Introducción: La ascitis se define como la presencia de líquido en la cavidad peritoneal. La etiología más común la constituyen las enfermedades hepáticas que cursan con hipertensión portal, dentro de ellas la cirrosis hepática reportada en un 40 por ciento, a 5 años de seguimiento de los casos. Estudios previos muestran que la ascitis por enfermedad cirrótica hepática es entre un 80-85 por ciento, también la carcinomatosis se presenta en un 10 por ciento, y dentro de las causas más raras están la insuficiencia cardiaca y la tuberculosis peritoneal en un 3 por ciento, junto con la trombosis de la vena porta, sarcoidosis, tumores intraperitoneales, ascitis pancreática y la enteritis eosinofílica. Objetivo: Describir presentaciones clínicas infrecuentes como causa de ascitis en pacientes hospitalizados en el Hospital Clínico Quirúrgico Hermanos Ameijeiras. Presentación de casos: Se presentan cinco casos que ingresaron en el Hospital Hermanos Ameijeiras con diagnóstico de Ascitis: quilosa, hemorrágica, eosinofílica y coloide, con las patologías que los llevaron a esa manifestación clínica y una breve descripción de la misma. Conclusión: El análisis de las presentaciones clínicas de los casos, los hallazgos en los estudios imagenológicos y en los exámenes de laboratorio, así como los resultados anatomopatológicos permitieron el diagnóstico de las entidades causantes de ascitis atípicas en estos pacientes(AU)

The safety and efficacy of indwelling intraperitoneal (IP) catheters for the management of refractory malignant ascites is unclear. A systematic literature overview and retrospective chart review of patients with malignant refractory ascites who underwent indwelling IP catheter placement was performed. Standardized literature abstraction and chart review templates were used to ensure that consistent information was collected. Fifteen publications met literature search criteria, representing 221 patients. Tenckhoff (Quinton Instrument Company, Seattle, WA, USA), Pleurex (Denver Biomedical Inc., Golden, CO, USA), and peritoneal catheters were used, along with IP ports. A median 5.9% of cases (range: 2.5%-34%) had documented peritonitis. In the literature, untunneled catheters were most commonly associated with infections. Our chart review added 19 cases from two academic institutions to this literature (median age: 60 years [range: 31-85]; females: 17 [89%]; gynecological malignancies: 14 [73%]). Palliative management before catheter placement included diuretics (n=4 [21%]) and multiple paracenteses (n=11 [58%] had two or more taps [range: 2-8]). Median time from diagnosis to catheter placement was 25 months (range: 1-77). Interventions were: French pigtail catheters (n=16 [84%]), Tenckhoff catheter (n=1 [5%]), and Port-A-Caths (Smith Medical MD, St. Paul, MN, USA) (n=2; 11%). Four (21%) catheters were tunneled. Prophylactic antibiotics were prescribed in six cases (32%). Two cases (11%) had documented infections, seven catheters (37%) became occluded, and two leaked (11%). The median time from catheter until death was 36 days (range: 4-660). Nine patients (47%) were admitted to hospice. In these retrospective studies, indwelling IP catheters appear to be a safe and effective palliative strategy to manage refractory malignant ascites, without overwhelming infection rates.

Abstract Objective. It is currently discussed if beta-blockers exert harmful effects and increase mortality in patients with cirrhosis and refractory ascites. In this study, we provide an overview of the available literature in this field in combination with a retrospective analysis of 61 patients with cirrhosis and refractory ascites in a tertiary unit. Material and methods. We performed a systematic search of literature in May 2014. In addition, 61 patients with cirrhosis and ascites were identified and followed from development of refractory ascites until death or end of follow-up. Results. Fourteen trials (9 trials on propranolol, 1 case-control study and 4 retrospective analyses) were identified. One trial suggested an increased mortality in patients treated with beta-blockers and refractory ascites. The results of the remaining trials were inconclusive. No increase in mortality among beta-blocker-treated patients was found in the present retrospective analysis. Conclusions. Treatment with beta-blockers may increase mortality in patients with cirrhosis and refractory ascites. However, the current evidence is sparse and high-quality studies are warranted to clarify the matter.

BACKGROUND/AIMS:

Meta-analysis designed to provide evidence-based guidance on the effect of TIPS and paracentesis on mortality and encephalopathy in cirrhotic patients with refractory ascites.

METHODS:

Five randomized trials published between 1989 and 2005 were identified.

