Unexplained Ascites Research Articles

Ascites of unknown origin in infant: a rare case report

Introduction. Ascites of unknown origin in infants are rare and diagnostically challenging. However, it can be associated with a poor prognosis if it is not treated promptly. Case presentation. A 3-month-old boy infant was admitted to the Dr. Soetomo General Academic Hospital, Surabaya because of a 2-week history of progressive abdominal distension with massive ascites following fever onset. Laboratory parameter measurement revealed increased liver function test, hypoalbuminemia, and prolonged coagulation factor. Hepatitis markers were negative. TORCH serological examination showed non-reactive. Urinalysis, renal function test, and echocardiography were normal. The ascitic fluid analysis showed SAAG >1.1 g/dL. An abdominal ultrasound examination revealed ascites. MRCP showed hepatomegaly and ascites. A liver biopsy showed foci of polymorphonuclear and mononuclear inflammatory cell distribution among hepatocytes with no hepatic fibrosis. He was treated with antibiotics, steroids, diuretics, and albumin transfusion. There were no ascites and laboratory parameters were improved after treatment. Conclusion. Progressive and rapid hepatic inflammatory mechanisms may play a role in the development of ascites. Steroids may be considered in cases of unexplained ascites thought to be related to liver injury to prevent further liver fibrosis.

Percutaneous endoscopic peritoneal biopsy for a patient with unexplained ascites.

Percutaneous endoscopic peritoneal biopsy for a patient with unexplained ascites.

Case Report: Unexplained ascites can be constrictive pericarditis

Here we present a patient who had unexplained ascites despite a lengthy series of investigations. Extrathoracic manifestations of constrictive pericarditis such as re- solving ascites often cover the true situation and lead to a delayed diagnosis. A six-year-old boy was referred to our hospital due to a three-year history of abdominal distention, and difficulty in breathing. A chest x-ray revealed heart enlargement. The diameter of the induration of the tuberculin skin test was 14 mm. Echocardiography and cardiac magnetic resonance imaging showed constrictive pericarditis. The patient was diagnosed with a tuberculosis origin of pericarditis. Cardiac catheterization was performed, and pericardiectomy. The patient was started on an anti-tuberculosis drug leading to a complete cure of ascites.

Unsuspected late presentation of post cesarean section vesico-peritoneal fistula.

SynopsisA rare case reporting a patient with chronic abdominal pain and unexplained recurrent ascites due to a vesico‐peritoneal fistula diagnosed 6 years after cesarean section.

The Roth Net at 40 years: celebrating the spirit of innovation

The Roth Net at 40 years: celebrating the spirit of innovation

Feasibility and Safety of Transgastric Natural Orifice Transluminal Endoscopic Surgery in the Diagnosis of Ascites of Unknown Origin.

Objective: The purpose of this study was to evaluate the feasibility and safety of transgastric natural orifice transluminal endoscopic surgery (TG-NOTES) combined with biopsy in the diagnosis of unknown ascites. Method: This retrospective study used data from the first affiliated hospital of Nanchang university on 51 patients who were diagnosed with ascites of unknown origin between January 2013 and May 2019 and experienced peritoneal biopsy through TG-NOTES. The outcome measures included diagnostic accuracy and procedure-related adverse events. Results: TG-NOTES was performed successfully in 46 of 51 patients, tuberculous ascites in 38 cases, carcinomatous ascites in 4 cases, cirrhotic ascites in 1 case, and 3 cases showed no obvious abnormalities in pathological result. Five cases failed to be diagnosed because of abdominal adhesions. The diagnostic rate of TG-NOTES was 84.3%. There were no severe procedure-related adverse events and no mortality. All patients had good wound healing and no complaint of discomfort on follow-up. Conclusion: The majority of ascites of unknown origin can be expounded through TG-NOTES combined with biopsy without severe complication, therefore, it is a feasible and safe method to detect the cause of unexplained ascites.

