Low Serum-ascites Albumin Gradient Research Articles

Endocytoscopy assisted laparoscopic intraoperative diagnosis of disseminated malignancy

An endocytoscope system is a novel accessory tool to the conventional luminal endoscope which provides 450X magnification of the gastrointestinal mucosa, thus allowing in vivo imaging of living cells (Fig. 1) [1]. It has been used with success in the evaluation of esophageal, gastric, and colorectal mucosal lesions during endoscopy [2]. First experience of its use in the intraoperative evaluation of the pancreatic ductal mucosa has also been reported [3]. However, the utility of the system in the in vivo microscopic evaluation of peritoneal lesions has not been reported yet. Two patients underwent diagnostic laparoscopy for evaluation of ascites of unknown origin. The first patient was a 45 year old woman who presented with complaints of painless distension of the abdomen associated with malaise for the past 1 month. Ultrasound of the abdomen showed ascites and thickened omentum. CT scan of the abdomen showed similar findings. The second patient was a 50 year old male patient who presented with progressive distension of the abdomen for past 3 months associated with low grade fever and weight loss. Ultrasound showed free fluid in the abdomen with thickened omentum and minimal bilateral pleural effusion. CT scan was noncontributory. Ascitic fluid examination in both the patients showed exudative ascites with low SAAG (serum ascites albumin gradient) values. Microscopic examination showed a lymphocytic picture and no atypical cells were identified. As all the above investigations were nondiagnostic, both patients underwent diagnostic laparoscopy. Both the patients were found to have moderate amount of straw colored ascites and multiple peritoneal nodules (Fig. 2A). The peritoneal nodules were biopsied and sent for histopathological examinations. Methylene blue solution, in half strength, of approximately 3–5 ml was sprayed via the laparoscope over the nodules. After the nodules were adequately stained the endocytoscope was passed into the peritoneal cavity via a 5 mm laparoscopic port (Fig. 2B). When the scope was applied in contact with the stained nodules, the intricate microscopic details of the lesions could be observed live on the video monitor. The video was relayed to the pathology department, and the pathologist helped inecognising the pathognomonic features of malignant lesions. The endocytoscopy picture in the first patient showed irregular clusters of cells with hyperchromatic nucleus and increased nuclear cytoplasmic ratio suggestive of malignancy (Fig. 3A). Similar cells were also found coursing as emboli in the capillaries of the nodules. The picture in the second patient showed cells with normal nuclear cytoplasmic ratio dispersed sparsely over the peritoneal surface, showing no evidence of malignancy (Fig. 3B). Conventional histopathological examination showed poorly differentiated carcinoma in the nodules of the first patient. The second patient was found to have granulomas suggestive of tuberculosis. With increasing experience the surgeons could make the diagnosis with accuracy without the assistance of the pathologist. The cytoscopy added an extra 5–10 minutes to the total procedure. In conclusion, the endocytoscope system when used via the laparoscope can provide on-table diagnosis of presence G. V. Rao M. J. Mansard (&) P. Rebala Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500082, India e-mail: jeymagnus@gmail.com

Serum-ascites albumin gradient: a predictor of esophageal varices with ascites.

Other investigators have found that in adults the Serum-Ascites Albumin Gradient (SAAG) to be 1.1 g/dl or greater in the presence of portal hypertension (PTHN) and less than that in its absence. We sought to determine the correlation between the level of SAAG and the complications of PTHN, manifested by the presence of esophageal varices in children with ascites. Our study included 26 patients with cirrhosis, diagnosed by liver biopsy and 14 patients with nephrotic syndrome (NS) diagnosed by established criteria. The SAAG was measured in all patients. The patients with cirrhosis had upper gastrointestinal (GI) endoscopy for assessment of esophageal varices (EV). We found that 84.6% (22 of 26) patients with cirrhosis had High SAAG (> or = 1.1 g/dl) and 15.4% (4 of 26) had low SAAG (< 1.1 g/dl) (p < 0.001). EV was found in 91% (20 of 22) patients with high SAAG and in 50% (2 of 4) patients with low SAAG (p = 0.013). The SAAG differentiated cirrhosis with EV from those without EV (sensitivity = 91%, specificity = 50%, positive predictive value = 91%, negative predictive value = 50% and efficacy = 85%). The high SAAG is a useful means to predict the presence of EV in children with ascites.

Nephrogenic ascites. Analysis of 16 cases and review of the literature.

