Ascites In Children Research Articles

Clinical profiles and causes of ascites in children at a tertiary care hospital, Bangladesh

Background: Ascites is an accumulation of serous fluid within the peritoneal cavity. Combined analysis of laboratory data and clinical and pathological details are essential for establishing a differential diagnosis. In children of Bangladesh our context, etiologies behind ascites are not yet studied well. The aim of our study was to evaluate the causes of ascites in the basis of clinical feature and laboratory investigation in children. Methods: This was a cross-sectional retrospective descriptive hospital-based record review of a tertiary center of hospital, Bangladesh. All children aged between 6 months to 17 years with ascites, irrespective of their primary cause admitted in pediatric ward were included in this study. The study was conducted during September 2019 to September 2020. During this period, 50 children presented with ascites were enrolled in the study. Result: The mean age was 8.174. The age range of the patients was from 6 months to 17 years. Twenty-eight (56.0%) of them were males and 44% of the participants were female. Maximum 54% have duration more than 7 days. The most common previous symptoms were fever (68%) and jaundice (38%) followed by bleeding manifestation (30%). The most common etiology of ascites was Chronic liver disease with portal HTN (48%), followed by abdominal tuberculosis (14%). Conclusion: This study found that CLD with Portal HTN is the most common cause of ascites in pediatric age group and second most common cause is infectious cause e.g. abdominal tuberculosis. This also highlighted that the presenting symptoms and laboratory parameter that guided to find out the causes of ascites.

Ascites and Chronic Liver Disease in Children.

Development of ascites in children with chronic liver disease is the most common form of decompensation. It is associated with a poor prognosis and increased risk of mortality. A diagnostic paracentesis should be performed in liver disease patients with- new-onset ascites, at the beginning of each hospital admission and when ascitic fluid infection (AFI) is suspected. The routine analysis includes cell count with differential, bacterial culture, ascitic fluid total protein and albumin. A serum albumin-ascitic fluid albumin gradient of ≥1.1g/dL confirms the diagnosis of portal hypertension. Ascites has been reported in children with non-cirrhotic liver disease like acute viral hepatitis, acute liver failure and extrahepatic portal venous obstruction. The main steps in management of cirrhotic ascites include dietary sodium restriction, diuretics and large-volume paracentesis. Sodium should be restricted to maximum of 2mEq/kg/d (max 90mEq/d) of sodium/day. Oral diuretic therapy comprises of aldosterone antagonists (e.g., spironolactone) with or without loop-diuretics (e.g., furosemide). Once the ascites is mobilized, the diuretics should be gradually tapered to the minimum effective dosage. Tense ascites should be managed with a large-volume paracentesis (LVP) preferably with albumin infusion. Therapeutic options for refractory ascites include recurrent LVP, transjugular intrahepatic porto-systemic shunt and liver transplantation. AFI (fluid neutrophil count ≥250/mm3) is an important complication, and requires prompt antibiotic therapy. Hyponatremia, acute kidney injury, hepatic hydrothorax and hernias are the other complications.

Management of Liver Related Ascites in Children

Management of Liver Related Ascites in Children

Etiology of ascites in 165 children

To study the etiology and clinical features of children with ascites, so as to provide a basis for the diagnosis and treatment of ascites in children. The medical data of the children with ascites, who were hospitalized from January 1, 2010 to December 31, 2019, were retrospectively reviewed. Among the 165 children with ascites, the male/female ratio was 1.53:1, and the mean age of onset was (6±4) years. The causes of ascites included surgical acute abdomen (39 children, 23.6%), infectious diseases (39 children, 23.6%), neoplastic diseases (27 children, 16.4%), hepatogenic diseases (18 children, 10.9%), pancreatitis (10 children, 6.1%), cardiogenic diseases (8 children, 4.8%), rheumatic immune diseases (6 children, 3.6%), and nephrogenic diseases (5 children, 3.0%). According to the age of onset, there were 33 infants, 24 young children, 30 preschool children, 41 school-aged children, and 37 adolescents. Surgical acute abdomen and hepatogenic diseases were the main causes of ascites in infants (P<0.05). Neoplastic disease was the leading cause in young children (P<0.05). Infectious diseases were the most common cause in adolescents (P<0.05). Surgical acute abdomen, infectious diseases, neoplastic diseases, and hepatogenic diseases are the common causes of ascites in children, and there are some differences in the leading cause of ascites between different age groups.

