Therapeutic Paracentesis Research Articles

Ascites Worsening Due to a Large Hiatal Hernia Compressing Hepatic Venous Outflow: A Case Report

A hiatal hernia causing or aggravating ascites by compressing the hepatic veins has been rarely reported in adults. We report a patient with a known hiatal hernia who was presented with refractory ascites. Echocardiography and CT examination demonstrated a huge hiatal hernia compressing the right atrium and the inferior vena cava. A right-sided heart catheterization demonstrated a significant pressure gradient between the inferior vena cava and the right atrium. Liver biopsy showed a nodular pattern and congestion without fibrosis. Hernioplasty was performed and an improvement in the rate of the accumulation of ascetic fluid was observed. Three months later and during a follow-up period of 3 years, the ascites was mild and there was no need for any therapeutic paracentesis. The outcome indicates that the huge hiatal hernia, by creating hepatic venous outflow obstruction, was the underlying mechanism for ascites aggravation. J Med Cases. 2014;5(11):573-575 doi: http://dx.doi.org/10.14740/jmc1559w

A Case of Sacromatoid Hepatocellular Carcinoma Without Prior Anticancer Therapy

Introduction: Sarcomatoid hepatocelluar carcinoma (SHCC), also referred as spindle cell carcinoma, pseudosarcoma, or carcinosarcoma is a rare histological type of hepatocelluar carcinoma (HCC). Incidence of SHCC is 1.8% in surgically resected, and 3.9% to 9.4% in autopsy cases. Previous chemotherapy use is presumed to promote sarcomatous change. We report a case of SHCC without prior anticancer therapy. Case Report: A 66-year-old Hispanic male presented with complaint of abdominal distension. The patient had past medical history of cirrhosis due to hepatitis C infection, portal hypertension, esophageal varices, recurrent ascites s/p therapeutic paracentesis (last done 3 months prior), diabetes mellitus, and hypertension. The patient had a 20-pack a year smoking history, but quit 20 years ago and denied alcohol or illicit drug abuse. He had no family history of any cancer. Vital signs on presentation, blood pressure 105/58 mm hg, pulse 74 per minute, and regular, respirations rate 20 per minute, temperature 97.8 F, BMI 25.2. On physical exam, the patient was found to have distended abdomen, dull on percussion. Labs showed hemoglobin 12.5 gm/dL, white count 5700/ul, platelet count 134,000/ul, prothrombin time 15.8 seconds, INR 1.2, sodium 130 meq/L, potassium 4.1 meq/L, chloride 100 meq/L, bicarbonate 28 meq/L, glucose 218 mg/dl, BUN 18 mg/dl, creatinine 0.9 mg/dl, calcium 8.2 mg/dl. albumin 2.6 G/DL, total protein 8.2 G/DL, bilirubin total 1.20 MG/DL, alkaline phosphatase 179 U/L, AST 34 U/L, ALT 20 U/L, and alfa-feto protein 4.3 ng/mL. CT abdomen showed a 4.3-cm rim-enhancing mass in the medial segment of the left lobe of the liver in periphery along the diaphragmatic crus. Biopsy of liver mass was done, which showed areas of moderately differentiated conventional HCC and other areas of high-grade spindle tumor. Immunohistochemical stains showed both components stained for keratin. The spindle component did not stain for desmin, CD31, CD34 but was positive for vimentin. The patient underwent upper and lower gastrointestinal endoscopy, which showed no evidence of malignancy. The patient refused any further treatment, and eventually died 8 months after diagnosis. Conclusion: SHCC, compared to ordinary HCC, has relative low serum AFP levels, higher incidence of intrahepatic and adjacent organ invasion, high tendency to large tumor size with central necrosis and hemorrhage in the tumor, delayed peripheral enhancement of the tumor on CT images, resistance to treatment, early recurrence after treatment, and a poorer prognosis, with approximate life expectancy less than 1 year after diagnosis. We should consider SHCC even when a patient has not undergone anticancer therapies.

