Ascites Volume Research Articles

O16 A diagnosis of BehÇet’s Disease with secondary antiphospholipid syndrome

O16 A diagnosis of BehÇet’s Disease with secondary antiphospholipid syndrome

Abdominal imaging findings on computed tomography in patients acutely infected with SARS-CoV-2: what are the findings?

ObjectivesTo investigate what findings are new on contrast-enhanced abdominopelvic CT in patients infected with SARS-CoV-2.MethodsContrast-enhanced CT of the abdomen and pelvis of patients with COVID-19 at a tertiary oncologic center acquired over a 2-month period were reviewed independently by two readers and scored for new imaging abnormalities compared with a prior scan. CT scans were included if the study was performed between − 3 and 45 days from the time of COVID-19 diagnosis. Clinical information was gathered from the medical records.ResultsA total of 63 patients (34 male, 29 female; mean age 60.6 years, range 24.4–85.0 years) were included in this retrospective cross-sectional study. Aside from new ground glass opacities seen at the lung bases (29/63, 46.0%), the most common findings were new thickening of the stomach, small bowel or colon or fluid-filled colon (14/63, 22.2%), new small volume ascites (7/63, 14.3%), gallbladder distention in those without prior cholecystectomy (3/43, 7.0%), and single cases each of acute pancreatitis (1/63, 1.6%) as well as new portal vein thrombosis (1/63, 1.6%).ConclusionAside from lung base ground glass opacities, the most common new imaging abnormality on abdominopelvic CT in patients with COVID-19 finding in our cohort was abnormalities of the gastrointestinal tract, followed by small volume ascites, gallbladder distention, and isolated cases of pancreatitis and portal vein thrombosis. These findings overlap with those previously reported that did not have a prior scan for comparison, and provide supportive evidence that some of these findings may be related to SARS-CoV-2 infection.

S2757 Not All Ascites Is From Cirrhosis

Introduction: New onset ascites commonly occurs in cirrhosis. Although uncommon, myxedema ascites should be considered when other more common causes of ascites are excluded and there is biochemical evidence of hypothyroidism. We present a case of myxedema ascites confounded initially by presence of alcoholic cirrhosis. Case Description/Methods: A 59-year-old African American male with a past medical history of alcohol misuse, CAD, Hashimoto’s disease s/p radioablation therapy with subsequent hypothyroidism, presented with chest pain and abdominal distension. Acute coronary syndrome was ruled out, and pain was attributed to a GI etiology. A contrast CT of abdomen/pelvis was done showing evidence of cirrhosis and large volume ascites, concerning for acute decompensation. A chronic liver disease panel was noncontributory, and etiology was thought to be secondary to alcohol misuse. Paracentesis revealed SAAG < 1.1, total protein 4.2, with negative cultures and cytology. Further evaluation revealed TSH of 86 with T4 < 0.1 and constellation of symptoms (cold intolerance, weight gain, puffiness, esophageal dysmotility causing burning chest pain, hypothyroidism induced myopathy) pointed to severe hypothyroidism. He was treated with IV levothyroxine for 3 days followed by oral therapy with complete resolution of the ascites, and the etiology was thought to be secondary to myxedema. Discussion: Cirrhosis causing portal hypertension is the commonest cause of ascites. Hypothyroidism is a rare cause of ascites wherein the fluid accumulation occurs because of increased capillary permeability. This results in ascitic fluid are high in total protein ( >2.5 g/dl; mean - 3.9 g/dl) and variable SAAG (mean - 1.5 g/dl; range 0.8–2.3 g/dl). Table 1 mentions common causes of ascites classified based on SAAG. WBC counts in ascitic fluid can be low or high, consisting predominantly of lymphocytes. Myxedema ascites responds well to thyroid replacement therapy and is completely reversible, without any role for diuretics. In our case a presumptive diagnosis of decompensated cirrhosis was made based on imaging evidence of ascites and cirrhosis, but ascitic fluid studies refuted portal hypertension. Further negative cytology, low WBCs, negative bacterial and tubercular cultures ruled out malignancies or infectious peritonitis. Based on further constellation of symptoms, biochemical abnormalities, and a good response to intravenous levothyroxine, patient was diagnosed with myxedema ascites.Table 1.: Classification of most frequent causes of ascites. SAAG, serum ascites albumin gradient.Figure 1.: (a) Coronal section showing ascites (red arrows) (b) Axial section showing widened hepatic fissure (green arrows) and ascites (red arrows).