Peritoneovenous Shunt for Intractable Ascites in Children: A Series of 4 Cases.

Intractable ascites is a rare condition in children mainly caused by cirrhosis or lymphatic disorders. Internal drainage may be considered as rescue therapy. In our department, 4 patients ages from 2 months to 15 years old underwent a peritoneovenous shunt (PVS) placement between 2010 and 2020. The surgically inserted device was a pumping device that enabled to drain ascites from the peritoneum into the venous system via the internal jugular vein (Denver shunt, BD Company, NJ). Immediate efficient drainage was achieved in all cases and lasted up to 9 years. Two major complications occurred: a postoperative fat embolism requiring urgent temporary ligation of the shunt and endocarditis shortly after inguinal hernia repair performed 16 months after placement of the shunt. Implementation of a PVS may be a useful procedure in patients with refractory ascites. Chylous ascites should be drained and washed totally before activating the device to avoid fat embolism. Antibiotic prophylaxis is required when abdominal surgery is planned while the device is in place.

Intranodal Lymphangiography and Lymphatic Embolization for Management of Iatrogenic Chylous Ascites in Children.

Background: To demonstrate the value of intranodal lymphangiography (INL) and lymphatic embolization (LE) in management of iatrogenic chylous ascites in children who fail conservative management. Methods and Results: Retrospective review of medical records revealed six patients (four males and two females; age range 11-39 months) who underwent eight INLs and three LEs between 2017 and 2019. In one patient, the leak was visualized and embolized. In three patients, the leak was not visualized and no embolization was done, but drain output decreased and INL was not repeated. In two patients, the leak was not visualized and no embolization was done, but drain output did not decrease and INL was repeated. Repeat INL identified a leak in one patient and targeted LE was done. Repeat INL did not identify a leak in the other patient, but empirical LE was performed at the sites suspicious for leakage after multidisciplinary discussion. INL was able to identify the site of lymphatic leak in two patients (33%). In the three patients who underwent LE (two targeted at the site of identified leak and one empirical at sites suspicious for leak), one (33%) was clinically successful and the other two required surgery to address the lymphatic leak. In three patients, chylous ascites resolved after INL alone with no additional interventions. Three patients developed complications after the procedure, but only one appears to be related to the procedure itself. Follow-up for 13.8 months (13-26 months) revealed no long-term complications or mortality. Conclusion: INL with or without LE is a safe treatment for iatrogenic pediatric chylous ascites. Early utilization before more invasive surgical intervention should be considered in light of the response to INL.

Management and Outcome of Chylous Ascites in Children: A CARE compliant Case Series

Background: Chylous ascites (CA) is accumulation of lipid rich lymph in peritoneal cavity. CA is rare among children. In pediatric age, causes of CA varies according to the age group, leading primary causes include congenital malformation of lymphatic system, and less likely lymphatic obstruction such as intestinal malrotation, gastroschisis, infections or trauma of thoracic duct. Aim of the work: We aim to report outcome of congenital CA in a pediatric cohort. Material and Methods: Retrospective analysis of data of 4 children (4 boys) who presented by CA to New Children Hospital, Cairo University during 2010- 2018. Results: Duration of follow up of the boys was 6.5, 5, 2.5, and 0.25 years respectively. All presented by abdominal distention and diagnostic tapping of ascitic fluid revealed triglyceride level more than 200 mg%, protein more than 2 g% and/or a cell count greater than 500 /cmm with a predominance of lymphocytes (> 80%). Lymphatic scintigraphy in 3 of them revealed no abnormality in lymph drainage. The course of disease was punctuated by chylothorax, and chylous hydrocoele in all 4 cases. All 4 did not respond to medium chain triglyceride based diet. One child underwent peritenovenous shunt, and the other 3 responded to somatostatin analogue octreotide SC injections during hospital stay and maintenance therapy. Last child was lost to follow up. All other 3 are fine with minimal complications and living with mild peritoneal ascites. Conclusion: Somatostatin analogue therapy provided well-tolerated non-invasive control of congenital CA in our studied pediatric cohort. Surgical intervention should be restricted to those with underlying surgical cause and in those failing to respond to medical treatment.

