Predictors of Paracentesis in Women with Severe Ovarian Hyperstimulation Syndrome: A Retrospective Cohort Study.

BACKGROUND: To identify predictors of paracentesis in women with severe ovarian hyperstimulation syndrome (OHSS). METHODS: In a retrospective cohort study, we assessed patient characteristics and outcome measures of women with severe OHSS Golan grade II/III from 1996 to 2010 using univariate and multivariate analyses with the number of paracenteses as the main outcome. RESULTS: Three hundred ninety four women with OHSS Golan grade II (n = 40) and grade III (n = 354) were included in the study. Paracentesis was performed in 108/394 (27%) of these women. One paracentesis was performed in 63 (16%), 2 paracenteses in 26 (6%), and ≥3 paracenteses 19 (5%) women, respectively. No thrombotic or cerebrovascular morbidity occurred. The mortality of the cohort was 0/394 (0%). In a univariate analysis, late onset OHSS (p = 0.02), pregnancy (p < 0.001), human chorionic gonadotropin use (p = 0.02), ovarian diameter (p = 0.006), and elevated serum levels of alanine aminotransferase (p < 0.001), hematocrit (p < 0.001), leucocytes (p < 0.001), thrombocytes (p < 0.001), and uric acid (p < 0.001) were associated with paracentesis. In a multivariate logistic regression analysis, only alanine aminotransferase (OR 1.006; 95% CI 1.001-1.01) and hematocrit (OR 1.16; 95% CI 1.05-1.27) were independently associated with paracentesis. CONCLUSION: Alanine aminotransferase and hematocrit at initial presentation are independent predictors of paracentesis.

Electrolyte depletion syndrome (McKittrick-Wheelock syndrome) successfully treated by endoscopic submucosal dissection.

A 66-year-old woman presented to us with malaise, anorexia and rectal mucous discharge, and her laboratory data showed severe hyponatremia, hypokalemia, hypochloremia and renal failure. Computed tomography revealed massive occupation of the rectum by a large tumor. Colonoscopy revealed a mucus-rich villous tumor in the rectum. As there were no other factors that could cause an electrolyte disorder, she was diagnosed with McKittrick-Wheelock syndrome (MWS). The current standard treatment for MWS is partial surgical colectomy. However, surgeries are invasive and postoperative complications sometimes become an issue. After confirming no signs of submucosal invasion of the tumor by magnifying chromoendoscopic examination, endoscopic submucosal dissection (ESD) was indicated. The tumor was completely removed en bloc without adverse events. The histology showed a mucosal adenocarcinoma containing a villous component, 24.5 x 17.0 cm in size. This removal dramatically improved the patient's symptoms and the electrolyte abnormalities without medication. Although several sessions of endoscopic balloon dilation were required to treat postoperative stricture, she has been symptom-free and had no recurrence for 4 years after treatment. We experienced a case of MWS treated by ESD instead of surgery. ESD should be feasible and beneficial for the treatment of MWS.

A case of difficult management of fluid-electrolyte imbalance in choroid plexus papilloma.

A 22-month-old boy presented with nausea and gradual deterioration of gait disturbance. Computed tomography (CT) demonstrated an intraventricular mass lesion in the right lateral ventricle. He was referred to our department 3 weeks after onset. Acute hydrocephalus gradually proceeded 4 days after admission, and external ventricular drainage (EVD) was performed. EVD revealed cerebrospinal fluid (CSF) overproduction (800-1,500 mL/day) under constant pressure of 10 cm H2O above external auditory meatus. Magnetic resonance imaging showed a multi-lobular mass in the inferior horn of the right lateral ventricle. A choroid plexus tumor was suspected. The ratio of blood urea nitrogen:creatinine (BUN:Cre) remained between 30 and 40, and hemoglobin was between 14.0-17.0 mg/dL, suggesting marked dehydration. Serum sodium varied between 117 and 140 mmol/L, and serum potassium between 2.2 mmol/L and 6.9 mmol/L. The amount of EVD was unstable and fluid balance management was difficult. Hypotonic fluid with sodium chloride supplement was used to adjust the fluid and electrolyte imbalance. Surgical removal of the tumor was performed 6 days after EVD and tumor was grossly and totally removed. The high BUN:Cre ratio decreased to about 15 and hemoglobin recovered to 7.5-9.0 mg/dL after removal. Electrolytes returned to the normal range. Overproduction of CSF also markedly improved to < 300 mL/day. Histopathological examination diagnosed choroid plexus papilloma.We experienced a case of choroid plexus papilloma associated with fluid-electrolyte imbalance due to over-drainage after EVD, which could not be effectively controlled before tumor removal. Cautious fluid management and emergent surgical resection might be required to manage the overproduction of CSF and fluid-electrolyte imbalance.