S3029 A Subtle Presentation of Duodenal Perforation in a Patient with Prior Roux-En-Y Gastric Bypass

Introduction: Bariatric surgery is widely used for the management of obesity. Patients with Roux-En-Y Gastric Bypass can develop peptic ulcer disease of the remnant stomach. Peptic ulcer perforation presents as acute abdomen, and free peritoneal air on imaging studies confirms the diagnosis. We discuss a case of perforation of the excluded duodenum in a patient with prior gastric bypass, with subtle clinical presentation of acute pancreatitis and absence of pneumoperitoneum on computerized tomogram (CT) scan of abdomen. Case Description/Methods: A 37 year-old female with no co-morbid conditions presented to our emergency room with a 8/10 intensity epigastric abdominal pain for 4 days, radiating to her back. Her pulse was 96 beats per minute , blood pressure of 108/72 mm of Hg, and epigastric tenderness on abdominal exam. Patient is a smoker and reports 5 to 9 alcoholic drinks per week . Denies NSAIDs use. She had Roux-En-Y Gastric Bypass surgery in 2011, with 100 lbs weight loss . She had cholecystectomy for acute cholecystitis in 2015. Laboratory parameter at presentation revealed total bilirubin levels of 1.6 mg/dl with predominant direct, ALT of 131 IU/dL, serum lipase of 1523 IU/dL. She had CT scan of abdomen that revealed fat stranding in vicinity of pancreatic head with small amount of free fluid (Figure 1A). She was managed as alcohol induced acute pancreatitis and planned for the magnetic resonance cholangiopancretiography (MRCP). Her clinical condition deteriorated over course of 48 hours requiring intensive care monitoring. Abdominal exam revealed peritoneal signs. Repeat CT scan of abdomen revealed large volume ascites with no free peritoneal air and absence of extravasation of the oral contrast (Figure 1B). A diagnostic aspiration revealed fluid lipase of 19264 U/L and, bilirubin of 11 mg/dL. She underwent exploratory laparotomy with drainage of 5 liters of biliary fluid from peritoneal cavity. Kocherization of duodenum revealed a 7 mm perforation in lateral wall of duodenum. Discussion: Absence of pneumoperitoneum on imaging studies can deceive the diagnosis of perforated peptic ulcer in patients with gastric bypass. Ingested air flows through gastrojejunostomy and bypasses remnant stomach. Worsening ascites with high bilirubin levels in aspirated fluid and the worsening clinical condition should raise suspicion for peptic ulcer in remnant gastro-duodenal area.Figure 1.: A. CT Abdomen at presentation showing peripancreatic stranding. B. CT Abdomen at 72 hours showing new onset ascites.

S2884 Pelvic Inflammatory Disease as an Unusual Cause of Ascites

Introduction: Pelvic inflammatory disease (PID) is an infection of the upper genital tract, including the uterus, fallopian tubes, and/or ovaries. Neisseria gonorrhea, Chlamydia trachomatis, and Mycoplasma genitalium are the most frequently isolated pathogens. Case Description/Methods: A 25-year-old female presented with an 8-day history of lower abdominal pain associated with fevers, chills, vomiting, and non-bloody diarrhea. Patient denied recent travel, changes in her diet, family history of Inflammatory Bowel Disease. Her abdomen was diffusely tender. Routine laboratory testing was unremarkable. CT scan of the abdomen and pelvis (Figure 1) showed focal small bowel mural thickening, concerning for gastroenteritis. COVID PCR, HIV antigen/antibody, blood cultures, Clostridium difficile toxin and stool pathogen PCR panel were all negative. Patient was presumed to have viral gastroenteritis and was discharged home. She was readmitted two days later for worsening nausea and vomiting. Laboratory testing was significant for WBC 12.7 x 109/L, potassium of 2.8 mEq, INR 1.7, CRP 19.24 mg/dL. A repeat CT abdomen and pelvis (Figure 2) showed a re-demonstration of marked wall thickening of the small bowel most consistent with enteritis, and the development of large loculated ascites in the mid abdomen and pelvis with peritoneal thickening and enhancement. Diagnostic paracentesis showed PMNs 990, RBCs 4000, SAAG < 1.1, total protein 3.7 g/dl, glucose 29 mg/dl, and LDH 1609 U/L. Peritoneal cultures grew Neisseria gonorrhea. Patient was discharged home on a two-week course of IV ceftriaxone, metronidazole and doxycycline with improvement in clinical symptoms. Repeat diagnostic imaging showed interval improvement and resolution of ascites. Discussion: Acute symptomatic PID presents with lower abdominal pain associated with fevers, chills, nausea, vomiting, vaginal discharge and/or intermenstrual bleeding. PID may present with RUQ pain in the setting of liver capsular inflammation, also known as perihepatitis i.e. Fitz-Hugh Curtis Syndrome. Perihepatitis occurs in about 10% of woman with acute PID. However, the development of ascites as a presenting complication of PID is very rare. In this case, the ascites fluid studies were not consistent with portal hypertension with a SAAG < 1.1. In addition, PMNs > 250 cells suggested bacterial peritonitis. Furthermore, per the Runyon’s criteria, this pattern resembled secondary bacterial peritonitis with a total protein >1 g/dL, glucose < 50 mg/dL, and LDH > upper limit of normal serum.Figure 1.: CT abdomen and pelvis on presentation showing small bowel mural thickening and enhancement.Figure 2.: CT abdomen and pelvis on representation showing large volume ascites with continued small bowel mural thickening and enhancement.