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.

Ascites in children with extrahepatic portal venous obstruction: Etiology, risk factors and outcome

BackgroundAscites in extrahepatic portal venous obstruction (EHPVO) is uncommon. We studied the etiology and natural history of ascites and risk factors of post-bleeding ascites in children with EHPVO. MethodsAll admitted EHPVO patients with clinically detectable ascites and/or gastrointestinal (GI) bleeding in previous 6 weeks were analysed. Subjects with ascites were classified as post-bleeding ascites and de-novo ascites (no GI bleeding) Post-bleeding ascites group was compared with controls (GI bleeding without ascites) for risk factors of developing ascites. ResultsOf the total 307 analysed EHPVO patients, 26% (n=79) had ascites. Majority (n=66, 83%) were post-bleeding ascites and 17% (n=13) had de-novo ascites due to secondary causes. Risk factors of ascites in post-bleeding ascites (n=56) versus controls (n=188) were younger age of disease onset, lower height z-scores and greater reduction in serum protein, albumin and hemoglobin from baseline non-bled state. 32%, 39%, and 29% of patients with post-bleeding ascites had ascites resolution with salt restriction, additional diuretics and large volume paracentesis respectively. ConclusionsMajority of ascites in EHPVO children is after GI bleeding where early age of disease onset, large volume of blood loss and poor nutritional status are risk factors. Overall outcome of EHPVO with ascites is favourable.

Therapeutic lymphangiography for refractory post-operative chylous ascites in children: Can a needle replace the knife?

Chylous ascites is a rare but well-known complication following surgeries involving extensive dissection of the retroperitoneal structures. It is noticed in children primarily after oncological resections. Meanwhile, conservative treatment is paramount in its management; refractory cases generally require an aggressive approach. A rare case of refractory chylous ascites in a two-year-old boy occurring after excision of recurrent retroperitoneal neuroblastoma is being reported. The child underwent therapeutic lymphangiography with ethiodized oil, as an alternative to surgery, to tackle the refractory post-operative chyle leak. A prompt response was noticed and no recurrence of ascites has been observed during a 15-month follow-up.

Primary chylous ascites in children: Rare cause of a common presentation

Primary chylous ascites in children: Rare cause of a common presentation

Management of cirrhotic ascites in children: Review and recommendations. Part 2: Electrolyte disturbances, nonelectrolyte disturbances, therapeutic options.

Ascites is a major complication of cirrhosis. There are several evidence-based articles and guidelines for the management of adults, but few data have been published in relation to children. In the case of a pediatric patient with cirrhotic ascites (PPCA), the following questions are raised: How are the clinical assessment and ancillary tests performed? When is ascites considered refractory? How is it treated? Should fresh plasma and platelets be infused before abdominal paracentesis to prevent bleeding? What are the hospitalization criteria? What are the indicated treatments? What complications can patients develop? When and how should hyponatremia be treated? What are the diagnostic criteria for spontaneous bacterial peritonitis? How is it treated? What is hepatorenal syndrome? How is it treated? When should albumin be infused? When should fluid intake be restricted? The recommendations made here are based on pathophysiology and suggest the preferred approach to diagnostic and therapeutic aspects, and preventive care.

Management of cirrhotic ascites in children. Review and recommendations. Part 1: Pathophysiology, diagnostic evaluation, hospitalization criteria, treatment, nutritional management.

Ascites is a major complication of cirrhosis. There are several evidence-based articles and guidelines for the management of adults, but few data have been published in relation to children. In the case of pediatric patients with cirrhotic ascites (PPCA), the following questions are raised: How are the clinical assessment and ancillary tests performed? When is ascites considered refractory? How is it treated? Should fresh plasma and platelets be infused before abdominal paracentesis to prevent bleeding? What are the hospitalization criteria? What are the indicated treatments? What complications can patients develop? When and how should hyponatremia be treated? What are the diagnostic criteria for spontaneous bacterial peritonitis? How is it treated? What is hepatorenal syndrome? How is it treated? When should albumin be infused? When should fluid intake be restricted? The recommendations made here are based on pathophysiology and suggest the preferred approach to its diagnostic and therapeutic aspects, and preventive care.

