin was well tolerated upon intravenous administration in a previous clinical phase I trial, where the dose limiting toxicity (DLT) was reversible liver toxicity. In this trial, MOC31PE was administered intraperitoneally in humans for the first time, with the rationale that killing residual cancer cells in the peritoneal cavity after CRS-HIPEC will improve outcome. Patients and methods: The ImmunoPeCa phase I/II clinical trial (NCT02219893) startet enrollment in 2014 and adult patients with EpCAM positive PM-CRC accepted for CRS-HIPEC were included. MOC31PE was administered on the first postoperative day through abdominal drainage catheters that were clamped for 6h before they were reopened to remove intraabdominal fluid. Standard dose escalation was applied, with four dose levels (2.5, 5.0, 7.5 and 10 μg/kg). Main endpoints were safety and toxicity (CTCAE version 4.0), and pharmacokinetic analyses of serum and peritoneal fluid were performed. Results: Twelve patients have received MOC31PE without major toxicity, and a maximum tolerated dose was not reached. Interestingly, MOC31PE was not detected in patient serum, suggesting that there was no systemic absorption of the drug. In peritoneal fluid samples at 6h and 24h MOC31PE was present in cytotoxic concentrations based on in vivo and in vitro studies, at least for the two highest dose levels, and the drug was impressively still fully active when analyzed in cell based assays. Conclusions: No DLT was observed upon peritoneal administration of MOC31PE, which is consistent with no systemic absorption. Remarkably, MOC31PE was fully active in peritoneal fluid samples 24h after treatment, with the intraperitoneal drug concentration in the cytotoxic range based on in vitro and in vivo studies. Taken together, treatment with MOC31PE represents a unique possibility for intraperitoneal treatment intensification without systemic toxicity. The highest dose level (10 μg/kg) has been chosen for further testing in a planned phase II expansion of the trial. Citation Format: Kjersti Flatmark, Yvonne Andersson, Ben Davidson, Svein Dueland, Øystein Fodstad, Ida S. Frøysnes, Karl Erik Giercksky, Lars Julsrud, Stein G. Larsen, Kari H. Olsen, Janne M T Øien. Novel intraperitoneal treatment for peritoneal metastases: results from the Immunotoxin in Peritoneal Carcinomatosis (ImmunoPeCa) phase I clinical trial. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT055.

Prognostic Significance of Molecular Analysis of Peritoneal Fluid for Patients with Gastric Cancer: A Meta-Analysis.

BackgroundAccurately distinguishing serosal invasion in patients with gastric cancer (GC) prior to surgery can be difficult. Molecular analysis of peritoneal fluid (MAPF) for free cancer cells with higher sensitivity than other methods; however, its prognostic value for GC remains controversial, precluding its application in clinical practice.MethodsPubMed, EMBASE and other databases were systematically searched. Thirty-one studies were eligible for the meta-analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled for overall survival (OS), disease-free survival (DFS) and peritoneal recurrence-free survival (PRF).ResultsThe current meta-analysis focused on patients with GC and negative cytological diagnoses. The results showed that positive MAPF status (MAPF+) led to poorer prognoses for OS (HR 2.59, 95% CI 1.99–3.37), DFS (HR 4.92, 95% CI 3.28–7.37) and PRF (HR 2.81, 95% CI 2.12–3.72) compared with negative MAPF status (MAPF-). Moreover, among the patients with GC who received curative treatment, the MAPF+ patients had poorer prognoses for OS (HR 3.27, 95% CI 2.49–4.29), DFS (HR 3.90, 95% CI 2.74–5.57) and PRF (HR 5.45, 95% CI 3.70–8.03). A meta-analysis of multivariate-adjusted HRs demonstrated that MAPF+ status was an independent prognostic factor for patients with GC who underwent curative treatment (OS: HR 2.19, 95% CI 1.47–3.28; PRF: HR 3.44, 95% CI 2.01–5.87). Using the identical target genes (CEA, CEA/CK20) as molecular markers, the patients with GC who were MAPF+ had significantly worse prognoses for OS (CEA: HR 3.03, 95% CI 2.29–4.01; CEA/CK20: HR 4.24, 95% CI 2.42–7.40), DFS (CEA: HR 3.99, 95% CI 2.24–7.12; CEA/CK20: HR 4.31, 95% CI 1.49–2.48) and PRF (CEA: HR 4.45, 95% CI 2.72–7.31; CEA/CK20: HR 6.46, 95% CI 3.62–11.55) than the patients who were MAPF-.Conclusion/SignificanceThe above results demonstrate that MAPF could be a prognostic indicator for patients with GC who have a negative cytological diagnosis and/or are receiving curative treatment. MAPF could provide clinicians with additional prognostic information that could aid in developing individualized treatment plans prior to surgery. The widely used target genes CEA, CEA/CK20 were confirmed to be valuable MAPF markers for predicting the prognosis of GC.