Basic principles and practical steps in the management of fluid balance in the newborn.

The fluid management of newborn babies can pose many problems. This article discusses the factors that affect fluid balance in the newborn infant, both term and preterm, and the special circumstances of the surgical neonate. The main determinants of management are: (1) an estimation of transepidermal water losses; (2) an awareness of glomerular filtration rate and how this is influenced by age, respiratory distress and medical intervention; and (3) knowledge of tubular function and its maturation and the processes of postnatal adaptation. This knowledge and appropriate monitoring are the mainstay of management of neonatal fluid balance.

Mucous fistula refeeding in neonates with short bowel syndrome.

BACKGROUND/PURPOSE: Neonates with enterostomies commonly suffer from a functional short bowel syndrome (SBS) and have a greater risk of electrolyte and fluid loss with poor weight gain. The authors describe their experience with refeeding stoma effluent into the mucous fistula in neonates. METHODS: A 5-year (1993 to 1997) chart review of neonates with stoma effluent refeeding was undertaken. Demographics, medical history, surgical procedures, timing, and duration of refeedings were reviewed. Enteral and total parenteral nutritional (TPN) requirements, electrolyte, and acid-base disturbances were recorded. RESULTS: Six neonates (gestational ages of 27 to 38 weeks, birth weights of 533 to 3400 g) were identified with nutritional or electrolyte complications before the commencement of refeeding. Enterostomy indications included necrotizing enterocolitis (n = 2), intestinal atresia type 3b (n = 1), complications from ruptured omphalocoele (n = 1), congenital adhesive band obstruction (n = 1), and midgut volvulus after congenital diaphragmatic hernia repair (n = 1). Weight gain during refeeding ranged from 5 to 25 g/kg/d with duration of refeeding lasting 16 to 169 days (two neonates were refed at home) until reanastomoses were done 6 to 44 weeks after the original surgery. There were no complications, and TPN requirements were diminished or eliminated. CONCLUSION: This technique represents a simple and safe method, which lessens the need for TPN and electrolyte supplementation in neonates with enterostomies and SBS before reanastomosis.

Transient pseudohypoaldosteronism in obstructive renal disease.

The cases of two patients with transient pseudohypoaldosteronism due to an up to this point unrecognized obstructive renal disease are reported. Both girls presented with a severe salt-losing episode in early infancy mimicking congenital adrenal hyperplasia. Extensive endocrinologic work-up revealed markedly elevated plasma-aldosterone levels. Clinical and laboratory data were consistent with transient pseudohypoaldosteronism. Sonographic and radiological investigation showed in both children a vesicoureteral reflux of differing grades. After therapy of the electrolyte-imbalance and recovery, one of the children required surgical treatment of vesicoureteral reflux.

Revision of intestinal bypass procedures.

The results of jejunoileal bypass have been satisfactory in 80 per cent of the patients. In the remaining 20 per cent, one or more problems eventually may require revision of the bypass. These problems fall into four categories: inadequate weight loss; excessive weight loss; persistent uncontrollable diarrhea or associated severe anorectal problems, or both, and severe unmanageable electrolyte and metabolic imbalance with or without liver failure. In our series, 108 patients were observed for one to five years, and ten patients required revision, one revision for every 12 bypass operations performed. The preoperative evaluation and management and the options available to the surgeon in correcting the abnormalities are evaluated. The results of ten patients who underwent revision of the bypass and the rationale for the revision are outlined. Criteria for an ideal operation have not as yet been attained.