Ascites in Children: A Single-Center Experience of 27 Years.

The aim of our study was to describe the changing prevalence, demographic features, etiologies, and treatment of ascites in children hospitalized during a 27-year period at the Johns Hopkins Hospital (Baltimore, MD). We retrospectively reviewed discharges from 1983 to 2010 to select patients whose records included a diagnosis of ascites. We assessed the etiologies and degrees of ascites (ascites grade 1 detectable only by radiologic tests; ascites grades 2 and 3 recognized by moderate and marked abdominal distension by physical examinations). We classified 518 children into 9 etiology groups: intrahepatic disease (IH) (105), hepatic vein outflow obstruction (HVOO) (45), congestive heart disease (CH) (33), nephrotic syndrome (NS) (36), pancreatitis (26), inflammatory and infectious diseases (77), malignancy (49), idiopathic (71), and miscellaneous (76). IH and CH were predominant in the younger age group (0-5 years) versus HVOO, pancreatitis, and malignancy in the older age group (13-21 years) (P < 0.001). The prevalence of ascites increased over time from 1983 to 2006 and declined thereafter. Ascites grade 1 was more common than ascites grades 2 and 3 in all the groups (P = 0.048). IH and NS were more likely to have ascites grade 2 and 3 (P = 0.02). Although spironolactone was more frequently used in the IH group versus other etiologies, furosemide was used more frequently in NS and CH versus other etiologies (P < 0.001). The increased prevalence of ascites during the initial study period could reflect improved detection radiologic detection. The proportion of severe ascites and the various medical treatments differed among the etiologic groups.

Clinical profile of ascites in children at tertiary care hospital, North Karnataka

Introduction: Ascites is a common clinical problem in children with liver and renal disease. The peripheral arterial vasodilation hypothesis is mostly accepted as the patho-physiological basis of ascites. The most important complication is spontaneous ascitic fluid infection in the form of spontaneous bacterial peritonitis (SBP) and its variants. Objective: To know the incidence, etiology, associated clinical co-morbidities & the outcome (morbidity & mortality) of the hospitalized children with ascites. Materials and Methods: After informed written consent from parents/ guardian, 102 children admitted with ascites irrespective of primary diagnosis were studied at department of Pediatrics, S. Nijalingappa Medical College, Bagalkot. The study was a prospective study and subjects were enrolled consecutively. Detailed history, complete physical examination & routine investigations were done in all patients and were recorded in predesigned proforma. A detailed etiological workup was done. Results: The most common symptoms were abdominal distension (100%), facial puffiness (62.74%), pedal edema (46.08%), & generalized swelling (35.29 %). The most common signs were facial puffiness in 62.74%, pedal edema in 46.07% & anasarca in 35.29% the most common etiology of ascites was dengue fever, followed by nephrotic syndrome. Of the 102 children with ascites, 2 expired (Gaucher’s disease & Wilson’s disease). Conclusion: Prompt and early diagnosis and appropriate management of ascites is warranted to prevent related morbidity and mortality in children.

Ascites in Children.

Ascites is an accumulation of serous fluid within the peritoneal cavity. It is the most common complication of liver cirrhosis. In children, hepatic, renal and cardiac disorders are the most common causes. Portal hypertension and sodium and fluid retention are key factors in the pathophysiology of ascites. Peripheral arterial vasodilatation hypothesis is the most accepted mechanism for inappropriate sodium retention and formation of ascites. Diagnostic paracentesis is indicated in children with newly diagnosed ascites and in children with suspected complications of ascites. Ascitic fluid is evaluated for cell count, protein level, and culture. The serum-ascites albumin gradient (SAAG) is the best single test for classifying ascites into portal hypertensive (SAAG >1.1g/dl) and non-portal hypertensive (SAAG <1.1g/dl). A neutrophil count ≥250 cells/mm3 is highly suggestive of bacterial peritonitis. The treatment of ascites due to non-liver disease depends on the underlying condition. In liver disease, diuretics as monotherapy or dual therapy and salt restriction form the mainstay of treatment in children with mild to moderate ascites. Fluid restriction is helpful in children with hyponatremia. In non-responsive ascites or in children with large ascites, large volume paracentesis (LVP) with albumin infusion should be performed. In children with refractory ascites, LVP with albumin administration, transjugular intrahepatic porto-systemic shunt (TIPS), peritoneo-venous shunting and liver transplantation are other therapeutic modalities that need to be considered.