Accuracy of the Fast Exam: A Retrospective Analysis of Blunt Abdominal Trauma Patients

Background: Point-of-care ultrasound (POCUS) is a vital tool for diagnosis and management of emergency room patients. Focused assessment with sonography for trauma (FAST) is a bedside ultrasound performed by clinicians in the evaluation of trauma patients. In 2012, Haroborview Medical Center, the only level-one trauma center in five northwestern states, officially incorporated emergency physician (EP) performed FAST exams for critically injured blunt abdominal trauma (BAT) patients. Objective: We sought to determine the accuracy of EP performed FAST exams for severely injured patients with blunt abdominal trauma (BAT). Secondary objectives included trends in use of diagnostic peritoneal lavage (DPL) to identify hemoperitoneum after the implementation of the new protocol. Design: We conducted a retrospective chart review using the emergency department tracking system to identify all Emergency Severity Index (ESI) 1 trauma patients with BAT over a 26-month study period (July 1, 2011 to August 31, 2013). Hemodynamically unstable BAT patients who had a FAST exam performed were included for further analysis. Results of EP FAST exams and radiology department FAST exams were compared against peritoneal fluid analysis, computed tomography results, and operative findings, where available. Results: 185 patients met inclusion criteria. In total there were 33 true positive, 109 true negative, 2 false positive, 12 false negative, and 29 indeterminate examinations, for an overall sensitivity, specificity, and accuracy of 73%, 98%, and 91% respectively. EP performed FAST exams had a sensitivity, specificity and accuracy of 88% (95% CI 67 to 96 %), 98% (95% CI 87 to 99 %), and 94% for moderate to large amounts of intra-peritoneal hemorrhage. The overall use of DPL in the evaluation of critically ill blunt trauma patient decreased slightly with the protocol change, however this decrease was not significant (p=0.17). Conclusion: Our study demonstrated that emergency physicians are accurate in identifying hemoperitoneum in critically injured BAT patients. Secondary findings suggest that utilization of DPL in hemodynamically unstable BAT patients decreased modestly

SLE Ascites: An Uncommon Initial Presentation

Ascites is uncommon in systemic lupus erythematosus (SLE) and it may be secondary to common causes such as nephrotic syndrome or malignancies, however it may also be associated with active SLE inflammation. When recognized early and properly treated, the clinical course may be benign, as exemplified in the following report. 46 year old female patient, without significant medical history, came to the clinic complaining of 3 months of worsening diffuse colicky abdominal pain, associated with abdominal distention and decreased appetite. She denied constitutional symptoms, change in bowel movement or abnormal vaginal bleeding. Vital signs were within normal limits. Breath sounds were decreased bilaterally at the bases. Abdominal was mildly distended and tympanitic, with decreased bowel sounds, no tenderness, rebound or guarding. She had a hemoglobin of 11.8g/dL, leukopenia at 3000 uL (Netrophils: 68%, Lymphocytes:28%) and albumin of 3.5 mg g/dL. Basic metabolic panel, rest of liver profile, lipase, ESR, AFP, CEA, Ca19-9 and urinalysis were all within normal limits. Chest X ray revealed mild right pleural effusion and CT of the abdomen showed significant ascites. Peritoneal fluid analysis found leukocytes of 0-1, protein of 3.4 g/dL and albumin of 3 g/dL, giving a SAAG score of 0.5. BK and cultures were both negative and pathology was negative for malignancy. Upper endoscopy was unremarkable while colonoscopy revealed active pancolitis. Histology showed mild evidence of neutrophilic activity in vessel wall and lamina propia. Autoimmune disease was considered high in the differential as we had a young female patient, with pan serositis and chronic abdominal pain. Rheumathoid factor was within normal limits, anti Smith Antibody was elevated at 102 U, C3 and C4 were decreased at 23 mg/dL and 1.2 mg/dL respectively, anti-dsDNA Antibody elevated at >800, ANA: positive and transthoracic echochardiogram revealed mild pericarditis with ejection fraction of 55%. After initial inpatient intravenous methylprednisolone 1mg for three days, she was discharged with improved symptoms and to continue taking prednisone 40mg orally daily. She returned to the clinic 1 week later with decreased abdominal pain and improved appetite. Patient has been told to return for outpatient gastroenterology and rheumatology follow up in one month. Ascites as first manifestation of SLE is rare. It is a diagnosis of exclusion and other more common causes for non portal hypertension ascites such as peritoneal carcinomatosis, primary mesothelioma, peritoneal tuberculosis, and nephrotic syndrome should be considered first. The astute clinician should be aware of this entity and the utility of steroids in its resolution.