Nephrogenic ascites is an entity that manifests as refractory ascites in patients with end-stage renal disease, where portal hypertensive, infectious, and malignant processes have been excluded. Most of these patients are undergoing hemodialysis. Hypoalbuminemia may predispose these uremic patients to ascites formation. The characteristics of the ascitic fluid suggest that the pathogenesis of the ascites is an alteration in peritoneal membrane permeability or impaired resorption due to peritoneal lymphatic channel obstruction. The ascitic fluid has a high protein content, low serum-ascites albumin gradient (SAAG), and low leukocyte count. Daily hemodialysis should be the initial therapy and is successful in one-third to three-fourths of patients within 3 weeks. Continuous ambulatory peritoneal dialysis or insertion of a peritoneovenous shunt are alternative treatments. Other therapies include instillation of intraperitoneal corticosteroids and binephrectomy, which have less predictable outcomes. Renal transplantation is the definitive treatment for nephrogenic ascites. Control of ascites reverses the progressive cachexia associated with uncontrolled disease, resulting in improved quality of life and survival approaching that of end-stage renal disease patients without ascites.

Low albumin gradient ascites complicating severe pseudomembranous colitis

Pseudomembranous colitis (PMC) is a frequently severe, sometimes fatal iatrogenic disease that is antibiotic-associated in almost all cases. The most common clinical features of PMC include abdominal pain, watery diarrhea, fever, leukocytosis, hypoalbuminemia, and hypovolemia. Ascites, not considered a well-known feature of PMC, is fairly common, based on a review of the English language literature but has not been characterized fully. This case report describes 5 patients with PMC who presented with low serum-ascites albumin gradient (SAAG) and neutrocytic ascites, without evidence of infectious, malignant, or inflammatory peritoneal disease, which has not been reported previously. In 1 patient, massive low SAAG ascites was the presenting manifestation of PMC, a feature also not reported previously. Three of the 5 (60%) patients had acquired immunodeficiency syndrome. The characteristics of the fluid specimens in these 5 patients and the possible pathogenetic mechanisms are proposed. The findings suggest that PMC should be included in the differential diagnosis of low SAAG ascites, especially in patients with acquired immunodeficiency syndrome.(Gastroenterology 1997 Mar;112(3):991-4)

Peritoneal coccidioidomycosis associated with human immunodeficiency virus infection

Peritoneal coccidioidomycosis is extremely rare. This report describes a patient infected with the human immunodeficiency virus who presented with unexplained ascites and was found to have peritoneal coccidioidomycosis. The ascites had a low serum-ascites albumin gradient, and laparoscopy showed peritoneal implants that grew Coccidioides immitis. This case is unique in several ways; this is the first case in which a patient's acquired immunodeficiency syndrome-defining illness was peritoneal coccidioidomycosis, and the serum-ascites albumin gradient determination as well as laparoscopy provided information critical to the diagnosis. This patient's dramatic response to systemic antifungal therapy, as evidenced by resolution of ascites and constitutional symptoms, underscores the importance of timely diagnosis and prompt therapy. In summary, this report reviews the previous cases of coccidioidal peritonitis and reports the first case in which localized peritoneal coccidioidomycosis was the acquired immunodeficiency syndrome-defining illness in a human immunodeficiency virus-infected patient.

Ascitic fluid analysis in malignancy-related ascites

A prospective study identified 45 patients with malignancy-related ascites among 448 ascites patients (10% of the total). Patients were categorized into five subgroups based on the pathophysiology of ascites formation. Each subgroup had a distinctive ascitic fluid analysis. Patients with peritoneal carcinomatosis but without massive liver metastases (53.3% of the patients with malignancy-related ascites) had a uniformly positive ascitic fluid cytology, high ascitic fluid protein concentration and low serum-ascites albumin gradient. Patients with massive liver metastases and no other cause for ascites formation (13.3% of the series) had a negative cytology, low ascitic fluid protein concentration, high serum-ascites albumin gradient and markedly elevated serum alkaline phosphatase. Those with peritoneal carcinomatosis and massive liver metastases (13.3% of the series) had a nearly uniformly positive ascitic fluid cytology, variable protein concentration, high serum-ascites albumin gradient and markedly elevated serum alkaline phosphatase. Chylous ascites (6.7%) was characterized by a milky appearance, negative cytology and an elevated ascitic fluid triglyceride concentration. Patients with hepatocellular carcinoma superimposed on cirrhosis (13.3%) had negative ascitic fluid cytology, low ascitic fluid protein concentration, high serum-ascites albumin gradient and elevated serum and ascitic fluid alpha-fetoprotein concentration. Two-thirds of patients with malignancy-related ascites had peritoneal carcinomatosis; 96.7% of patients with peritoneal carcinomatosis had positive ascitic fluid cytology. Ascitic fluid analysis is helpful in identifying and distinguishing the subgroups of malignancy-related ascites.