Tu1835 Cirrhosis Complications After Development of Ascites in Children With Biliary Atresia

Tu1835 Cirrhosis Complications After Development of Ascites in Children With Biliary Atresia

Elevated C‐Reactive Protein and Spontaneous Bacterial Peritonitis in Children With Chronic Liver Disease and Ascites

The aims of this study were to compare laboratory indices of spontaneous bacterial peritonitis (SBP) and noninfected ascites in children with chronic liver disease and to determine the infectious agents involved in SBP. The medical records of 90 children with chronic liver disease and ascites studied between January 2005 and August 2011 were reviewed for laboratory data of diagnostic significance in SBP. Standard laboratory tests included blood cell count, coagulation indices, liver and renal function tests, C-reactive protein (CRP), serum sodium concentration, serum albumin, and serum cultures. Ascitic fluid obtained from 152 paracentesis procedures was assayed for cytology, Gram stains, neutrophil counts, and bacteriological cultures. The SBP group manifested significantly lower albumin levels and elevated CRP levels, prothrombin times, international normalized ratios, and leukocyte number (P<0.05 in each case). CRP was shown to be an independent variable in the prediction of SBP. Values of serum creatinine, sodium concentration, urea, total bilirubin and differential leukocyte shift were comparable in SBP and noninfected ascites. Streptococcus pneumoniae was the most prevalent infectious agent in the ascitic fluid (44%). CRP may be useful in early detection and monitoring of SBP in children with liver disease.

Chronic granulomatous disease presenting as aseptic ascites in a 2-year-old child.

Chronic granulomatous disease (CGD) is a rare inherited immunodeficiency syndrome that results from abnormal nicotinamide adenine dinucleotide phosphate (NADPH) oxidase function. This defect leads to recurrent catalase-positive bacterial and fungal infections as well as associated granuloma formation. We review the case of a 2-year-old boy who presented with ascites and fever of an unknown origin as manifestations of CGD. Cultures were negative for infection throughout his course, and CGD was suspected after identification of granulomas on peritoneal biopsy. Genetic testing revealed a novel mutation in the CYBB gene underlying his condition. This paper highlights the importance of considering CGD in the differential diagnosis of fever of unknown origin and ascites in children.

Management of Severe Ascites in Children after Liver Transplantation with the Use of Peritoneo-Venous Denver Shunt - Two Case Reports

Introduction: Denver shunt is the peritoneo-venous shunt which is indicated for patients in whom ascites has not responded to medical management. Aim: The aim of this study is to present our experience with the use of Denver shunts in pediatric patients after liver transplantation. Material and methods: Between 2008-2012 in the Children's Memorial Health Institute there were 6 patients treated with the insertion of the Denver Shunt. In two of them the indication for the shunt was prolonged severe ascites after liver transplantation that could‘t be managed in any other way. Two boys: 17 year old and 15 years old with body mass 54 and 47 kg were transplanted due to liver failure caused by Budd-Chiari syndrome and cystic fibrosis respectively. The severe ascites has appeared just after transplantation despite of the proper graft function and normal portal and hepatic veins flow. The waste of ascitic fluid ranged between 40-120 ml/kg/24h (2200-5600ml/24h) and required albumin supplementation. The shunts were inserted on the 8 and 10 day after transplantation respectively. Results: In the first patient the shunt was removed after 7 months with the complete resolution of the ascites. He is in remission with the observation time 5 months. In the second patient the shunt is still functioning with two months follow-up. In the first one the revision of the shunt was performed due to the shunt occlusion. There was no other complications. Conclusion: It seems that the Peritoneo-venous Denver Shunt can be used effectively in selected children as the management of otherwise incurable ascites with low complication rate.