Primary peritoneal mesothelioma: A rare cause of malignant ascites

Introduction: The evaluation of peritoneal masses requires a focused, systematic approach. While peritoneal fluid analysis and axial imaging are essential to the workup, further analysis is often needed for a final diagnosis. We present a case of primary peritoneal mesothelioma mimicking peritoneal carcinomatosis of gastrointestinal origin on computerized tomography (CT) imaging. Case presentation: A 61-year-old man presented to the hospital with an approximate 1-month history of abdominal distention, dyspnea, nausea and fatigue. Peritoneal studies revealed serum-ascites-albumin-gradient (SAAG) of lessthan 1.1, consistent with non-portal hypertension ascites. CT abdomen revealed large-volume ascites with omental caking, concerning for peritoneal carcinomatosis. Peritoneal fluid cytology was initially inconclusive, prompting ultrasound-guided peritoneal biopsies, which revealed primary abdominal mesothelioma. Conclusions: Neither CT nor peritoneal cytology are typically sufficient for the diagnosis of peritoneal mesothelioma. When strong clinical suspicion exists, early tissue biopsies should be pursued.

Epidemiological studies on forestomach disorders in cattle and buffaloes.

Aim:To study epidemiology of forestomach (reticuloruminal, omasal, and abomasal) disorders in cattle and buffaloes.Materials and Methods:The 106 buffaloes and 32 cattle referred for treatment to the university large animals teaching hospital with the complaint of gastrointestinal diseases constituted the study material. The cases were diagnosed based on history, clinical examination, hematology, biochemistry, radiography, peritoneal fluid analysis and ultrasonography, rumenotomy, and postmortem. A questionnaire was prepared containing important information on housing, husbandry practices, including feeding practices and individual animal information viz. age, species, month of the year, parity, gestation (month), and recent parturition. The animals were divided into eight groups and analysis of variance was performed to study risk factors associated with each condition.Results:The forestomach disorders are widely prevalent in cattle and buffaloes between April and October, during summer and rainy season (90%) and constituted a significant proportion of diseased cows and buffaloes (138/1840) at the hospital. Different forestomach disorders and their prevalence was: Diaphragmatic hernia (DH) 17%, traumatic reticuloperitonitis (TRP) 14%, idiopathic motility disorder or vagus indigestion (VI) 22%, adhesive peritonitis (AP) 13%, frank exudative peritonitis (FEP) 12%, reticular abscess (RA) 8%, ruminal and omasal impaction (RI) 5%, and abomaso duodenal ulceration (ADU) 9%. DH and RA were significantly more common in buffaloes as compared to cattle. Similarly, impactions were more in buffaloes but its incidence was very low (5%). ADU was present in buffalo as commonly as in cows. Exclusive feeding of wheat straw was present in an abysmally low number of animals and hence could not be considered the cause of these disorders. DH was significantly higher in buffaloes (>5 years) of 5-8 years of age and TRP, VI and AP were observed in cattle and buffalo of 2-8 years of age during the second half of gestation to 1 month post-calving. FEP (12%) occurred more commonly within 1 month of parturition.Conclusions:DH, TRP, frank and AP and ADU are causes of the widely prevalent forestomach (reticuloruminal, omasal and abomasal) disorders in cattle and buffaloes.