Persistent cloaca with fetal ascites: clinical features and perinatal management.

Fetuses with persistent cloaca are known to develop urine or meconium backflow into the abdominal cavity caused by obstruction of the common channel, thus leading to fetal peritonitis with fetal ascites. We analyzed the impact of prenatal fetal ascites on postnatal clinical features and management. This retrospective single-center cohort study was conducted to compare the perinatal parameters of patients with isolated persistent cloaca who were born and treated at our hospital between 1991 and 2021. The clinical features and management of those with and without fetal ascites were compared. Among the 17 eligible patients, fetal ascites were recognized in seven. The occurrence of fetal ascites was significantly related to preterm birth, higher birth weight z-score, birth via emergency cesarean delivery, low Apgar scores at 1min and 5min, higher C-reactive protein levels at birth, longer duration of oxygen administration, the need for a urinary drainage catheter at initial discharge, and shorter neonatal hospital stays. The postnatal management of patients with persistent cloaca with fetal ascites differed significantly from that of patients without fetal ascites. For patients with unexplained fetal ascites, magnetic resonance imaging may be helpful for determining the definite diagnosis of persistent cloaca.

Extracardiac imaging findings in COVID-19-associated multisystem inflammatory syndrome in children.

BackgroundCoronavirus disease 2019 (COVID-19)-associated multisystem inflammatory syndrome in children (MIS-C) is an emerging syndrome that presents with a Kawasaki-like disease and multiorgan damage in children previously exposed to COVID-19.ObjectiveTo review the extracardiac radiologic findings of MIS-C in a group of children and young adults with a confirmed diagnosis of MIS-C.Materials and methodsIn a retrospective study from April 1, 2020, to July 31, 2020, we reviewed the imaging studies of 47 children and adolescents diagnosed with MIS-C, 25 females (53%) and 22 males (47%), with an average age of 8.4 years (range 1.3–20 years). Forty-five had chest radiographs, 8 had abdominal radiographs, 13 had abdominal US or MRI, 2 had neck US, and 4 had brain MRI.ResultsThirty-seven of 45 (82%) patients with chest radiographs had findings, with pulmonary opacities being the most common finding (n=27, 60%), most often bilateral and diffuse, followed by peribronchial thickening (n=26, 58%). Eight patients had normal chest radiographs. On abdominal imaging, small-volume ascites was the most common finding (n=7, 54%). Other findings included right lower quadrant bowel wall thickening (n=3, 23%), gallbladder wall thickening (n=3, 23%), and cervical (n=2) or abdominal (n=2) lymphadenopathy. Of the four patients with brain MRI, one had bilateral parieto-occipital abnormalities and another papilledema.ConclusionThe diagnosis of MIS-C and its distinction from other pathologies should be primarily based on clinical presentation and laboratory evidence of inflammation because imaging findings are nonspecific. However, it should be considered in the setting of bilateral diffuse pulmonary opacities, peribronchial thickening, right lower quadrant bowel inflammation or unexplained ascites in a child presenting with Kawasaki-like symptoms and a history of COVID-19 infection or recent COVID-19 exposure.

A case report of severe veno-occlusive disease following autologous stem cell transplantation successfully treated with Defibrotide

Veno-occlusive disease (VOD) is one of the complications of hematopoietic stem cell transplantation that can also be caused by high-dose chemotherapy. This complication can lead to high mortality following bone marrow transplantation. It is more common after allogeneic stem cell transplantation, and is rare after autologous stem cell transplantation. While mild cases of VOD may reduce over a period of a few weeks, very severe cases can cause multi-organ damage, which has a high mortality. is therefore required with early diagnosis and treatment of this complication. In this paper, we present a sever VOD case after autologous stem cell transplantation, that was treated successfully with Defibrotide. The patient was a 14-month-old girl who has neuroblastoma with bone metastasis. VOD should be considered in the differential diagnosis of haematopoietic stem cell transplantation recipients who present with unexplained liver injuries, ascites and/or multi organ failure. Recipients of haematopoeitic stem cell transplantation who present with unexplained liver injuries, ascites and/or multi organ failure should have VOD considered in their differential diagnosis. If there is severe VOD diagnosed, then Defibrotide could be an option for treatment.