Albendazole in malignant ascites: a case report and literature review on the successes and adverse effects of therapy

Malignant ascites places a significant burden on the healthcare system and has a profound effect on patient quality of life. Albendazole (ABZ) is an anti-helminthic agent that has shown to rapidly reduce malignant ascites with minimal side effects in pre-clinical trials. The following case study explores the effect of ABZ on ascitic volume in a patient with malignant ascites secondary to metastatic colorectal adenocarcinoma. The patient is a 54-year-old man who underwent an ultrasound guided ascitic drainage for worsening ascites secondary to hepatic metastases from sigmoid adenocarcinoma. He was commenced on ABZ based on literature demonstrating that ABZ decreases the volume of malignant ascites via the inhibition of vascular endothelial growth factor. Over the next week, the volume of ascitic fluid decreased significantly, however the patient developed neutropenia unresponsive to granulocyte colony stimulating factor likely in the context of impaired liver function. The efficacy of ABZ in this case study as well as in the literature demonstrates the promising potential for use in reducing malignant ascites. However, this case demonstrates the need for caution for use in patients with liver impairment due to changes to first pass metabolism leading to increased circulating drug toxicity and thus, adverse outcomes.

Restoration of Intestinal Mucosa in Euphorbia kansui-treated Severe Acute Pancreatitis Rats based on HMGB1/MFG-E8 Expression.

The pathogenesis of Severe Acute Pancreatitis (SAP) is mediated substantially by dysfunctions in the intestinal barrier. Euphorbia kansui (EK) is a medicinal plant used widely in traditional Chinese medicine to treat inflammation; however, its efficacy and mechanism of action in SAP treatment are not yet well understood. To investigate the role of EK in intestinal barrier tissue repair and in the pathogenesis and development of SAP. The rat SAP model was established by a retrograde injection of sodium taurocholate into the pancreatic bile duct. The SAP model group and the SAP + EK treatment groups were divided into 6 subgroups according to timing: 2, 6, 12, 24, 48, or 72h after inducing SAP. The progression of the SAP rats and of the rats receiving the EK treatment was evaluated using the ascites volume, serum amylase and plasma endotoxin levels, and histological grading of intestinal mucosal damage. In addition, serum inflammatory factor contents were measured using Enzyme-Linked Immunosorbent Assay (ELISA) tests and apoptotic cells in damaged ileum tissue were detected using TUNEL staining. Apoptosis markers and other signaling proteins in intestinal mucosal cells were detected by immunohistochemical assays and then validated by combining these data with quantitative polymerase chain reactions and western blotting. Compared with the results of the SAP model rats, the results of the rats that received EK treatment demonstrated that EK could effectively reduce the ascites volume and serum amylase and plasma endotoxin levels. EK treatment also greatly reduced the abnormal intestinal morphological alterations in the rat SAP model and significantly downregulated the serum contents of Interleukin (IL)-1β, IL-6, and tumor necrosis factor-α. EK treatment inhibited the elevation of capapse-3, inhibited the decrease of the Bcl-2 protein, and decreased the number of apoptotic cells in rat ileum tissue. Finally, EK treatment abrogated the increase of HMGB1 and the suppression of MFG-E8 protein expression in the SAP + EK rat ileum tissue. EK suppresses SAP pathogenesis by restoring the intestinal barrier function and modulating the HMGB1/MFG-E8 signaling axis.

Treatment of refractory ascites with an automated low flow ascites pump in patients awaiting liver transplantation

BackgroundFor patients with liver cirrhosis awaiting liver transplantation who suffer from refractory ascites (RA), standard treatment consists of repeated large volume paracentesis. The automated low-flow ascites-pump (alfapump) offers an innovative treatment alternative for patients with RA, if TIPSS is contraindicated or ineffective. This study addresses the feasibility of alfapump treatment in patients awaiting liver transplantation. MethodsBetween 2012 and 2018, patients listed for liver transplantation who were treated with an alfapump were included in this retrospective single centre study. ResultsOf 22 patients listed for liver transplantation and treated with an alfapump, 14 were finally transplanted. Alcohol-related liver disease was the most common aetiology for liver cirrhosis (n = 11), followed by hepatitis C, hepatitis B and NASH. Mean age at listing was 56.3 years and 68.2% of patients were male. The average daily ascites volume pumped by the device was 1076 ml. During transplant surgery, no alfapump-related complications occurred. The alfapump was removed at the end of the transplant procedure in eight patients and left in place in three patients for up to 104 days, whereas three patients had the pump removed prior to the transplantation. Overall survival was significantly better in patients that were finally transplanted (log-rank p < 0.0001). Five patients (22.7%) required at least one alfapump-related re-intervention. ConclusionTreatment with an alfapump in patients on the liver transplant waiting list with refractory ascites is feasible. The alfapump did not affect the transplant procedure and was explanted in most patients at the end of the transplant surgery.