Relationship Between Plasma and Peritoneal Fluid Concentrations of D-dimer and Transforming Growth Factor Beta 1 in Horses With Colic

The aim of the study was to analyze the correlation between D-dimer and transforming growth factor beta 1 (TGF-β1) in plasma and peritoneal fluid of horses with different types of colic. The study included 124 horses with colic and 12 control horses. The horses with colic were grouped according to diagnosis (obstructions, enteritis, ischemic problems, peritonitis, and other mixed problems), results of the peritoneal fluid analysis (transudate, modified transudate, and exudate), and outcome (survivors and nonsurvivors). There were significant weak correlations between the evaluated proteins and the diagnosis, the outcome, and the type of peritoneal fluid. However, when specific colic groups were evaluated significant (P = .0001), moderate correlations were observed between plasma D-dimer and peritoneal TGF-β1 concentrations in the enteritis (0.67) and mixed (0.82) colic groups. The results suggest a concomitant activation of the fibrinolysis system and the peritoneal local compensatory anti-inflammatory response mediated by TGF-β1 in horses with colic due to enteritis and other problems excluding obstructions, ischemic problems, and peritonitis.

Characterizing the Protective Role of Pre‐Pubertal Status in Sepsis Outcomes

Epidemiologic data suggest that pre-pubertal children exhibit a natural resistance to dying from SIRS/sepsis. We used an endotoxemia model of sterile sepsis to assess the effects of pubertal status on SIRS progression and outcome in mice. Following acute endotoxin injection (23μg/g i.p., all ~ 1:00 PM), pre-pubertal mice (25 days old) exhibited significantly better survival than post-pubertal mice (35 days old) over a 72 hour period (7 trials, n蠅50 per age group, p<0.0001). In addition to improved survival, pre-pubertal mice exhibited increased weight loss at both early (2hr) and later (20hr) time points during endotoxemia (n=20, p=0.025; n蠅50, p<0.0001). Serum endotoxin concentrations were similar in both groups at 2 and 20hr, providing argument against differential absorption as a cause for better survival in the pre-pubertal group. At 2hr, pre-pubertal mice had higher absolute white blood cell counts (n蠅50, p=0.004). By 20hr, pre-pubertal mice had similar white blood cell counts as post-pubertal mice, but exhibited a lower percentage of lymphocytes (p=0.01) and higher percentages of monocytes (p=0.0001) and eosinophils (p=0.002). Analysis of peritoneal lavage fluid showed more Ly6G+Cd11b+ cells (granulocytes) in pre-pubertal mice at 2 and 20hr (n=12, p=0.02; n>20, p=0.0001). Preliminary multiplex analysis revealed age-dependent differences in the concentrations of certain serum cytokines (n=4 per age group). At 2hr, post-pubertal mice had increased TNF-α and IL-10 while at 20hr, pre-pubertal mice showed increased IL-10, M-CSF, and G-CSF. These findings suggest that post-pubertal mice have a greater initial inflammatory response to endotoxin while pre-pubertal mice more efficiently promote later resolution. Support from DARPA

Clinico-haemato-biochemical, Peritoneal Fluid and Rumen Fluid Alterations in Buffaloes with Peritonitis

This study was designed to investigate the clinico-haemato-biochemical, rumen fluid and peritoneal fluid alteration in buffaloes with peritonitis. Buffaloes with peritonitis had anorexia, dehydration, abdominal distension, ruminal atony, pain, fever, reduced milk yield and loss of defecation. Pungent smelling peritoneal fluid was yielded on abdominocentesis. Hemato-biochemical alterations revealed absolute neutrophilia, increased levels of plasma aspartate aminotransferase, alkaline phosphatase, bilirubin, glucose, blood urea nitrogen, creatinine, globulin and fibrinogen and decreased levels of plasma sodium, potassium, calcium and chloride. Peritoneal fluid analysis showed increased total leucocyte count, neutrophil count and total protein level. Whereas, rumen liquor of diseased buffaloes had microbial inactivity, increased methylene blue reduction time, increased ammonia nitrogen and decreased total volatile fatty acids.