A case report of severe veno-occlusive disease following autologous stem cell transplantation successfully treated with Defibrotide.

Veno-occlusive disease (VOD) is one of the complications of hematopoietic stem cell transplantation that can also be caused by high-dose chemotherapy. This complication can lead to high mortality following bone marrow transplantation. It is more common after allogeneic stem cell transplantation, and is rare after autologous stem cell transplantation. While mild cases of VOD may reduce over a period of a few weeks, very severe cases can cause multi-organ damage, which has a high mortality. is therefore required with early diagnosis and treatment of this complication. In this paper, we present a sever VOD case after autologous stem cell transplantation, that was treated successfully with Defibrotide. The patient was a 14-month-old girl who has neuroblastoma with bone metastasis. VOD should be considered in the differential diagnosis of haematopoietic stem cell transplantation recipients who present with unexplained liver injuries, ascites and/or multi organ failure. Recipients of haematopoeitic stem cell transplantation who present with unexplained liver injuries, ascites and/or multi organ failure should have VOD considered in their differential diagnosis. If there is severe VOD diagnosed, then Defibrotide could be an option for treatment.

Eozinofilik Gastroenterit: Adölesan Bir Hastada Nadir Görülen Bir Assit Nedeni

Eosinophilic gastroenteritis (EGE) is a rare disorder and eosinophilic infiltration of the gastrointestinal tract is characteristic for it. Eosinophilic ascites may seen in lymphoma, eosinophilic gastroenteritis, peritoneal dialysis, and parasitic infections too. Depending on the dominant layer of infiltration EGE is classified into three types namely, mucosal, muscularis and serosal. Rarest type is the serosal type characterized by primary serosal disease, peripheral eosinophilia and eosinophilic ascites. Here we report a case of serosal EGE. We have discussed clinical cornerstones for diagnosis and response to treatment.A male patient age of 16 presented to the clinic with complaints of self-limiting diarrhea which stop within three weeks and abdominal distension. In physical examination tachypnea, orthopnea and marked abdominal distension were seen. Contrast-enhanced abdominal computed tomography showed the presence of ascites and diffuse thickening of small bowel wall, but did not detect a primary malignancy in the abdominal cavity; and no signs of portal hypertension or liver disease. In laboratory tests significant eosinophilia in blood and abdominal fluid were seen. Leukocyte count was 16680 /mm3 in the hemogram and 60% eosinophil was detected in the peripheral smear. In paracentesis fluid analysis; eosinophilia (70% eosinophil) were detected. Steroid treatment to be completed in six weeks in total was applied to the patient who was diagnosed with eosinophilic ascites. Therapy with corticosteroids resulted in resolution of both the gastrointestinal symptoms and the ascites without hesitation. He had not any complaint during four months follow-up; ascites regressed and examination was normal. EGE is a rare disorder and it should be flashed in patients who presented with unexplained ascites. Since diagnosis of EGE is a diagnosis of exclusion and, apart from malignancies, there are many other secondary causes of eosinophilic intestinal infiltration that must be excluded.

Hypothyroidism Manifesting as a Combination of Ascites and Malnutrition Requiring Total Parenteral Nutrition: A Unique Presentation