Paracentesis Catheter Fixator: Introducing a New Instrument and a Pilot Study

Background: Paracentesis is a common bedside therapeutic and diagnostic procedure that requires insertion of a catheter into the peritoneal cavity; however, lack of a specialized fixator for securing the catheter causes frequent catheter kinking and patient discomfort. Objectives: This study aimed to demonstrate the efficacy of a designed paracentesis fixator in reducing patient discomfort and procedure failure rates. Materials and Methods: This interventional study was conducted on 20 patients referred to Imam Khomeini General Hospital for therapeutic paracentesis. A fixator was used to secure the catheter in the experimental group. This designed fixator consisted of an inverted plastic cup with six square-shaped appendages, a cylinder-shaped tube, a flexible silicone hose in continuation of the cylindrical tube, and a connector piece. In the control group, catheter was fixed using tape and sterile gauze. A questionnaire regarding subjective discomfort and overall satisfaction was filled by patients after the procedure. Results: Mean score for subjective discomfort was significantly lower (P = 0.03) and patients’ overall satisfaction was higher in the experimental group (P = 0.04) in comparison to control group. Failure occurred in 20% and 70% of patients in the experimental and control groups, respectively. Coclusions: The designed paracentesis fixator effectively secures the catheter, reduces catheter kinking incidents, and improves patient's comfort and satisfaction.

PWE-134 Overview Of Efficacy And Cost Effectiveness Of Nurse Led Day Case Abdominal Paracentesis Service At Gloucestershire Hospital Nhs Foundation Trust

IntroductionLiver disease is the fifth most common cause of death in England and Wales1 and is one of the important causes of acute hospital admissions. Ascites is a common complication...

PTH-022 Safety And Efficacy Of Day Case Therapeutic Paracentesis For Malignant Ascites

IntroductionAscites is a common consequence of cancer, occurring in 15–50% of patients, and causes symptoms such as abdominal discomfort, anorexia, nausea and a reduced quality of life. Therapeutic paracentesis is...

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To determine the effect of adjunct therapy, we carried out a prospective cohort study on 190 patients with tuberculous pleural effusion during May 2003–April 2004. Patients were divided into 3 groups. All groups were treated with anti-tuberculosis (TB) drugs for 6 months; in group 2 (n = 46) prednisolone, 30 mg/day for 10 days, was added; group 3 (n = 78) were given paracentesis to remove fluid. Fever and constitutional symptoms disappeared faster in group 2 (P > 0.05). After 10 days, there was a significantly greater reduction in the size of pleural effusion in group 2, but after 6 months the difference was not statistically significant. We found steroids and therapeutic paracentesis are not necessary in the management of TB pleural effusion.

Chylous Ascites: Evaluation and Management.

Chylous ascites refers to the accumulation of lipid-rich lymph in the peritoneal cavity due to disruption of the lymphatic system secondary to traumatic injury or obstruction. Worldwide, abdominal malignancy, cirrhosis, and tuberculosis are the commonest causes of CA in adults, the latter being most prevalent in developing countries, whereas congenital abnormalities of the lymphatic system and trauma are commonest in children. The presence of a milky, creamy appearing ascitic fluid with triglyceride content above 200 mg/dL is diagnostic, and, in the majority of cases, unless there is a strong suspicion of malignancy, further investigations are not required in patients with cirrhosis. If an underlying cause is identified, targeted therapy is possible, but most cases will be treated conservatively, with dietary support including high-protein and low-fat diets supplemented with medium-chain triglycerides, therapeutic paracentesis, total parenteral nutrition, and somatostatins. Rarely, resistant cases have been treated by transjugular intrahepatic portosystemic shunt, surgical exploration, or peritoneovenous shunt.

Procalcitonin, and cytokines document a dynamic inflammatory state in non-infected cirrhotic patients with ascites