Diagnostic and prognostic value of hematology and clinical chemistry in bovine peritonitis associated with advanced pregnancy

The present study was conducted on 16 advanced pregnant animals (10 buffaloes and 6 cows) suffering from peritonitis. Seven buffaloes and five cows served as the control. Clinical signs included anorexia, reduced water intake, fever, recurrent and persistent tympany, depression, congested or anaemic mucous membranes and dehydration, loss of defecation or reduced faecal output. Out of 16 cases, septic peritonitis was seen in nine cases and seven had non-septic peritonitis. In general, peritoneal fluid changes were increased volume, altered colour, increased total protein, albumin and lactate concentrations and presence of degenerated neutrophils, fibrin, bacteria and gut contents and based upon the predominance of cells and other constituents, the peritonitis was further classified into fibrinous, fibrinopurulent, frank suppurative and adhesive peritonitis. Fibrinous peritonitis was diagnosed in four, fibrinopurulent in five, frank suppurative peritonitis in two and adhesive peritonitis in five cases. Hematology revealed neutrophilic leukocytosis with reversal of lymphocyte to neutrophil ratio, left shift and toxic changes in neutrophils, in majority of animals. Clinical chemistry revealed increase in globulin, aspartate amino transferase (AST), gamma-glutamyl transferase (GGT), total bilirubin, lactate and creatine phosphokinase (CK) and decrease in albumin, indicating chronic hepatitis. The present investigation was done to determine the value of hematology and clinical chemistry in the diagnosis and prognosis of peritonitis in bovines associated with advanced pregnancy, besides the utility of peritoneal fluid analysis in classifying peritonitis.

Resolution of Budd-Chiari syndrome secondary to needle foreign body migration in a dog: treatment with surgery and intravascular stenting

A 6.5-year-old, female spayed German short-haired pointer dog was presented with a two-week history of ascites. The dog was depressed with a severely distended abdomen. Peritoneal fluid analysis revealed a...

Ovarian Cancer Despite Previous Oophorectomy in Liver Transplant Patient

Introduction: Paracentesis is the initial procedure to determine the etiology of ascites. Ascites is most commonly a result of increased portal pressure; however, other less common considerations include malignancies, which account for 7-10% of cases. We present an unusual case of ovarian cancer causing malignant ascites despite a previous oophorectomy. Case Report: A 70-year-old female with hepatitis C cirrhosis status post orthotopic liver transplantation 18 years prior to presentation and total abdominal hysterectomy with bilateral salpingooophorectomy (TAHBSO) 16 years prior, presented with new abdominal distention, shortness of breath, decreased appetite, and fatigue for 1 month. Physical examination was remarkable for abdominal distention and flank dullness. Right upper quadrant ultrasound was normal and showed no cirrhosis. A doppler ultrasound of the portal vessels showed no obvious clot. A paracentesis was performed with serum-ascites albumin gradient (SAAG) of 0.4, total protein of 3300 mg/dL, and cytology revealing adenocarcinoma. EGD and colonoscopy were negative for a primary source of cancer. An MRI of the abdomen/pelvis revealed a pelvic mass and omental thickening that was most consistent with a primary ovarian tumor despite the patient having a previous TAHBSO. She underwent resection of the pelvic mass, omentectomy, left ureterolysis, and radical dissection with suboptimal cytoreduction. Pathology showed clear cell carcinoma. Her post-operative course was complicated by a cardiac event. Despite aggressive care strategies, this led to respiratory failure and death. Discussion: Peritoneal fluid analysis is indispensable in diagnosing the etiology of ascites. In the setting of a low SAAG and elevated total protein, de novo and recurrent malignancies need to be included in the differential. This is amplified in the setting of previous transplant, as malignancy is a leading cause of death in liver transplant patients on immunosuppression. As our case typifies, this includes ovarian malignancies in all females, despite their previous gynecologic surgeries.Figure 1: Imaging shows multiloculated cystic mass with septations and solid components within the left pelvis.