Ascites is the abnormal buildup of fluid in the abdomen. Despite appropriate workup, including diagnostic paracentesis with fluid analysis and abdominal imaging, the cause of ascites is sometimes unknown. In this case, testing for less common causes should be performed, including checking thyroid function test (TFT) because hypothyroidism has also been reported to be a rare cause of ascites. Patients may also have concomitant malnutrition as an effect of severe hypothyroidism, rather than as its cause. We report the case of a 62-year-old female with a history of hypothyroidism and non-compliance who presented with unexplained ascites and then also developed severe malnutrition, requiring total parenteral nutrition (TPN). Extensive testing, including laparotomy, was unable to reveal the cause of ascites and malnutrition until the patient mentioned, during her hospital stay, non-compliance with her home dose of levothyroxine (175 μg) because of the cost. TFT results indicated that the patient had severe hypothyroidism, with a thyroid-stimulating hormone (TSH) level of 21.9 IU/mL and a free thyroxine level (T4) level of 0.2 IU/mL. The patient’s home levothyroxine dose was resumed. The patient clinically improved and was discharged on an oral diet. The patient’s ascites resolved completely, the TSH level was 2.39 IU/mL, and the T4 level was 1.7 IU/mL at the eight-week follow-up.

Diagnosis of filariasis by cytology of unexplained ascites

Diagnosis of filariasis by cytology of unexplained ascites

Clinical characteristics of malignant peritoneal mesothelioma misdiagnosed as tuberculous peritonitis: a report of 6 cases

Objective: To reduce the misdiagnosis rate of ascites and improve the diagnosis rate of malignant peritoneal mesothelioma. Methods: From May 2008 to May 2018, in Xiangya Hospital of Central South University,the clinical data of malignant peritoneal mesothelioma misdiagnosed as tuberculous peritonitis were retrospectively analyzed. Results: (1) Among the 6 patients, they were male; the age of onset was 42-70 (52±9.57) years old, and there was no history of asbestos exposure. (2) All cases with abdominal pain or abdominal distension were there and the course of disease was more than 1 month to more than 2 years. (3) In all patients,the nature of ascites was exudate; ADA was higher than normal value and below 45 U/L; LDH value in ascites was higher than 200 U/L (83.3%); mesothelioma was considered in ascites cytology in 1 case. (4) Laparoscopic biopsy was performed in 2 cases and B-ultrasound guided biopsy in 4 cases; Among them, malignant peritoneal mesothelioma diagnosed by pathology. (5) In Immunohistochemical positive markers, MC was the most sensitive (100%), followed by CR (67%), CK-Pan (67%), Ki-67 (67%) and EMA (67%). (6) Two patients received treatment with operation, abdominal hyperthermic perfusion and postoperative systemic chemotherapy. Conclusions: (1) Malignant peritoneal mesothelioma should be considered in middle-aged and aged male patients with unexplained ascites and early laparoscopy or laparotomy for diagnosis. (2) ADA and LDH level in ascites are significant in differentiating tuberculous peritonitis from malignant peritoneal mesothelioma. (3) Immunohistochemical positive marker MC may be a potential specific marker for malignant mesothelioma. (4) The survival time of patients is improved by comprehensive treatment such as operation and chemotherapy.

Acquired heart disease in children is not necessarily rheumatic.

Acquired heart diseases (AHD) cause significant morbidity and mortality in children. There are limited studies on their burden in children. We conducted a retrospective study of 85 consecutive children diagnosed with AHD using clinical evaluation and echocardiography at Medical College, Kanpur, India to determine the aetiology and outcome of AHD in children. We found rheumatic heart disease (RHD) in one-third, cardiomyopathies or myocarditis combined in a further third and the remaining third were other causes, including pericardial diseases and metabolic or genetic disorders. These latter diseases were frequently misdiagnosed, causing significant morbidity and mortality. Hence, in children of all age groups presenting with unexplained shock, dyspnoea, hepatomegaly and ascites, cardiac status should be carefully and critically evaluated so that non-rheumatic AHD may not be missed.