To quantitate the simultaneous serum and ascitic fluid levels of procalcitonin and inflammatory markers in cirrhotics with and without ascites. A total of 88 consecutive severe cirrhotic patients seen in a large city hospital liver clinic were studied and divided into two groups, those with and without ascites. Group 1 consisted of 41 cirrhotic patients with massive ascites, as demonstrated by necessity for therapeutic large-volume paracentesis. Group 2 consisted of 47 cirrhotic patients without any clinically documented ascites to include either a recent abdominal computed tomography scan or ultrasound study. Serum and ascitic fluid levels of an array of inflammatory markers, including procalcitonin, were measured and compared to each other and a normal plasma panel (NPP). The values for inflammatory markers assayed in the serum of Groups 1 and 2, and ascitic fluid of the Group 1. The plasma levels of the inflammatory cytokines interleukin (IL)-2, IL-4, IL-6, IL-8, interferon gamma (IFNγ) and epidermal growth factor (EGF) were all significantly greater in the serum of Group 1 as compared to that of the serum obtained from the Group 2 subjects (all P < 0.05). There were significantly greater serum levels of IL-6, IL-8, IL-10, monocyte chemoattractant protein-1, tumor necrosis factor-α, vascular endothelial growth factor and EGF when comparing Group 2 to the NPP. There was no significant difference for IL-1A, IL-1B, IL-2, IL-4 and IFNγ levels between these two groups. Serum procalcitonin levels were increased in cirrhotics with ascites compared to cirrhotics without ascites, but serum levels were similar to ascites levels within the ascites group. Furthermore, many of these cytokines, but not procalcitonin, demonstrate an ascites-to-serum gradient. Serum procalcitonin does not demonstrate any significant difference segregated by liver etiology in the ascites group; but ascitic fluid procalcitonin is elevated significantly in cardiac cirrhosis/miscellaneous subgroup compared to the hepatitis C virus and alcoholic cirrhosis subgroups. Procalcitonin in the ascitic fluid, but not in the serum, differentiates between cirrhotic subgroup reflecting the dynamic interplay of ascites, bacterial translocation and the peri-peritoneal cytokine.

Ascites Worsening Due to a Large Hiatal Hernia Compressing Hepatic Venous Outflow: A Case Report

A hiatal hernia causing or aggravating ascites by compressing the hepatic veins has been rarely reported in adults. We report a patient with a known hiatal hernia who was presented with refractory ascites. Echocardiography and CT examination demonstrated a huge hiatal hernia compressing the right atrium and the inferior vena cava. A right-sided heart catheterization demonstrated a significant pressure gradient between the inferior vena cava and the right atrium. Liver biopsy showed a nodular pattern and congestion without fibrosis. Hernioplasty was performed and an improvement in the rate of the accumulation of ascetic fluid was observed. Three months later and during a follow-up period of 3 years, the ascites was mild and there was no need for any therapeutic paracentesis. The outcome indicates that the huge hiatal hernia, by creating hepatic venous outflow obstruction, was the underlying mechanism for ascites aggravation. J Med Cases. 2014;5(11):573-575 doi: http://dx.doi.org/10.14740/jmc1559w

Incarcerated Umbilical Hernia as an Immediate Complication of Large Volume Paracentesis

Purpose: Therapeutic paracentesis is a common procedure used in the management of refractory ascites in patients with cirrhosis. The procedure, while generally simple and safe, has known complications such as bleeding, viscus perforation and metabolic disturbances. We present a rare complication of therapeutic paracentesis: immediate post-procedure incarcerated umbilical hernia. A 57-year-old woman with alcoholic cirrhosis (Child's classification B) was admitted to ambulatory surgery unit for an elective paracentesis. She had massive ascites and a 6-cm umbilical hernia filled with fluid. Seven liters of clear, straw-colored fluid were removed with a 14-gauge needle, and this appeared to be a total paracentesis. She was given 50 grams of salt-poor albumin and prepped for discharge. After standing and dressing for discharge, the patient developed abdominal pain and distension. On examination, it was obvious that she had gas-filled bowel loops in a hernia that could not be reduced (figure). Abdomen was tympanic, consistent with bowel obstruction. Surgical consult was obtained and she underwent reduction and repair of the umbilical hernia, which she tolerated well. Elective repair of umbilical hernias in patients with cirrhosis is usually frowned upon, as hernia recurrence is common unless the ascites can be controlled with diuretics. In addition, this patient group is generally a poor surgical risk due to infection, bleeding and poor wound healing. However, there was not an option in this case, as the hernia presented acutely. Incarceration can occur due to a decrease in tension in the umbilical ring following large volume paracentesis. It may be reasonable to consider TIPS in patients with a significant umbilical hernia whose ascites cannot be controlled with diuretics and whose hernia size runs a risk of incarceration. At the very least, clinicians should be aware of this complication and evaluate patients complaining of pain and distention after paracentesis to rule out this life-threatening condition and be prepared to act quickly to avoid poor outcomes in this compromised group of patients.Figure

A Case of Metastatic Signet Ring Cell Carcinoma Presenting as Tuberculous Peritonitis in an HIV/HCV Coinfected Patient