Evaluation of a technique for percutaneous endoscopic gastrostomy tube placement in horses

To develop and assess the short-term feasibility, maintenance, and complications associated with percutaneous endoscopic gastrostomy (PEG) tube placement in standing horses. 6 adult horses. Feasibility of the technique was evaluated in 2 horses. In each of 4 other horses, a PEG tube was maintained for 14 days and used to provide fluid requirements during the latter 7 days, before removal. Following air inflation of the stomach, each PEG tube was placed via a left intercostal approach; proper tube location was ascertained by percutaneous ultrasonography and gastroscopy. The horses underwent physical examinations, CBCs, and peritoneal fluid analyses before and at intervals after tube placement. Seven days after tube removal, horses were euthanized and necropsied. Placement of a PEG tube was feasible in all 6 horses. The 4 horses assessed long term tolerated water administration through the PEG tube and remained clinically stable throughout the 21-day experiment. However, during the period PEG tubes were in place, significant increases in some peritoneal and hematologic variables were detected. Postmortem evaluation revealed localized peritonitis in 1 horse and body wall inflammation along the PEG tube tracks in 3 additional horses. Placement and maintenance of a PEG tube were tolerated well by the study horses, although peritoneal and systemic inflammation were detectable. Fluid requirements were adequately met with this technique, which could provide an alternative method for managing chronically dysphagic horses. Nevertheless, further research is warranted to evaluate the feasibility of enteral feeding by use of this approach in horses.

Ancillary tests to improve the accuracy of laparoscopy in the diagnosis of tuberculous peritonitis

It has been suggested in your journal that laparoscopy and biopsy should be deployed to diagnose tuberculous peritonitis.1 In 1993, the World Health Organization took an unprecedented step and declared tuberculosis (TB) a global emergency.2 The prevalence of extrapulmonary TB is rising, possibly related to coinfection with HIV. In patients with extrapulmonary TB, the abdomen is involved in 11% of patients.2 Tuberculous peritonitis is believed to exhibit a female predominance; other causes of abdominal pain may delay diagnosis. Over a 2-year period, we carried out a prospective study of 92 patients admitted to the Government Medical College at Srinagar with the clinical suspicion of abdominal TB. Of these patients, 50 were subsequently proven by biopsy to have peritoneal TB. All the patients underwent the following diagnostic tests after a thorough clinical examination: erythrocyte sedimentation rate (ESR); Mantoux test; ascitic fluid analysis for adenosine deaminase (ADA) levels, Ziehl–Neelsen staining and culture of mycobacterium tubercle bacilli (MTB); and contrast enhanced computed tomography (CT) of the abdomen. We then undertook diagnostic laparoscopy. Features of a positive laparoscopy included thickened peritoneum, adhesions and peritoneal tubercles, which were biopsied (Fig. 1). Our patients were mainly young adults from rural areas, with a slight female predominance. Patients presented with fever (50%), weigh loss (40%), aneroxia (74%), malaise/pain (80%), diarrhea (10%), vomiting (40%) and constipation (25%). Physical signs were palor (74%), tender abdomen (70%), abdominal distension (50%), abdominal mass (20%), ascitis (15%) and lymphadenopathy (8%). The Mantoux test was positive in 23 patients (46%). Anaemia was present in 84% of patients and the ESR was high in 90%. Fig. 1 Adhesions between the colon and the parietal peritoneum in a patient with tuberculous peritonitis. Diagnostic laparoscopy was positive in 46 of 50 patients with biopsy-proven peritoneal TB, with a sensitivity of 92%. Contrast enhanced CT of the abdomen detected 30 of 50 cases of abdominal TB with a sensitivity of 60% and specificity of 71.42%. Ziehl–Neelsen staining for MTB of ascitic fluid was positive in only 2 patients (4%) and culture for MTB was positive in 8 cases (16%), whereas ascitic fluid polymerase chain reation (PCR) for TB increased the sensitivity to 83.33%. Ascitic fluid analysis for ADA (> 33 U/L) showed a sensitivity and specificity of 100% and 96%, respectively. Diagnostic laparoscopy was falsely positive in 10 of 42 patients who did not have TB peritonitis. Difficulties in the diagnosis of TB peritonitis owe to its nonspecific associated clinical features, unhelpful laboratory tests and a high level of false-negative tests (i.e., Mantoux test, Ziehl–Neelsen staining and culture of ascitic fluid and false-negative imaging). High levels of ascitic ADA is associated with TB peritonitis.3 Ascitic fluid was found clinically in only 15% of our patients, but may be available at the time of operation. Histopathology of peritoneal lesions is appropriate for diagnosing TB and to rule out other diseases, such as cancer. In the past, this required laparotomy4 even though the potential for laparoscopy was known before the advent of video laparoscopy.5 We agree with the previous report1 on the value of laparoscopy, but we found a false-positive rate of 18%. We suggest that the laparoscopic diagnosis of TB peritonitis be confirmed by histopathology of peritoneal lesions or ascitic fluid analysis for ADA greater than 33 U/L, depending on the local availability of these tests.