The composition of ascites lymphocytes in high-grade serous ovarian cancer and its correlation with clinical features

Objective: To explore the composition of ascites lymphocytes in high-grade serous ovarian carcinoma (HGSOC) and its correlation with clinical features. Methods: A total of 59 newly-diagnosed HGSOC patients, aged (58±11) years old, who were treated at the Department of Obstetrics and Gynecology of Peking University Third Hospital from July 2019 to December 2020 were included, collecting ascites and peritoneal irrigation fluid respectively. Detect the proportion of T, B, NK cell and its subpopulations by flow cytometry, and analyze its correlation with the clinical characteristics of patients. Results: Among 59 patients, 48 patients (81.4%) had ascites, and 11 patients (18.6%) had no ascites. Compared with the peritoneal irrigation fluid, the CD3+T (70.2%±15.6% vs 78.1%±6.7%, P=0.014), CD8+T (38.3%±11.2% vs 47.7%±10.1%, P=0.014) and CD16-CD56bright NK [2.0% (0.8%, 3.6%) vs 4.2% (1.5%, 7.1%), P=0.026] cells were significantly decreased in the ascites, while the CD16+CD56dim NK cells was significantly increased [6.8% (2.8%, 15.7%) vs 2.6% (1.6%, 4.3%), P=0.008]. In patients with ascites volume ≥1 000 ml, CD16-CD56bright NK cells were significantly increased than those ascites volume<1 000 ml [3.1% (1.2%, 3.9%) vs 0.8% (0.4%, 2.3%), P=0.002]. Age was significantly positively correlated with the level of CD4+T cells (r=0.332, P=0.021) and the ratio of CD4+T/CD8+T (r=0.379, P=0.008) in ascites. In ascites from patients with poor response to treatment, the proportion of CD4+T cells was increased significantly than those with better response (64.7%±4.2% vs 48.3%±11.7%, P=0.002). Conclusion: The formation of ascites in newly diagnosed high-grade serous epithelial ovarian cancer patients would affect the lymphocyte composition in the abdominal cavity microenvironment, which is related to the patient's age, cancer progression and treatment response.

Advanced Gastric Adenocarcinoma in a 12-Year-Old Girl

Introduction: Gastric adenocarcinoma is extremely rare in children, and it is typically seen among the elderly in their sixth and seventh decades of life. There are few studies on the clinical manifestations, treatment, and prognosis of this malignancy in children. Case Presentation: In this paper, we describe a 12-year-old girl presented with abdominal pain, anorexia, nausea, and abdominal distension. A high volume of ascites was reported in ultrasound and computed tomography (CT) scan of the abdomen and pelvis. The patient underwent endoscopy and biopsy of the gastric mucosa. The histopathological findings were positive for gastric adenocarcinoma. Unfortunately, the patient died two months after chemotherapy because she was at the advanced stage of the disease. Conclusions: Although gastric adenocarcinoma is rare in children, it should be considered in patients with persistent upper gastrointestinal symptoms.

Ascites volume at the time of primary debulking and overall survival of patients with advanced-stage epithelial ovarian cancer

