[Pay attention to the diagnosis and treatment of "easily neglected" complications in liver cirrhosis].

Managing cirrhosis complications is an important measure for improving patients' clinical outcomes. Therefore, in order to provide a complete disease assessment and comprehensive treatment, improve quality of life, and improve the prognosis for patients with cirrhosis, it is necessary to pay attention to complications such as thrombocytopenia and portal vein thrombosis in addition to common or severe complications such as ascites, esophagogastric variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome. The relevant concept that an effective albumin concentration is more helpful in predicting the cirrhosis outcome is gradually being accepted; however, the detection method still needs further standardization and commercialization.

Amount of ascites impacts survival in patients with hepatocellular carcinoma undergoing transarterial chemoembolization advocating for volumetric assessment.

Preliminary work has shown that portal hypertension plays a key role for the prognosis in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). Specifically, the presence of ascites appears to be a strong negative predictor for these patients. However, it remains unclear whether different ascites volumes influence prognosis. Therefore, the aim of this work was to investigate the influence of different ascites volumes on survival for patients with HCC undergoing TACE. A total of 327 treatment-naïve patients with HCC undergoing initial TACE at our tertiary care center between 2010 and 2020 were included. In patients with ascites, the fluid was segmented, and the volume quantified by slice-wise addition using contrast-enhanced CT imaging. Median overall survival (OS) was calculated and univariate and multivariate Cox regression analysis has been performed. Ascites was present in 102 (31.9%) patients. Ascites volume as continuous variable was significantly associated with an increased hazard ratio in univariate analysis (p < 0.001) and remained an independent predictor of impaired median OS in multivariate analysis (p < 0.001). Median OS without ascites was 17.1 months, and therefore significantly longer than in patients with ascites (6.4 months, p < 0.001). When subdivided into groups of low and high ascites volume in relation to the median ascites volume, patients with low ascites volume had a significantly longer median OS (8.6 vs 3.6 months, p < 0.001). Ascites in patients with HCC undergoing TACE is strongly associated with a poor prognosis. Our results show that not only the presence but also the amount of ascites is highly relevant. Therefore, true ascites volume as opportunistic quantitative biomarker is likely to impact clinical decision-making once automated solutions become available.

Chinese guidelines on the management of ascites in cirrhosis : Chinese Society of Hepatology, Chinese Medical Association.

In 2023, Chinese Society of Hepatology of Chinese Medical Association convened a panel of experts to update the Chinese guidelines on the management of ascites and associated complications in cirrhosis which was launched in 2017 and renamed this guidelines as "Guidelines on the Management of Ascites in Cirrhosis." This comprehensive resource offers essential recommendations for the diagnosis and treatment of cirrhotic ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.

Effective palliation of refractory ascites in cirrhosis is challenging.

BACKGROUND: Palliative care is often suboptimal for patients with end-stage liver disease (ESLD). Ascites remains the most common complication in ESLD. Though long-term abdominal drains (LTAD) are commonly used in refractory malignant ascites, the standard care for ESLD is hospital drainage (large volume paracentesis (LVP)). There is an ongoing National Institute for Health and Care Research (NIHR) funded trial (REDUCe 2 Study) (ISRCTN269936824) comparing palliative LTAD to LVP in ESLD. This 35-site trial is being conducted in England, Scotland and Wales. AIM: To understand the views and experience of healthcare professionals (HCP) on the use of palliative LTAD in ESLD. METHODS: An electronic survey comprised of seven questions with fixed quantitative options and three exploratory questions was used between August-December 2019. The survey was distributed electronically via the British Association for Study of Liver newsletter and to relevant hospital departments in Southeast England and Northeast London. An email reminder was sent at 4 and 8 weeks after the initial invitation to the survey. RESULTS: There were 211 respondents (hepatologists (36.5%), specialist nurses (24.6%), gastroenterologists (16.6%), trainees (17%) and others (5.2%)). All respondents had access to LVP, 86% to a transjugular intrahepatic portosystemic shunt procedure for patients, 67% to LTADs and 10% to other options, such as the automated low-flow ascites (ALFA) pump. The majority of respondents to the survey (68%) reported their experience of using LTAD. Almost all respondents (91%) were willing to consider LTAD in ESLD. However, the main deterrents of this were the perceived risk of infection (90%), followed by LTAD management in community (57%). Some 51% of those with prior experience of using LTAD reported clinical complications for patients (including bleeding, infection and renal impairment), 41% reported technical issues and 35% inadequate community support. CONCLUSIONS: Almost all HCPs are willing to consider palliative LTAD in refractory ascites due to ESLD, but the main deterrents are the perceived infection risk and lack of published data to guide community management. The REDUCe 2 trial will clarify if these concerns are real and provide conclusive evidence on role, if any, of palliative LTADs in this vulnerable and under researched cohort with ESLD.