A case of inflammatory ascites

Case background:Ascites appears mainly as a consequence of portal hypertension in patients with liver cirrhosis, or can be caused by several other causes, such us congestive heart failure, peritoneal malignancy, or tuberculosis. In some cases, ascites can pose a diagnostic challenge for clinicians and in some patients, despite thorough and extensive work-up, the origin of this ascites remains unknown.Case report:In the unusual case hereby reported, a 52-year-old man developed severe ascites in a few weeks, in the absence of known liver disease or congestive hearth failure. We performed laboratory analysis, endoscopic, and imaging investigations, including abdominal contrast-enhanced computed tomography and 18-fluorodeoxyglucose-positron emission tomography. Peritoneal fluid analysis showed exudative fluid without neoplastic cells. A diagnostic laparoscopy with multiple diagnostic biopsies was carried out, but no macroscopic cause of the ascites was found; histopathological examination showed minimal aspects of diffuse and non-specific chronic inflammation.Conclusions:We decided to empirically treat the patient with steroid therapy (methylprednisolone: 0·5 mg/kg/day). Over a period of 6 weeks, his ascites resolved and at 2 months, he was in remission on low-dose methylprednisolone. Our final hypothesis was reactive inflammatory ascites. The literature on ascites and its management has also been reviewed.

Retraction: Eosinophilic Enteritis with Eosinophilic Ascites without Eosinophilia

Eosinophilic enteritis is an uncommon disease of unknown cause characterized by eosinophilic infiltration in various areas of the gastrointestinal tract with symptoms. It is generally classified according to the layer of the gastrointestinal tract involved. Eosinophilic infiltration of the serosa is the rarest form of presentation and may manifest eosinophilic ascites. We report a case of a 47-year-old man who experienced progressing abdominal pain. A diffuse erythematous change of the gastric mucosa was observed on gastrofibroscopy. An abdominal computed tomography and colonoscopy showed diffuse wall thickening of the small bowel and colon with a small amount of ascites. Eosinophilic infiltration was confirmed by multiple biopsies of the gastrointestinal tract and peritoneal fluid analysis. The patient was treated with corticosteroid and responded

Prognostic information derived from RT‐PCR analysis of peritoneal fluid in gastric cancer patients: Results from a prospective multicenter clinical trial

The purpose of this study is to define the clinical significance of the molecular analysis of peritoneal lavage fluid in patients with gastric cancer in a multicenter prospective trial. Quantitative RT-PCR with CEA and CK-20 mRNA as target markers was introduced for peritoneal lavage diagnosis in 141 patients with clinically advanced gastric cancer from 9 different institutes. We then evaluated the prognostic factors in patients and also evaluated predictive markers for peritoneal recurrence in 124 patients without peritoneal metastasis at surgery Out of the 141 cases, 140 patients were successfully analyzed by RT-PCR of peritoneal lavage fluids. According to multivariate analysis, the combined results of RT-PCR (CEA and CK-20) and CK-20 alone in addition to pathological N (pN)-stage were significantly correlated with overall survival. Multivariate analysis showed that the RT-PCR (CEA and CK-20) and CEA alone in addition to pathological T-stage, pN-stage, and histological grade were significantly correlated with peritoneal recurrence after surgery. This is the first multicenter prospective study to show that RT-PCR analysis of peritoneal lavage fluid with the combination of CEA and CK-20 markers was useful for predicting overall survival and peritoneal recurrence in patients with clinically advanced gastric cancer.