Objectives: Investigate the impact of malignant ascites volume on the overall survival of patients with advanced stage epithelial ovarian carcinoma who undergo primary debulking surgery and achieve complete gross resection. Methods: Patients without a history of another tumor diagnosed with stage III-IV epithelial ovarian carcinoma and bulky intra-abdominal disease between 2004-2015, who underwent primary debulking surgery followed by adjuvant chemotherapy and achieved complete gross resection were drawn from the National Cancer Database. Based on available information, the presence and volume of malignant ascites was assessed and categorized as absent, low (<980 ml) and high (≥980 ml) volume. Median overall survival was determined following generation of Kaplan-Meier curves and compared with the log-rank test. A multivariate Cox model was constructed to control for confounders. Results: A total of 1040 patients who met the inclusion criteria were identified; 50.4% had no ascites, 34.2% had low and 15.4% had high volume malignant ascites at the time of primary debulking surgery. Median patient age was 61 years, while the majority were White (87.7%), without co-morbidities (81.1%) and had serous tumors (91.8%). Groups were comparable in terms of patient race, presence of comorbidities, tumor histology and grade. Median OS of patients without malignant ascites was 59.79 months, compared to 50.33 months for those who had low volume and 41.95 months for those who had high volume malignant ascites. After controlling for patient age, race, insurance status, presence of comorbidities and tumor histology and grade, compared to patients with no malignant ascites those with low (HR: 1.37, 95% CI: 1.09, 1.72) and high volume ascites (HR: 1.94, 95% CI: 1.47, 2.55) had worse overall survival. Patients with low volume ascites had better survival compared to those with high volume ascites (HR: 0.71 95% CI: 0.54, 0.93) after controlling for the aforementioned confounders. Conclusions: Presence and volume of ascites at the time of primary debulking surgery may be associated with worse oncologic outcomes. Investigate the impact of malignant ascites volume on the overall survival of patients with advanced stage epithelial ovarian carcinoma who undergo primary debulking surgery and achieve complete gross resection. Patients without a history of another tumor diagnosed with stage III-IV epithelial ovarian carcinoma and bulky intra-abdominal disease between 2004-2015, who underwent primary debulking surgery followed by adjuvant chemotherapy and achieved complete gross resection were drawn from the National Cancer Database. Based on available information, the presence and volume of malignant ascites was assessed and categorized as absent, low (<980 ml) and high (≥980 ml) volume. Median overall survival was determined following generation of Kaplan-Meier curves and compared with the log-rank test. A multivariate Cox model was constructed to control for confounders. A total of 1040 patients who met the inclusion criteria were identified; 50.4% had no ascites, 34.2% had low and 15.4% had high volume malignant ascites at the time of primary debulking surgery. Median patient age was 61 years, while the majority were White (87.7%), without co-morbidities (81.1%) and had serous tumors (91.8%). Groups were comparable in terms of patient race, presence of comorbidities, tumor histology and grade. Median OS of patients without malignant ascites was 59.79 months, compared to 50.33 months for those who had low volume and 41.95 months for those who had high volume malignant ascites. After controlling for patient age, race, insurance status, presence of comorbidities and tumor histology and grade, compared to patients with no malignant ascites those with low (HR: 1.37, 95% CI: 1.09, 1.72) and high volume ascites (HR: 1.94, 95% CI: 1.47, 2.55) had worse overall survival. Patients with low volume ascites had better survival compared to those with high volume ascites (HR: 0.71 95% CI: 0.54, 0.93) after controlling for the aforementioned confounders. Presence and volume of ascites at the time of primary debulking surgery may be associated with worse oncologic outcomes.

Baicalein exerts antitumor effect in cervical cancer

The work verified that baicalein (BCN) inhibited the appearance and progress of cervical cancer in vitro and in vivo. MTT and CCK-8 methods were used to detect the toxicity of BCN to C33A cells and the number of C33A cells, respectively. For in vivo assays, a solid tumor model of cervical cancer and ascites tumor model was successfully established. The body weight, tumor volume and weight, survival time, and ascites volume were recorded. The anti-tumor ratio and increasing rate of life span were computed. H&amp;E staining was performed to examine the liver tissues, kidney tissues, and tumor tissues. BCN inhibits the proliferation of human cervical cancer cell line C33A and induces apoptosis. The results from in vivo assays showed that BCN suppressed tumor growth and progression with decreased tumor volume and weight in a solid tumor model. BCN significantly induced cell apoptosis in solid tumor tissues. BCN also reduced ascites volume, prolonged survival time, and increased life extension rate in the ascites tumor model. These findings indicated that BCN exerted an antitumor effect against cervical cancer both in vitro and in vivo. According to the results, BCN might act as an important antitumor agent against cervical cancer.

Tumor extracelluar hyroxyapatite: a potential biomarker for imaging ovarian cancer