RESULTS:

The five trials involved 330 patients, and none included patients >76 years, with bilirubin >5-10 mg/dl or creatinine >3 mg/dl. Ascites recurrence was lower in the TIPS arm (RR 0.56; 95% CI 0.47-0.66). TIPS was associated with a greater risk of encephalopathy (RR 1.36; 95% CI 1.1-1.68) and severe encephalopathy (RR 1.72; 95% CI 1.14-2.58). TIPS did not affect mortality, as estimated by the RR (0.93; 95% CI 0.67-1.28, random effect model) and pooled hazard ratio (RR 1.09; 95% CI 0.84-1.88). Analysis of this outcome measure was limited by significant heterogeneity among trials. Liver-related mortality was homogenous and similar in both arms. Results were unaffected by excluding trials of lower quality or with a greater number of alcoholics. Meta-analysis of trials including patients with recidivant ascites revealed a lower mortality in the TIPS arm (RR 0.68; 95% CI 0.49-0.93).

CONCLUSIONS:

In patients with refractory ascites, a better control of ascites by TIPS does not translate into improved survival and worsens encephalopathy.

BACKGROUND & AIMS:

Nonselective β-blockers (NSBBs), given to reduce the risk of variceal bleeding, have been associated with increased mortality in patients with cirrhosis and refractory ascites in some, but not all, studies. We performed a systematic review and meta-analysis to evaluate the effect of NSBBs on all-cause mortality in patients with cirrhosis and refractory ascites.

METHODS:

We performed a comprehensive search of MEDLINE, Embase, Web of Science, and Scopus databases through January 2015, supplemented with a manual search. Trial-specific risk ratios (RRs) were pooled using the random-effects model.

RESULTS:

Our analysis included 3 randomized control trials and 8 observational studies of propranolol, carvedilol, nadolol, and metoprolol, reporting 1206 deaths among 3145 patients with ascites. The control groups received other interventions to prevent variceal bleeding. NSBB use was not associated with increased all-cause mortality in all patients with ascites (RR, 0.95; 95% confidence interval [CI], 0.67-1.35); nonrefractory ascites alone (RR, 0.96; 95% CI, 0.50-1.82), or refractory ascites alone (RR, 0.95; 95% CI, 0.57-1.61). Results were similar in randomized controlled trials and observational studies. Use of NSBBs was not associated with increased mortality at 6, 12, 18, and 24 months. Overall, the included studies had a medium to high risk of bias, except for 3 clinical trials in which the risk of biased was determined to be low.

CONCLUSIONS:

The use of NSBBs was not associated with a significant increase in all-cause mortality in patients with cirrhosis and ascites or refractory ascites. Certainty in the available estimates is low; a randomized trial of only patients with ascites is needed to answer this question. This meta-analysis does not support the position that NSBBs routinely be withheld from patients with ascites.

ANTECEDENTES:

La peritonitis bacteriana espontánea es frecuente en pacientes cirróticos y está asociada a una importante morbilidad y mortalidad. Se ha propuesto la descontaminación intestinal selectiva con antibióticos como una medida profiláctica. Aunque existen datos sobre esta modalidad en los pacientes cirróticos con hemorragia gastrointestinal, no hay una síntesis de datos suficiente con respecto a los pacientes cirróticos con ascitis y sin hemorragia gastrointestinal.

OBJETIVOS:

Evaluar si la profilaxis con antibióticos reduce la peritonitis bacteriana espontánea y la mortalidad en los pacientes cirróticos con ascitis y sin hemorragia gastrointestinal.

ESTRATEGIA DE BÚSQUEDA:

Se identificaron los ensayos aleatorios pertinentes mediante búsqueda en los Registros Especializados de Ensayos Controlados del Grupo Cochrane Hepatobiliar (Cochrane Hepato-Biliary Group) y de la Colaboración Cochrane (Cochrane Collaboration), en los motores de búsqueda de bibliografía médica, y la revisión de toda la bibliografía encontrada sobre el tema hasta febrero de 2009.

CRITERIOS DE SELECCIÓN:

Se buscaron los ensayos clínicos aleatorios que evaluaron el tratamiento profiláctico en los pacientes cirróticos adultos con ascitis y sin hemorragia gastrointestinal, que compararon la antibioticoterapia con ninguna intervención, placebo o con otro régimen de antibiótico.

OBTENCIÓN Y ANÁLISIS DE LOS DATOS:

Tres autores independientes buscaron y colectaron los ensayos y extrajeron los datos pertinentes. Otros cuatro autores independientes validaron y evaluaron los resultados. Se evaluó el diseño, las características de los pacientes y de la intervención y la calidad de los estudios. Se realizó un metanálisis para estimar las medidas de asociación entre la profilaxis con antibióticos y la peritonitis bacteriana espontánea o la mortalidad.