A Case for Norepinephrine versus Octreotide and Midodrine in Hepatorenal Syndrome

Introduction: Hepatorenal syndrome (HRS) type I is an uncommon, but often fatal, complication of end-stage liver disease. Prompt diagnosis and treatment is essential to sustain kidney function prior to liver transplant, which is the definitive treatment. Currently in the United States, a combination of midodrine, octreotide, and albumin is the standard of care. Norepinephrine with albumin has been shown to be effective in management of HRS type I. We report a case of HRS type I refractory to standard therapy that improved with norepinephrine and albumin. Case Report: A 67-year-old male with longstanding decompensated cirrhosis secondary to alcohol abuse and hepatitis B was admitted to the hospital from gastroenterology clinic when he was found to have worsening renal function following large-volume paracentesis, along with albumin infusion. The patient was recently treated for spontaneous bacterial peritonitis (SBP). On presentation, the patient was afebrile, hypotensive, alert, and oriented. Physical examination revealed a cachectic-appearing male in no distress, non-tender abdomen without guarding or rebound and moderate ascites. Admission labs, including peritoneal fluid analysis, were negative for SBP and showed chronic thrombocytopenia and anemia without leukocytosis. His baseline creatinine was 1 mg/dl, but on admission, his creatinine was elevated at 1.7 mg/dl and continued to rise to 2 mg/dl even after a therapeutic trial of albumin. HRS type 1 was suspected, and octreotide, along with midodrine, was added to his regimen. Despite six days of standard therapy, his renal function continued to worsen for several days to a maximum creatinine of 3 mg/dl. At that time, octreotide and midodrine were replaced with norepinephrine. The patient's renal function immediately stabilized and improved to a creatinine of 2.2 mg/dl only after 2 days, with improved urine output. During this time, pre-transplant evaluation determined that the patient was not a candidate for liver transplantation. The patient elected for hospice care, thus, the norepinephrine and albumin were discontinued. Conclusion: This case highlights the superior results of norepinephrine compared to octreotide and midodrine. Although there is scarcity of case reports or studies comparing octreotide and midodrine versus norepinephrine, this case illustrates that patients with hepatorenal syndrome type 1 may benefit from norepinephrine initially, as standard of care. Further studies are needed, which compare standard therapy of midrodrine and octreotide with norepinephrine.

Modification of an evidence-based protocol for advanced appendicitis in children

IntroductionWe previously developed an evidence-based clinical pathway for children with advanced appendicitis. The pathway standardized the choice and duration of antibiotic therapy and established discharge criteria. Initially, the pathway led to a 50% decrease in the rate of superficial and deep surgical site infections and a significant decrease in hospital length of stay. Four years after implementation, we noted an increase in the infectious complication rate and the emergence of resistant bacteria to commonly used antibiotics. In this study, we prospectively collected peritoneal fluid cultures at the time of appendectomy in an effort to optimize our antibiotic therapy and decrease complication rates. MethodsMicrobiology analysis of peritoneal fluid cultures obtained at the time of appendectomy was performed in patients with an intraoperative diagnosis of advanced appendicitis. Clinical information, including demographics, laboratory data, and postoperative outcomes were collected and compared to the historic cohort. X2, Student’s t-test, and Fisher exact test were used where appropriate. ResultsThe historic and prospective cohorts were similar with respect to clinical and demographic data. The postoperative intra-abdominal abscess rate remained unchanged (28% from 24%, P = 0.603). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated aerobic bacteria from peritoneal fluid in the prospective cohort. Thirty-two percent of these patients had Pseudomonas spp., and 12% had Enterococcus spp. or Escherichia coli resistant to cefoxitin in their peritoneal fluid cultures. DiscussionA significant proportion (40%) of children with advanced appendicitis had organisms either not susceptible or resistant to our first line antibiotic in their peritoneal fluid cultures. Our clinical pathway now recommends piperacillin-tazobactam as the most effective empiric therapy for advanced appendicitis in children. Microbiologic analysis of peritoneal fluid at appendectomy may be used to tailor antibiotic therapy in advanced appendicitis.