Celiac disease with Budd–Chiari syndrome: A rare association

Budd–Chiari syndrome is characterized by hepatic venous outflow tract obstruction. We describe an 18-year-old female of known celiac disease presented with progressive abdomen distention and shortness of breath for the last 1 month. Computed tomography of abdomen revealed hepatic vein obstruction. The patient was diagnosed with Budd–Chiari syndrome. Coagulation profile showed an increased homocysteine level. Serum folate level was also decreased. The patient was put on oral anticoagulant with a gluten-free diet. After 4 weeks, the patient showed significant improvement with decreased ascites. The association of Budd–Chiari syndrome with Celiac disease has not yet been fully understood. There have been few reports that described this rare association. Budd–Chiari syndrome should be considered as an important differential in a patient with unexplained ascites and celiac disease.

Evaluation of a closer ultrasonographic vision to peritoneal cavity as a powerful tool in the diagnosis of abdominal Tuberclosis. 2015-2018, National Centre of Gastrointestinal & liver disease

200 cases of unexplained ascites randomly enrolled. Age range 19-69, comparable male to female ratio 7.5 MHz linear ultrasound probe used for peritoneal cavity exploration following initial abdominal scan with 3.5-5 MHz probe. 22% of cases had liver cirrhosis & 14.5% were on haemodialysis, 95% of cases had diffuse or segmental peritoneal thickening up to 0.8 cm, 89% had prominent omentum, 35% of these had omental hypoechoic infiltration, 75% had lymphadenopathy at mesenteric, para-aortic +/- inguinal locations, 69% had variable degrees of peritoneal adhesions13% had splenic infiltration, 8% had purulent non tender abdominal collections, 5% had lymph nodes calcifications. 3% had haemorrhagic ascites, 2% had patchy hepatic locations of fine calcifications. Only a single case had none of the mentioned signs & his ascites responded to therapeutic trial & was cured with TB therapy. Pleural effusion with pleural thickening was seen in 16.5% of cases, minor Pericardial effusion was noted in 98% of cases, a single case of pericardial calcification, a single case of lymph nodes in the pericardial fat. Fine needle aspiration(FNA) from mesenteric & inguinal lymph nodes had the best yield in the diagnosis of TB, FNA from omental thickening was significantly superior to FNA from peritoneal thickening in demonstrating granulomas & caseation, while splenic FNA was not informative. Ascetic fluid lymphocyte count was a prilimanary test in the diagnosis of TB with significant sensitivity & specificity, 94% of cases had at least 3 combinations of the above mentioned peritoneal findings, 84.5% had 4 combinations. 94% of cases provisionally diagnosed as abdominal TB by ultrasound means proved tuberculous by other diagnostic means, including, laproscopy, PCR, ADA & culture, 36% received therapeutic trial for diagnosis. Conclusion would support adopting a targeted ultrasound protocol for the diagnosis of abdominal Tuberculosis.

Transvaginal natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin

Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies, but few clinical studies have investigated transvaginal NOTES in the diagnosis of unexplained refractory ascites. We aimed to assess the feasibility, efficacy, and safety of transvaginal NOTES for the diagnosis of unexplained ascites in female patients. A prospective study was done involving 3 female patients with unexplained ascites. After general anesthesia and disinfection, a 1.0-cm incision was made in the posterior fornix of the vagina. A gastroscope was inserted into the abdominal cavity through the transvaginal incision and an artificial pneumoperitoneum was created; NOTES peritoneoscopy was performed to scrutinize the pathologic changes. Endoscopic biopsy specimens were obtained for pathologic examination. The transvaginal incision was closed by direct suturing. Transvaginal NOTES for diagnostic peritoneoscopy was successfully performed in 3 patients. The mean operative time was 61 minutes. The estimated blood loss was 5 to 10 mL. The pathologic diagnoses were tuberculosis for all patients, and the symptoms and ascites disappeared after antituberculosis therapy. During the 4-year follow-up, no clinically significant adverse events occurred in any patient after NOTES. No patient experienced an annex inflammation, vaginitis, dyspareunia, or sexual dysfunction. All patients were comfortable and satisfied with the nonscarring surgical procedure. Transvaginal NOTES for the diagnosis of unexplained ascites is feasible, effective, and safe. This method had no long-term effect on female sexual function and is particularly suitable for women who have special aesthetic requirements. (Clinical trial registration number: ChiCTR-TRC-10001053.).