RESULTADOS PRINCIPALES:

Se incluyeron nueve ensayos en esta revisión. Se realizó un metanálisis de siete ensayos que compararon los antibióticos con placebo o con ningún tratamiento. Los resultados del ensayo sugieren que hay sesgo sistemático en el diseño o en la publicación. Los resultados de la asignación al azar indican que la probabilidad de que fuera realmente aleatoria en todos los ensayos es muy pequeña, y el informe del diseño en la mayoría de los ensayos fue deficiente. La proporción de participantes con peritonitis bacteriana espontánea varió entre los ensayos desde 15% a 50%. Los riesgos relativos calculados (intervalo de confianza del 95%) de la peritonitis bacteriana espontánea y de la mortalidad en los pacientes tratados con antibióticos comparado con ningún tratamiento o con placebo fueron 0,20 (IC del 95%: 0,11 a 0,37) y 0,61 (IC del 95%: 0,43 a 0,87). Hubo muy pocos informes de eventos adversos.

CONCLUSIONES DE LOS AUTORES:

Las estimaciones agrupadas indican que la profilaxis con antibióticos puede ser acertada en los pacientes cirróticos con ascitis y sin hemorragia gastrointestinal. Sin embargo, la metodología deficiente de los ensayos y de los informes, junto con resultados que sugieren la existencia de un sesgo sistemático en la publicación y el diseño, reflejan la fragilidad de estos resultados. Se debe considerar el riesgo potencial para la sociedad y para los mismos pacientes de que aparezcan agentes patógenos resistentes, al promover la profilaxis de larga duración con antibióticos. Parece que la recomendación de profilaxis con antibióticos está todavía lejos de ser una estrategia fundamentada de prevención. Se necesitan con urgencia ensayos mejor diseñados, bien informados y con seguimiento más largo.

BACKGROUND:

Chylous leakage is a relevant clinical problem after major abdominal surgery leading to an increased length of stay.

DATA SOURCES:

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement. The search for the MeSH terms "chylous ascites" and/or "lymphatic fistula" retrieved a total of 2,348 articles, of which 36 full-text articles were reviewed by 2 independent investigators.

RESULTS:

Chylous ascites is described with an incidence of up to 11%, especially after pancreatic surgery. The incidence is increasing with the number of lymph nodes harvested. In patients treated with total parenteral nutrition, conservative treatment is demonstrated to be effective in up to 100% of cases.

CONCLUSIONS:

The extent of abdominal surgery mainly predicts the risk of chylous ascites. Conservative treatment has been shown to be effective in almost all cases and is the treatment of choice.

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.

The value of ascitic fluid adenosine deaminase activity in distinguishing tuberculosis from other causes of ascites was examined in a retrospective study of 41 patients with bacteriologically confirmed tuberculous peritonitis and 41 control patients, matched for age and sex, with ascites of other causes (12 alcoholic cirrhosis, 5 cryptogenic cirrhosis, 12 malignant disorders, 3 pancreatitis, and 9 miscellaneous causes). The mean ascites adenosine deaminase activity was 99.8 (SD 49.1) in tuberculous patients and 14.8 (8.4) U/l in control patients (p less than 0.0001). A cutoff of 32.3 U/l had a sensitivity of 95% and specificity of 98% in distinguishing between the two groups. In a subsequent prospective study of 64 patients with ascites, 11 were found to have tuberculosis. Of the others, 23 had cirrhosis (18 alcoholic, 5 cryptogenic), 17 malignant disorders, 3 pancreatitis, 5 cor pulmonale, 3 congestive cardiac failure, 1 systemic mastocytosis, and 1 renal failure and hypothyroidism. The mean ascites adenosine deaminase activity was 112.6 (45.0) U/l in the patients with tuberculous ascites and 16.3 (36.7) U/l (p less than 0.0001) in those with ascites of other causes. In this study, adenosine deaminase had a sensitivity of 100% and specificity of 96% in discriminating tuberculosis from other causes of ascites. These findings suggest that the ascitic fluid adenosine deaminase activity may be used to identify patients in whom the diagnosis of abdominal tuberculosis must be pursued.

Adenosine deaminase was estimated in ascitic fluids of 49 patients with ascites (19 tuberculous, 20 cirrhotic, and 10 malignant). The adenosine deaminase concentration in tuberculous ascitic fluid was 98.8 +/- 20.1 U/L (mean +/- SD), which was significantly more than that noted in cirrhotic (14 +/- 10.6 U/L) or malignant (14.6 +/- 6.7 U/L) ascitic fluids (p less than 0.001 for each). At a cut-off value of greater than 33 U/L, the sensitivity, specificity, positive and negative predictive value, and the overall diagnostic accuracy for diagnosing tuberculous ascites were 100%, 96.6%, 95%, 100%, and 98%, respectively. We conclude that estimation of adenosine deaminase in ascitic fluid is an easy and reliable method for diagnosing tuberculous ascites.