Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites.

INTRODUCTION: Large-volume paracentesis (LVP) is the first-line treatment for decompensated cirrhosis with refractory ascites. While ascitic drain removal (ADR) within 72 hours of the procedure was once considered safe, it was uncertain whether ADR within 24 hours could further reduce the risk of ascitic drain-related bacterial peritonitis (AdBP). This study aimed to investigate the association between the timing of ADR and the presence of AdBP. METHODS: All patients with cirrhosis with refractory ascites who underwent LVP in our institution from 2014 to 2017 were studied. AdBP was diagnosed based on an ascitic fluid neutrophil count ≥ 250 cells/mm3 or positive ascitic fluid culture following recent paracentesis within two weeks. RESULTS: A total of 131 patients who underwent LVP were followed up for 1,806 patient-months. Their mean age was 68.3 ± 11.6 years, and 65.6% were male. Their mean Model for End-Stage Liver Disease score was 15.2. The overall incidence of AdBP was 5.3%. ADR beyond 24 hours was significantly associated with a longer median length of stay (five days vs. three days, p < 0.001), higher risk of AdBP (0% vs. 8.9%, p = 0.042) and acute kidney injury (AKI) following LVP (odds ratio 20.0, 95% confidence interval 2.4-164.2, p = 0.021). The overall survival was similar in patients who underwent ADR within and beyond 24 hours of LVP. CONCLUSION: ADR within 24 hours of LVP is associated with a reduced risk of AdBP and AKI. As AdBP is associated with resistant organisms and AKI, we recommend prompt ADR within 24 hours, especially in patients who have Child-Pugh class C alcoholic cirrhosis.

Do total parenteral nutrition and bowel rest reduce the risk for perforation in patients with gastrointestinal tract lymphoma receiving chemotherapy?

OBJECTIVES: Gastrointestinal tract (GIT) lymphoma is associated with a risk for perforation while the patient is receiving chemotherapy. The role of total parenteral nutrition (TPN) and bowel rest in preventing perforation is unknown. The aim of this study was to examine the clinical outcomes of TPN and bowel rest in patients with GIT lymphoma who were receiving chemotherapy. METHODS: We reviewed all patients with GIT biopsy-proven lymphoma in our institution between 2013 and 2017. Patients were stratified into two groups, with and without TPN and bowel rest during chemotherapy. We identified 158 patients with GIT lymphoma. Of these, 47 (29.7%) received TPN and bowel rest before chemotherapy. Patients who received TPN were younger, more likely to have aggressive lymphoma in the small or large bowel. The primary outcome was to compare the perforation rate between the two groups. Secondary outcome analysis included infection rate and survival. RESULTS: Patients with perforation had significantly poorer survival. Perforation rate was similar between the TPN and the non-TPN groups (8.5% versus 2.7%, P = 0.197). Overall survival was similar between the two groups (P = 0.659). The TPN group had a higher infection rate (odds ratio, 5.32; 95% confidence interval, 1.36-20.8) after adjustment for covariates (age, types of lymphoma, and location of lymphoma). CONCLUSION: The present study demonstrated that TPN and bowel rest did not reduce the risk for perforation among patients with GIT lymphoma who were receiving chemotherapy. As the practice of prophylactic TPN and bowel rest was associated with higher infection risk and longer hospitalization, we do not recommend such practice for all patients with GIT lymphoma receiving chemotherapy.