Purpose: New onset ascites is most commonly due to chronic liver disease, but infectious and malignant causes must also be considered. This is a case of new onset ascites due to metastatic gastric signet cell adenocarcinoma in a patient with chronic hepatitis C and HIV coinfection. Case: A 59-year-old male with HIV (CD4 54) and chronic hepatitis C presented with abdominal pain, nausea, weight loss, and increasing abdominal girth for 2 months. Physical exam revealed bulging flanks with fluid wave and dullness to percussion. Laboratory findings were significant for hypoalbuminemia, absence of transaminitis, or thrombocytopenia, and elevated INR. PPD and Quantiferon-TB tests were negative. Right upper quadrant ultrasound with vascular dopplers did not show cirrhotic features or vascular thrombus. Abdominal CT was negative for intraabdominal organ abnormality. Diagnostic and therapeutic paracentesis revealed a low serum albumin-ascites albumin gradient (SAAG) and high WBC count with monocytic predominance. Peritoneal fluid was tested for cytology, acid-fast bacilli smear, culture, and gram stain, which were all negative. Repeat diagnostic and therapeutic paracentesis again revealed a low SAAG, and adenosine deaminase (ADA) testing was elevated at 26.3 IU/mL. The patient underwent a diagnostic laparoscopy with peritoneal biopsy. On laparoscopy, innumerable peritoneal lesions were noted, grossly resembling tuberculous seeding of the peritoneum. The presumed diagnosis of tuberculosis peritonitis was made and anti-tuberculin therapy was initiated. The following day, pathology from the peritoneal biopsy specimen returned as metastatic signet cell adenocarcinoma. An esophagoduodenoscopy was performed revealing a large, firm ulcerated tumor in the greater curvature of the gastric body. Pathology was consistent with diffuse signet ring cell carcinoma. Conclusion: As demonstrated by a recent meta-analysis, the ADA test has a high sensitivity and high specificity for revealing tuberculous peritonitis in ascitic fluid. This case underscores the importance of the ADA pre-test probability and of confirming the diagnosis with peritoneal biopsy, as malignancy may also present with high ADA levels.Figure: Ulcerated gastric mass, greater curvature.

A Diagnostic Dilemma of New Onset Ascites

Introduction: Successful treatment of ascites depends on identifying the correct cause, since some non-hepatic causes of ascites, such as peritoneal carcinomatosis, do not respond to diuretic therapy. We present an interesting case of new onset ascites involving a delayed diagnosis as well as the multidisciplinary approach for resolution of the diagnosis. Case Report: A 40-year-old man presented with abdominal distension, vomiting, fever, and 20-lb weight loss. A diagnostic paracentesis performed at an OSH excluded SBP and patient was transferred to us for further management. USG suggested a large amount of ascites and cirrhotic morphology of liver but a normal-sized spleen and normal portal flow. The CBD was non-dilated at 3 mm. Initial labs revealed total bilirubin 2.3 mg/dL, direct bilirubin 1.1 mg/dL, AST 22 U/L, ALT 39 U/L, ALP 450 U/L, and GGT 65 U/L. A therapeutic paracentesis was performed revealing dark brown fluid. Further history revealed the patient underwent laparoscopic cholecystectomy for biliary dyskinesia 2 months prior. Ascitic fluid bilirubin was obtained and was elevated at 17.4 mg/dL. HIDA scan revealed a large confined area medial to the liver with extension into the stomach area, and CT confirmed the biloma. During ERCP the guide wire was unable to be advanced into the CBD and no contrast was found proximal to this area of resistance and hence procedure was aborted. A percutaneous transhepatic cholangiography (PTC) was performed, which revealed marked leakage of contrast into the peritoneum with poor opacification of biliary tree, confirmatory of bile leak due to CBD injury. Subhepatic and intrahepatic drains were placed for decompression of bile for 1 month's time. Discussion: Initial SAAG of 15.5 g/L reported from OSH generated a differential list of cirrhotic ascites, cardiac ascites, and Budd-Chiari syndrome. However, clinical, laboratory, and radiological findings did not support any of these. Removal of dark brown peritoneal fluid raised a possibility of a biliary leak, which was later confirmed with high bilirubin and CT/HIDA imaging. With the emergence of the ERCP and PTC, the management of bile leaks has evolved away from the patient returning to surgery. Endoscopic internal stenting is currently the procedure of choice for treating bile duct leaks with a therapeutic response, with cessation of bile extravasation in 70-95% of cases within a period of 1-7 days. PTC is often used when intrahepatic bile duct injuries are unable to be accessed by the retrograde route, as with this patient. This interesting case of new onset ascites involves discussion of misleading factors for delayed diagnosis and emphasizes a multidisciplinary approach for resolution of the diagnosis and its management.