<h3>Objectives:</h3> Identifying new strategies to improve response to poly ADP-ribose polymerase inhibitors (PARPi) in women with homologous recombination (HR)-proficient ovarian cancer is a key clinical challenge. The nuclear orphan receptor NR4A1 has pro-tumor effects in ovarian cancer cells through transcriptional regulation of key genes promoting growth, survival and HR DNA repair. NR4A1 is also expressed in immune cells in the tumor microenvironment and may play a role in inhibiting re-polarization of pro-tumor M2-like tumor-associated macrophages (TAMs) to a more effective anti-tumor M1-like TAM phenotype. Our group has shown that the NF-kappaB (NF-ĸB) pathway is a key regulator of TAM phenotype, with upregulated NF-ĸB signaling promoting M1-like functions. Our goal therefore was to determine whether inhibition of NR4A1 can improve responses to PARPi both by increased tumor DNA damage and apoptosis, and by promoting an anti-tumor M1 phenotype in TAMs by modulating NF-ĸB activity. <h3>Methods:</h3> Cultured HR-proficient ID8 mouse ovarian cancer cells, mouse ovarian TAMs and mouse bone marrow-derived macrophages were treated with the established NR4A1 antagonist C-DIM-pPHOH (C-DIM) and/or the PARPi olaparib (OLA) for 24-72 hours. C57BL/6 mice with established intra-peritoneal ID8 tumors were treated with vehicle, C-DIM, OLA or combined C-DIM/OLA for 3 weeks. Standard techniques were used to determine cell growth (Sulforhodamine B assay), HR efficiency (<i>BRCA1</i> and RAD51 foci formation), NF-ĸB activity (nuclear p65, luciferase reporter activity), and expression of markers of DNA damage (pH2AX), apoptosis (cleaved PARP), proliferation (PCNA), and macrophage M1 (CCL3, iNOS) and M2 (CD206, arginase-1) polarization. Statistical significance (p<0.05) between group means was determined by Student's t test for <i>in vitro</i> studies and Mann-Whitney test for mouse studies. <h3>Results:</h3> In ID8 cells, co-treatment with C-DIM and OLA significantly reduced cell growth and HR efficiency, and increased DNA-damage-induced apoptosis, compared to OLA treatment alone. NR4A1 was highly expressed in macrophages, and C-DIM increased NF-ĸB activity and induced M1 polarization alone and when combined with olaparib. Similar effects of combined treatment were observed <i>in vivo.</i> Compared to mice treated with OLA alone, there was significantly reduced ascites volume and omental tumor mass in C-DIM/OLA mice at the time of sacrifice. Combined treatment also reduced proliferation and increased DNA damage and apoptosis in harvested tumors, and increased M1 polarization of TAMs in ascites fluid, compared to OLA mice. <h3>Conclusions:</h3> NR4A1 inhibition sensitizes ovarian tumors to PARPi though direct effects on tumors by targeting the HR pathway, and by modulating TAM function towards an anti-tumor phenotype. These findings have important implications for expanding the use of PARPi in women with HR-proficient ovarian tumors, which would benefit a substantial number of women with this devastating disease.

Comparison of respiratory-triggered 3D MR cholangiopancreatography and breath-hold compressed-sensing 3D MR cholangiopancreatography at 1.5 T and 3 T and impact of individual factors on image quality

PurposeTo evaluate the image quality of an accelerated compressed-sensing single-breath-hold 3D magnetic resonance cholangiopancreatography (BH-CS-MRCP) prototype sequence compared to the standard 3D sequence with respiratory triggering (STD-MRCP) at 1.5 T and 3 T. To assess the individual factors that can affect image quality. MethodThis is a retrospective analysis. Both sequences (BH-CS-MRCP and STD-MRCP) were performed in 200 patients at 1.5 T and 200 patients at 3 T. Overall image quality and the visualization of the bilio-pancreatic ducts were rated on a 5-point scale. Image sharpness and background suppression were rated on a 4-point scale. A double reading was performed in 50 patients to assess the inter-observer reproducibility.Individual characteristics studied were gender, age, BMI, ascites, abdominal surface and breath-hold quality. ResultsAt 1.5 T, BH-CS-MRCP was inferior to STD-MRCP in terms of overall quality (p = 0.0046), background suppression (p < 0.0001), visualization of the cystic duct (p < 0.0001), the right bile duct (p = 0.0008), the left bile duct (p = 0.0152), and the main pancreatic duct (p < 0.0001). However, BH-CS-MRCP was sharper than STD-MRCP (p = 0.028).At 3 T, BH-CS-MRCP was superior to STD-MRCP for overall quality (p < 0.0001), sharpness (p < 0.0001), and visualization of the bilio-pancreatic ducts (p < 0.0001). Background signal was conversely better suppressed in STD-MRCP (p < 0.0001).At 1.5 T, the volume of ascites was inversely correlated with image quality for BH-CS-MRCP while BMI was inversely correlated with image quality for STD-MRCP.Breath-hold quality was correlated with image quality for BH-CS-MRCP at 1.5 T and 3 T. ConclusionBH-CS-MRCP is feasible in clinical routine at 1.5 and 3 T, yielding significantly better perceived image quality at 3 T but not at 1.5 T.BH-CS-MRCP appears to be influenced by ascites whereas STD-MRCP is influenced by BMI at 1.5 T.This study was approved by the Ethics Review Board for Research in Medical Imaging (IRB: CRM-2003–065).