Peritoneal dialysis in an end-stage renal disease patient with massive ascites and primary liver cancer.

End-stage renal disease (ESRD) coexisted with cirrhosis, ascites, and primary liver cancer represents an extraordinarily rare clinical condition that typically occurs in very late-stage decompensated cirrhosis and is associated with an extremely poor prognosis. We present a case of a 68-year-old male patient with ESRD who experienced various decompensated complications of liver cirrhosis, particularly massive ascites and hepatic space-occupying lesions. Peritoneal dialysis (PD) catheter insertion and continuous ambulatory peritoneal dialysis (CAPD) treatment were successfully performed. During meticulous follow-up, the patient survived for one year but ultimately succumbed to complications related to liver cancer. PD can serve as an efficacious therapeutic approach for such late-stage patients afflicted together with severe cirrhosis, massive ascites and primary liver cancer.

Surgical management of chronic lymphatic pleural effusions and chronic lymphatic ascites.

Patients with central lymphatic conduction disorders commonly have recalcitrant pleural effusions and or ascites. These conditions cause a profound deterioration in the patient's quality of life. Support measures such as low-fat diet and diuretics alone hardly ever provide meaningful improvement. New understanding of the pathophysiology of these disorders has opened the door in recent years to the development of several surgical procedures that have remarkable success rates. However, these patients must be managed by expert multidisciplinary teams.

Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative Inquiry.

BACKGROUND: Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. AIM: This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. METHODS: The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. RESULTS: Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. CONCLUSION: This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.

Oncolytic adenovirus in treating malignant ascites: A phase II trial and longitudinal single-cell study.

Malignant ascites is a common complication resulting from the peritoneal spread of malignancies, and currently lacks effective treatments. We conducted a phase II trial (NCT04771676) to investigate the efficacy and safety of oncolytic adenovirus H101 and virotherapy-induced immune response in 25 patients with malignant ascites. Oncolytic virotherapy achieved an increased median time to repeat paracentesis of 45 days (95% confidence interval 16.5-73.5 days), compared with the preset control value of 13 days. Therapy was well-tolerated, with pyrexia, fatigue, nausea, and abdominal pain as the most common toxicities. Longitudinal single-cell profiling identified marked oncolysis, early virus replication, and enhanced CD8+ T cells-macrophages immune checkpoint crosstalk, especially in responsive patients. H101 also triggered a proliferative burst of CXCR6+ and GZMK+CD8+ T cells with promoted tumor-specific cytotoxicity. Further establishment of oncolytic virus-induced T cell expansion signature (OiTE) implicated the potential benefits for H101-responsive patients from subsequent anti-PD(L)1 therapy. Patients with upregulated immune-signaling pathways in tumor cells and a higher proportion of CLEC10A+ dendritic cells and GZMK+CD8+ T cells at baseline showed a superior response to H101 treatment. Our study demonstrates promising clinical responses and tolerability of oncolytic adenovirus in treating malignant ascites and provides insights into the relevant cellular processes following oncolytic virotherapy.

Successful Transcatheter Arterial Embolization of Abdominal Wall Hematoma from the Left Deep Circumflex Iliac Artery after Abdominal Paracentesis in a Patient with Liver Cirrhosis: Case Report and Literature Review.

The occurrence of an abdominal wall hematoma caused by abdominal paracentesis in patients with liver cirrhosis is rare. This paper presents a case of an abdominal wall hematoma caused by abdominal paracentesis in a 67-year-old woman with liver cirrhosis with a review of the relevant literature. Two days prior, the patient underwent abdominal paracentesis for symptom relief for refractory ascites at a local clinic. Upon admission, a physical examination revealed purpuric patches with swelling and mild tenderness in the left lower quadrant of the abdominal wall. Abdominal computed tomography revealed advanced liver cirrhosis with splenomegaly, tortuous dilatation of the para-umbilical vein, a large volume of ascites, and a large acute hematoma at the left lower quadrant of the abdominal wall. An external iliac artery angiogram showed the extravasation of contrast media from the left deep circumflex iliac artery. Embolization of the target arterial branches using N-butyl-2-cyanoacrylate was then performed, and the bleeding was stopped. The final diagnosis was an abdominal wall hematoma from the left deep circumflex iliac artery after abdominal paracentesis in a patient with liver cirrhosis.

Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting.

Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.

Review article: Recent advances in ascites and acute kidney injury management in cirrhosis.

BACKGROUND: Better understanding of disease pathophysiology has led to advances in managing ascites and its associated complications including hepatorenal syndrome-acute kidney Injury (HRS-AKI), especially medicinal and interventional advances. AIM: To review the latest changes in the management of ascites and HRS-AKI. METHODS: A literature search was conducted in Pubmed, using the keywords cirrhosis, ascites, renal dysfunction, acute kidney injury, hepatorenal syndrome, beta-blockers, albumin, TIPS and vasoconstrictors, including only publications in English. RESULTS: The medicinal advances include earlier treatment of clinically significant portal hypertension to delay the onset of ascites and the use of human albumin solution to attenuate systemic inflammation thus improving the haemodynamic changes associated with cirrhosis. Furthermore, new classes of drugs such as sodium glucose co-transporter 2 are being investigated for use in patients with cirrhosis and ascites. For HRS-AKI management, newer pharmacological agents such as vasopressin partial agonists and relaxin are being studied. Interventional advances include the refinement of TIPS technique and patient selection to improve outcomes in patients with refractory ascites. The development of the alfa pump system and the study of outcomes associated with the use of long-term palliative abdominal drain will also serve to improve the quality of life in patients with refractory ascites. CONCLUSIONS: New treatment strategies emerged from better understanding of the pathophysiology of ascites and HRS-AKI have shown improved prognosis in these patients. The future will see many of these approaches confirmed in large multi-centre clinical trials with the aim to benefit the patients with ascites and HRS-AKI.

Disparities in Care for Low-Income Patients with Cirrhosis: Implementing an Innovative Outpatient Clinic for Refractory Ascites in a Safety Net Hospital.

BACKGROUND: Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. AIM: To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. SETTING: A large safety net hospital in Los Angeles. PARTICIPANTS: MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. PROGRAM DESCRIPTION: According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. PROGRAM EVALUATION: After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. DISCUSSION: Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care.

TPN ascites: an uncommon cause for acute deterioration on mechanical ventilation in a neonate with congenital diaphragmatic hernia.

On ventilation since birth, a term neonate with an antenatally detected left-sided congenital diaphragmatic hernia (CDH) had a sudden worsening in respiratory parameters on day 5 of life. Tube displacement, obstruction, pneumothorax and equipment failure were all ruled out. The examination revealed decreased air entry on the left side and mild abdominal fullness. The chest and abdomen radiographs revealed the absence of bowel gas with a complete whiteout of the abdominal cavity. Since birth, the neonate had received parenteral nutrition via the umbilical venous line. Keeping a possibility of ascites and pleural effusion, an abdominal sonogram was performed, timely glove drain insertion was ensured, and umbilical lines were removed. The neonate improved dramatically and underwent CDH patch repair. Given the likely distorted vascular anatomy, this case underscores the need to re-examine the umbilical venous line insertion practice on the first day in CDH neonates.

Recent developments in the management of ascites in cirrhosis.

In recent years, advances have been made for treating ascites in patients with cirrhosis. Recent studies have indicated that several treatments that have been used for a long time in the management of portal hypertension may have beneficial effects that were not previously identified. Long-term albumin infusion may improve survival in patients with cirrhosis and ascites while beta-blockers may reduce ascites occurrence. Transjugular intrahepatic porto-systemic shunt (TIPS) placement may also improve survival in selected patients in addition to the control with ascites. Low-flow ascites pump insertion can be another option for some patients with intractable ascites. In this review, we summarize the latest data related to the management of ascites occurring in cirrhosis. There are still unanswered questions, such as the optimal use of albumin as a long-term therapy, the place of beta-blockers, and the best timing for TIPS placement to improve the natural history of ascites, as well as the optimal stent diameter to reduce the risk of shunt-related side-effects. These issued should be addressed in future studies.