PTU-088 Variation in Practice of Management of Spontaneous Bacterial Peritonitis (SBP)

IntroductionSpontaneous Bacterial Peritonitis (SBP) is the most frequent and life-threatening infection in patients with liver cirrhosis, requiring prompt recognition and treatment. Clinical practise guidelines on management of SBP were released...

Endoscopic Ultrasound-Guided Therapeutic Thoracentesis

Diagnostic or therapeutic thoracentesis in patients with mechanical ventilation is typically performed with ultrasound guidance using a posterolateral approach.1 Recently, the use of endoscopic ultrasound (EUS) for detection and aspiration of pleural effusions2,3 and the feasibility of bedside EUS in critically ill patients has been described.4,5 We present a case of EUS-guided therapeutic thoracentesis performed at the bedside in a critically ill patient on mechanical ventilation. A 69-year-old female was admitted to our hospital with acute liver failure suspected to be secondary to drug toxicity. She was transferred to the intensive care unit because of worsening liver failure, hepatic encephalopathy, atrial fibrillation, fluid overload, and respiratory distress requiring intubation. Chest radiography (Fig. 1) and abdominal computed tomography revealed a large right pleural effusion, pancreatic mass and possible cirrhosis. She was not deemed a candidate for an urgent liver transplant because of the indeterminate pancreatic mass. Furthermore, systemic chemotherapy and radiation were not considered because of acute liver failure. Bedside EUS was requested by the intensive care unit team for both tissue diagnosis of the pancreatic mass and therapeutic thoracentesis to facilitate ventilation. Endoscopy was performed in a supine position while the patient was on mechanical ventilation. EUS revealed a 25×20 mm T2NxMx solid and cystic mass in the pancreatic body (Fig. 2), and fine needle aspiration (FNA) using a 22-gauge needle with on-site cytology review was consistent with adenocarcinoma. Therapeutic thoracentesis of the right-sided pleural effusion was then performed. The stylet was removed from a 19-gauge needle (Echotip; Wilson-Cook Endoscopy, Winston-Salem, NC, USA), and transesophageal puncture of the right pleural space was performed (Fig. 3). Fluid was removed by attaching tubing between the proximal end of the needle and a suction canister. A total of 2 L was removed without complications over a 30-minute period. The total procedure time was 70 minutes. Cytology from the pleural fluid was negative for malignancy, and the fluid was transudative. Hypoxemia improved following the procedure, and follow-up chest radiography showed no pneumothorax or worsening pulmonary edema. The patient's family was informed of the diagnosis of pancreatic malignancy. Based on the patient's previous written wishes, the confirmed diagnosis of malignancy and the liver failure, medical care was withdrawn 24 hours later, and the patient expired. Fig. 1 Large right pleural effusion observed using chest radiograph. Fig. 2 Solid and cystic mass in the pancreatic body. Fig. 3 Aspiration of right pleural space with 22-gauge needle. To our knowledge, this case represents the first report of EUS-guided therapeutic thoracentesis performed at the bedside in a critically ill patient on mechanical ventilation. Currently, there are limited data on the utility of EUS for thoracentesis3 and bedside EUS.4,5 Furthermore, only one case of EUS-guided therapeutic paracentesis has been described.6 EUS-FNA of pancreatic cyst fluid is traditionally performed using a 22- or 25-gauge needle with a 10-mL syringe attached to the proximal end for suction. Aspiration of large volumes of fluid using such a small needle and syringe would be time-consuming and impractical. Using a 19-gauge FNA needle attached to continuous suction, we were able to perform large-volume therapeutic thoracentesis in a fashion similar to that described in a previous report of EUS-guided therapeutic paracentesis.6 Thoracentesis was requested in our patient only because simultaneous EUS-FNA of a pancreatic mass was necessary. As percutaneous ultrasound-guided thoracentesis in patients on mechanical ventilation has been shown to be feasible and safe in patients without significant coagulopathy,1,7-9 we believe that EUS guidance should be considered only in cases in which EUS is required for another reason. Pleural effusions are commonly recognized in critically ill patients, and their management remains poorly standardized.9 Commonly cited reasons for drainage include diagnosis of infection, hypoxemia, excessive ventilator pressure or difficulty in weaning from mechanical ventilation. With the exception of established infection of the pleural space, the balance of risk and benefit of pleural drainage remains fairly controversial for each of these indications.9 Pleural drainage may improve hypoxemia or lung mechanics, but the physiological response depends on a complex interplay among lung and chest-wall compliance, applied positive expiratory pressure and drainage volume.9 In conclusion, EUS-guided therapeutic thoracentesis is feasible and may be considered when EUS is required for another indication or when the traditional posterior approach is not feasible.