Active drain system with reticulated open-pore foam-surface dressing for postoperative pancreatic fistula in a rat model

BackgroundPostoperative pancreatic fistula (POPF) is one of the most harmful complications after pancreatic resection. Efficient drainage affects the clinical outcome of POPF. Inefficient drain of the fluid collection should contribute greatly to the need of additional interventional drainage, secondary morbid complications, and death. MethodsA rat model of POPF was established by distal pancreatosplenectomy. A novel active drain system (ADS) for POPF was developed by wrapping polyvinyl alcohol sponges (PVA) to an end of the drainage tube. Passive drain system (PDS), ADS and ADS with PVA were used for POPF in rat models. The volume and amylase of ascites were measured. CT scan was applied to assess abdominal fluid collection. Rats pancreatic transection stumps were stained by hematoxylin and eosin (H&E). ResultsThe volume of drainage of ADS with PVA group was less than that of PDS group and ADS group at late stage. CT scan showed obvious abdominal fluid collections in 2/8, 2/8 and 0/8 rats in PDS, ADS and ADS with PVA group separately. Macrofindings showed significant intra-abdominal adhesions and inflammation in PDS and ADS group but not in ADS with PVA group. H&E staining showed less inflammatory cells and destroyed pancreatic glands in ADS with PVA group. ConclusionADS with PVA drained ascites effectively in the rat model of POPF. The effective drainage of pancreatic juice reduced the inflammation of abdominal organs and pancreatic resection stumps, and might promote the healing of POPF.

ZEB2 facilitates peritoneal metastasis by regulating the invasiveness and tumorigenesis of cancer stem-like cells in high-grade serous ovarian cancers

Peritoneal metastasis is a common issue in the progression of high-grade serous ovarian cancers (HGSOCs), yet the underlying mechanism remains unconfirmed. We demonstrated that ZEB2, the transcription factor of epithelial–mesenchymal transition (EMT), was upregulated in ascites cells from HGSOC patients and in CD133+ cancer stem-like cells (CSLCs) from epithelial ovarian cancer (EOC) cell lines. SiRNA-mediated knockdown of ZEB2 in EOC cells decreased the percentage of CSLCs and reduced the colony forming potential, cell invasion capacity and expression of pluripotent genes Oct4 and Nanog. Inhibition of ZEB2 also induced cellular apoptosis and impacted the tumorigenicity of ovarian CSLCs. The mesenchymal markers N-cadherin and vimentin were downregulated, while the epithelial marker E-cadherin was upregulated after ZEB2 knockdown. MiR-200a, a molecule that downregulates ZEB2, had the opposite effect of ZEB2 expression in EOC-CSLCs. A retrospective study of 98 HGSOC patients on the relationship of ascites volume, pelvic and abdominal metastasis, International Federation of Gynecology and Obstetrics (FIGO) stage and the malignant involvement of abdominal organs and lymph nodes was performed. Patients with high expression of ZEB2 in tumour tissues had a higher metastasis rate and a poorer prognosis than those with low expression. The parameters of ZEB2 expression and ascites volume were strongly linked with the prognostic outcome of HGSOC patients and had higher hazard ratios. These findings illustrated that ZEB2 facilitates the invasive metastasis of EOC-CSLCs and can predict peritoneal metastasis and a poor prognosis in HGSOC patients.

Comparison of Diagnostic Accuracy of Portal Serum Ascitic Albumin Gradient (SAAG) with Ascitic Fluid Total Protien (AFTP) Differentiating Portal Hypertension from Non-Portal in Patients with Ascites

Introduction: Although majority of the cases of ascites have cirrhosis, there are 15% patients where there is a non-hepatic cause of fluid retention like malignancy, congestive heart failure and tuberculous peritonitis. Ascites is the most common complication of cirrhosis that leads to hospital admission. Objective:To compare the diagnostic Accuracy of Serum Ascitic Albumin Gradient (SAAG) and Ascitic Fluid Total Proteins in patients with ascites by taking Ultrasound abdomen &amp; Pelvis as gold standard. There are international studies on the accuracy of SAAG in determining cause of ascites but not much local data. Additionally, SAAG is not widely used in our setup. The results of this study will add to the existing knowledge and will help in the diagnosis and better management of these patients. Material &amp; Methods: A cross sectional validation study was conducted in the department of General Medicine, DHQTH, Dera Ismail Khan from 29th April to 29th Oct, 2019. Diagnostic Ascitic fluid was aspirated from the peritoneal cavity and ascitic fluid was sent to hospital laboratory for total protein and albumin. Blood was taken at the same time and was send to the hospital laboratory for the serum albumin. SAAG was calculated by subtracting ascitic albumin value from the serum albumin value. Both, Ascitic fluid total protein and SAAG values was documented in the proforma. Ultrasound Abdomen &amp; Pelvis was done on each patient with special instruction for radiologist to comment upon Portal Vein diameter and any changes in its diameter with respiration. Results: As per comparison Of SAAG with ultrasound in detecting ascites, sensitivity was 36.26%, specificity was 75%, PPV was 84.62%, NPV was 23.68% and accuracy was 44.35%. P Value was 0.299. As per comparison of AFTP with ultrasound in detecting ascites, sensitivity was 33.33%, specificity was 59.34%, PPV was 17.78%, NPV was 77.14% and accuracy was 53.91%. P value was 0.513. Conclusion:SAAG exhibits that patients with ascites fluid possess the basis of portal hypertension. Thus we have come to this conclusion that SAAG can effectively enhance the diagnostic value of ascites fluid tests and therefore its classification can be considered to be a novel standard in the analysis of ascites fluid. Keywords: Diagnostic Accuracy, Ascites Volume, Ascitic Albumin Gradient (SAAG), Ascitic Fluid Total Proteins (AFTP)