Intractable ascites associated with mycophenolate in a simultaneous kidney-pancreas transplant patient: a case report

BackgroundMycophenolic acid (MPA), either given as an ester pro-drug or as an enteric-coated sodium salt, is the most commonly prescribed anti-proliferative immunosuppressive agent used following organ transplantation and widely applied in immune-mediated diseases. Clinicians are well aware of common adverse reactions related to MPA treatment, in particular diarrhea, leukopenia and infections. Here we report a case of severe, persistent ascites associated with MPA treatment. The otherwise unexplained and intractable ascites, requiring repeated paracenteses for more than 8 months, rapidly ceased with stopping the MPA treatment. To our knowledge this is the first case of severe ascites associated with MPA treatment reported in the scientific literature.Case PresentationA 45-year old female with type 1 diabetes mellitus received a simultaneous kidney-pancreas transplant. The surgery was uneventful. However, post-operatively she developed severe transudative ascites requiring in total more than 40 paracenteses treatments draining in the average 2.8 l of ascites fluid. The ascites formation persisted despite exclusion of a surgical complication, fully functioning kidney and pancreas allografts, lack of any significant proteinuria, normalization of circulating albumin levels, intensive use of diuretics and deliberate attempts to increase the intervals between the paracentesis treatments. Various differential diagnoses, including infectious, hepatic, vascular and cardiac causes were ruled out. Nine months after surgery enteric-coated mycophenolate sodium was switched to azathioprine after which ascites completely resolved. When mycophenolate was recommenced abdominal fullness and weight gain reoccurred. The patient had to be switched to long-term azathioprine treatment. More than 1 year post-conversion the patient remains free of ascites.ConclusionMPA is the most widely used antimetabolite immunosuppressive agent. We suggest to consider MPA treatment in the differential diagnosis of severe and unexplained ascites in transplant and non-transplant patients.

The Almost-Normal Liver Biopsy: Presentation, Clinical Associations, and Outcome.

Liver biopsies obtained for abnormal liver enzymes or unexplained ascites occasionally appear histologically almost normal. The differential diagnosis for these cases is challenging because literature addressing this topic is lacking. We aimed to establish a differential diagnosis and determine clinical associations and outcomes for almost-normal liver biopsies. Ninety-seven histologically almost-normal liver biopsies were collected from 2 institutions. All cases lacked significant inflammation, fatty change, biliary tract disease, vascular disease, nodular regenerative hyperplasia, iron overload, inherited metabolic or storage disorder, viral hepatitis, or fibrosis. Biopsies for follow-up of known liver diseases were excluded. Transplant biopsies, lesion-directed biopsies, biopsies obtained during bariatric surgery, liver donor biopsies, and biopsies to evaluate methotrexate toxicity were excluded. Clinical (including follow-up) and laboratory data were collected. The frequency of almost-normal liver biopsies was 0.6% and 3.7% at the 2 institutions. The most common biopsy indications were elevated liver biochemistries or clinical findings that suggested portal hypertension. In 70 patients (72%), an associated clinical abnormality was identified; the most common were autoimmune systemic inflammatory conditions (18%), vascular/ischemic events (13%), metabolic syndrome (11%), drug effects (8%), and inflammatory conditions of the gastrointestinal tract (7%). The median follow-up period was 4.3 years (range=0 to 10 y); detailed clinical follow-up was available for 66 patients (68%). Liver biochemistries normalized in 32 patients (48.5%) and remained elevated in 34 (51.5%). Seven patients (7.2%) eventually developed chronic liver disease (autoimmune hepatitis [n=3], primary biliary cirrhosis [n=3], cryptogenic cirrhosis [n=1]). This multicenter study determines the differential diagnosis for almost-normal liver biopsies; this will guide pathologists in subsequent workup efforts in these challenging cases.