A fatal complication of ultrasound‐guided abdominal paracentesis

Ultrasound-guided abdominal paracentesis is a procedure that is frequently performed by radiologists for both diagnostic and therapeutic purposes. This procedure has been shown to be safe with few complications. We report the case of a patient who underwent an ultrasound-guided therapeutic abdominal paracentesis for refractory ascites complicated by intraperitoneal hemorrhage leading to death. This case suggests that ultrasound-guided paracentesis may need to become a more standardized procedure and that in the event of hemorrhage, alternative treatment options such as embolization or surgical intervention should be utilized when manual compression fails.

Diagnosis and Management of Delayed Hemoperitoneum Following Therapeutic Paracentesis

Abdominal paracentesis is a frequently employed diagnostic and therapeutic procedure for patients with refractory ascites, typically in patients with cirrhosis. It is generally regarded as a safe procedure with significant complications occurring in <1% of cases. Most hemorrhagic complications are due to abdominal wall trauma, during which clear evidence of active bleeding is usually visualized during the procedure. Delayed hemoperitoneum is a rare complication of large-volume paracentesis in which clinical evidence of active bleeding is typically absent until substantial blood loss has taken place (often several days to a week later), leading to an exceedingly high mortality rate. Herein we describe a case of delayed hemoperitoneum in a 55-year-old man with heart failure. This case emphasizes the importance of identifying patients who are at high risk for delayed hemoperitoneum as well as the need to closely monitor complete blood counts in the days following a large-volume paracentesis.

Cirrhotic ascites review: Pathophysiology, diagnosis and management

Ascites is a pathologic accumulation of peritoneal fluidcommonly observed in decompensated cirrhotic states.Its causes are multi-factorial, but principally involve significant volume and hormonal dysregulation in the setting of portal hypertension. The diagnosis of ascites is considered in cirrhotic patients given a constellation of clinical and laboratory findings, and ultimately confirmed, with insight into etiology, by imaging and paracentesis procedures. Treatment for ascites is multi-modal including dietary sodium restriction, pharmacologic therapies, diagnostic and therapeutic paracentesis, and in certain cases transjugular intra-hepatic portosystemic shunt. Ascites is associated with numerous complications including spontaneous bacterial peritonitis, hepato-hydrothorax and hepatorenal syndrome. Given the complex nature of ascites and associatedcomplications, it is not surprising that it heralds increased morbidity and mortality in cirrhotic patients and increased cost-utilization upon the health-care system. This review will detail the pathophysiology of cirrhotic ascites, common complications derived from it, and pertinent treatment modalities.

Low incidence of spontaneous bacterial peritonitis in asymptomatic cirrhotic outpatients