Factors affecting long-term survival of advanced high-grade serous ovarian cancer

Objective: To identify the factors associated with long-term survival and guide the decision for primary surgery in patients with advanced high-grade serous ovarian cancer(HGSOC). Methods: In this case-control study, clinical parameters, including surgical and non-surgical associated factors, were collected and compared between the patients with short-term (<2 years) and long-term (>5 years) survival who all underwent primary debulking surgery (PDS) followed by carboplatin and paclitaxel chemotherapy from January 2004 to December 2016. Univariate analysis was examined by chi-square test and multivariate analysis was performed by logistic regression analysis. Results: There were 95 cases long-term survival (LTS group) and 77 cases short-term survival (STS group) in 698 newly diagnosed HGSOC patients with International Federation of Gynecology and Obstetrics (FIGO) stage Ⅲc and Ⅳ who met include and exclude criteria. (1) Univariate analysis showed that the proportion of complete cytoreduction with no visible residual disease (R0) at PDS and platinum sensitivity in LTS group were significantly higher than those in STS group (P<0.01). The surgical complexity score (SCS), the preoperative serum CA125 level and the ascites volume in the LTS group were significantly lower than those of the STS group (all P<0.05). In the LTS group, the preoperative incidence of lesions in retrograde peritoneum of the bladder, serosal and mesangial membrane of the small intestine, upper abdominal peritoneum and liver parenchyma were significantly lower than those in the STS group (all P<0.05). Multivariate logistic regression analysis showed that platinum sensitivity (OR=0.016, 95%CI: 0.004-0.063, P<0.01), ascites volume >500 ml (OR=3.193, 95%CI: 1.285-7.930, P=0.012), and SCS ≥8 (OR=17.433, 95%CI: 2.281-133.25, P=0.003) were independent factors affecting long-term survival (P>0.05). (2) Totally 37 of 95 in long-term survival and 16 of 77 in short-term survival achieved R0 cytoreduction at PDS. Univariate analysis showed that preoperative serum CA125 level, preoperative lesion score, preoperative lesion (DS) score, ascites volume, platinum sensitivity,and SCS were significantly correlated with the R0 PDS (all P<0.05). Multivariate analysis showed that ascites volume >500 ml (OR=5.199, 95%CI: 2.015-13.409, P=0.001), DS >2 (OR=15.264, 95%CI: 5.843-39.874, P<0.01) and SCS ≥4 (OR=4.176, 95%CI: 1.618-10.777, P=0.003) were independent factors associated with R0 cytoreduction. In patients with DS ≤2 or SCS <4, but not those with DS >2 or SCS ≥4, R0 cytoreduction was significantly associated with long-term survival. Conclusion: The intrinsic biology of tumor is the factor influencing long-term survival of advanced HGSOC patients, and those who present with wide intraperitoneal metastases and need to remove multiple organs may not benefit from R0 cytoreduction.

Ultrasound findings in suspected ascites referred for paracentesis

Complications of diagnostic and therapeutic paracentesis include bowel perforation, hemorrhage, and death. At present, medical practitioners identify an area for paracentesis using either physical examination alone or with the addition of ultrasound. The preferable method is still debated within the medical literature. This case series compares photographs of patients with abdominal distension, diagnosed as ascites by physical examination, to the respective ultrasound findings. The ultrasound images show a variety of findings: large volume ascites, bowel loops extending to the abdominal wall (unilaterally or bilaterally), and distended bowel loops due to intestinal obstruction in the absence of substantial ascites. Studies have shown that performing ultrasound before ascites paracentesis procedures improves the procedure success rate and reduces complications. This case series illustrates examples of why ultrasound-assisted paracentesis has a better safety profile and a lower procedure failure rate, compared to physical examination techniques alone.

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

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