To compare the incidence of spontaneous bacterial peritonitis in cirrhotic outpatients and inpatients undergoing therapeutic paracentesis From January 1 to May 31, 2004, 1041 patients from 70 different hospitals underwent 2123 therapeutic abdominal paracentesis (AP) performed as a outpatient procedure in 355 and as inpatient procedure in 686 cases respectively. The following parameters were compared prospectively between outpatients and inpatients: spontaneous bacterial peritonitis (SBP) prevalence, age, gender, cause of cirrhosis, symptoms, score and grade according to Child-Pugh classification, cirrhosis complications, antibiotics treatment, serum creatinine, platelet count and ascitic protein concentration. SBP was observed in 91 patients. In the whole population the SBP prevalence was 8.7% (95%CI: 7.2-10.6) it was 11.7% (95%CI: 9.5-14.3) in inpatients and 3.1% (95%CI: 1.7-5.5) in outpatients (P < 0.00001). SBP prevalence was 8.3% (95%CI: 4.3-15.6) in symptomatic outpatients vs 1.2% (95%CI: 0.4-3.4) in asymptomatic outpatients (P < 0.002). Patients undergoing outpatient AP were significantly different from those undergoing inpatient AP; they were older (61.1 ± 11.1 years vs 59.4 ± 11.7 years; P = 0.028), cause of cirrhosis was less often alcohol (83 .7 vs 88.2%; P < 0.001), Child-Pugh score was lower (8.9 vs 10.1; P < 0.001) and more often B than C (63.7% vs 38%; P < 0.001). In addition, in outpatients the platelet count was higher (161 ± 93 Giga/L vs 143 ± 89 Giga/L; P = 0.003), serum total bilirubin concentration was lower (38.2 ± 60.7 μmol/L vs 96.3 ± 143.3 μmol/L; P < 0.0001), and ascitic protein concentration higher (17.9 ± 10.7 g/L vs 14.5 ± 10.9 g/L; P < 0.001) than in inpatients. In asymptomatic cirrhotic outpatients, the incidence of spontaneous bacterial peritonitis is low thus exploratory paracentesis could be avoided in these patients without significant risk.

Anticoagulation in minor therapeutic procedures: A dilemma?

The patient on chronic anticoagulation (warfarin and aspirin) underwent therapeutic pleural paracentesis for massive tubercular pleural effusion, developed thromboembolic stroke within 48 hours after the procedure, after stopping anticoagulants for one day prior to the pleural paracentesis. To examine the rationale and problems associated with preoperative/pre-procedure anticoagulation withdrawl. Review of the medical literature. When anticoagulation(warfarin) is stopped prior to any minor therapeutic procedure where the patient is at increased risk for thromboembolism, the bleeding risk is extremely low and can be easily managed.In view of narrow therapeutic index and the drug interaction between warfarin with anti-tubercular drugs like rifampicin, risk of thromboembolism significantly increases further. Warfarin should not be discontinued prior to any minor therapeutic paracentesis/procedure because the risk of thromboembolism over weighs the risk of bleeding.

Malignant Ascites, an Atypical Initial Presentation for Pancreatic Adenocarcinoma: A Case Report

Introduction: Malignant ascites is a known complication of pancreatic cancer and is associated with a very poor prognosis. Recent data reveals that the median survival time from the diagnosis of malignant ascites secondary to pancreatic cancer is 64 days, and the only available treatment for these patients is palliative. We present a case of metastatic pancreatic adenocarcinoma found incidentally in an HIV/AIDS patient who presented with ascites and acute kidney injury. While malignant ascites is commonly found in advanced stage pancreatic cancer, it is rarely if ever the sole presenting symptom. Case: A 55-year-old male with a history of diabetes type II, hypertension and AIDS (absolute CD4 190 on HAART therapy) who was referred for admission secondary to acute kidney injury and hyperkalemia. On exam, the patient was afebrile with normal vital signs and physical exam was remarkable only for large volume ascites and a positive fluid wave. Laboratory data was notable for a pre-renal etiology of acute kidney injury, anemia of chronic disease and a normal liver panel. Diagnostic and therapeutic paracentesis were performed with results negative for infection and a serum-ascites albumin gradient (SAAG) of 0.8. However, cytology studies returned positive for malignant adenocarcinoma and subsequent CT evaluation revealed a mass at the body and tail of the pancreas with prominent peripancreatic lymph nodes and extensive omental caking. Biopsy subsequently confirmed the diagnosis of pancreatic cancer and the patient was transferred to the oncology service for initiation of chemotherapy. Conclusion: While malignant ascites is often a symptom of advanced pancreatic cancer, it is rarely the presenting symptom. In this case we highlighted a patient with no previous history of abdominal pain, liver dysfunction or jaundice who was found to have advanced stage pancreatic cancer incidentally after an admission for acute kidney injury. Recent data has indicated an increased prevalence of pancreatic cancer in patient's with HIV/AIDS receiving HAART leading to the increased mortality. This leads one to question the possibility and utility of screening for underlying malignancy in the patients receiving HAART. More studies are needed to establish benefits of screening for malignancy in patients with HIV/AIDS receiving HAART.