Personalised human albumin in patients with cirrhosis and ascites: design and rationale for the ALB-TRIAL - a randomised clinical biomarker validation trial.

INTRODUCTION: Human albumin is used in the treatment of complications of cirrhosis. However, the use of long-term human albumin administration is costly and resource demanding for both patients and healthcare systems. A precision medicine approach with biomarkers to predict human albumin treatment response, so-called predictive biomarkers, could make this a viable treatment option in patients with cirrhosis and ascites. METHODS AND ANALYSIS: ALB-TRIAL is a multinational, double-blind, placebo-controlled randomised controlled trial. We aim to validate a predictive biomarker, consisting of a panel of circulating metabolites, to predict the treatment response to human albumin in patients with cirrhosis and ascites. All enrolled patients are stratified into a high-expected or low-expected effect stratum of human albumin based on the biomarker outcome. After stratification, patients in each group are randomised into either active treatment (20% human albumin) or corresponding placebo (0.9% NaCl) every 10th day for 6 months. The primary outcome is the cumulative number of liver-related events (composite of decompensation episodes, transjugular intrahepatic shunt insertion, liver transplantation and death). Key secondary outcomes include time-to-event analysis of primary outcome components, an analysis of the total healthcare burden and a health economic analysis. ETHICS AND DISSEMINATION: The trial obtained ethical and regulatory approval in Denmark, Germany, the Netherlands, Belgium, Hungary and Spain through the Clinical Trials Information System (CTIS) from 13 February 2023, while UK approvals from the Health Regulatory Authority, Medicines and Healthcare products Regulatory Agency and Research Ethics Committee are pending. Findings will be published in peer-reviewed journals, presented at conferences, communicated to relevant stakeholders and in the public registry of CTIS, following trial completion. TRIAL REGISTRATION NUMBER: NCT05056220 EU CT: 2022-501006-34-01.

Enhancing proficiency in ascites puncture through procedural simulation: an audit type study investigating medium-term skill retention.

INTRODUCTION: Medical simulation has become an essential teaching method for all health professionals. It not only allows to acquire technical and non-technical knowledge, but also helps the maintenance of acquired knowledge in the medium and long term. Ascites puncture is part of the basic technical procedures learned by medical students during their internship. OBJECTIVES: To evaluate the role of simulation-based learning of ascites puncture on the improvement of theoretical knowledge and maintenance of skills at 3 months. METHODS: We conducted an audit type study with two cycles of data collection at the simulation center at the Faculty of Medicine of Sousse between November 2020 and June 2021. We included learners in their third year of medical studies who had a hospital internship in the gastroenterology department at Sahloul Hospital in Sousse. All learners attended the initial simulation session on ascites fluid puncture. Thereafter, they were free to accept or refuse participation in the evaluation session that was scheduled after 3 months, depending on their availability. RESULTS: Forty learners participated in the procedural simulation of the ascites fluid puncture technique. Thirty-four (85%) were female and six (5%) were male. In our study, we showed that following procedural simulation training of ascites puncture, there was a significant improvement in the theoretical knowledge of the learners (p < 0.000). Objective assessment of technical skills after 3 months showed the benefit of performance maintenance (p < 0.000). CONCLUSION: Our study confirmed the benefit of simulation-based learning on the improvement of theoretical knowledge and the maintenance of technical performance in the medium term.

Reappraisal of a Renovated Cell-free and Concentrated Ascites Reinfusion Therapy for Malignant Ascites.

BACKGROUND/AIM: Cell-free and concentrated ascites reinfusion therapy (CART) was established for refractory ascites and renovated CART (Keisuke Matsusaki (KM) -CART) has been recently developed especially for malignant ascites; however, the actual clinical efficacy of KM-CART has been rarely reported. PATIENTS AND METHODS: We performed 226 KM-CART procedures in 104 patients with malignant ascites in three hospitals from August 2013 to September 2018. Medical records were retrospectively reviewed for ascites data, related complications, symptoms before and after each CART and prognosis after the first CART. The modified Glasgow Prognostic Score (mGPS) was reviewed before every procedure, as an indicator of nutritional status. RESULTS: Pancreatic cancer was the most common indication for the KM-CART procedure, followed by gastric cancer, hepatocellular carcinoma, ovarian cancer, and cholangiocarcinoma (five major diseases). The 50% survival times of these five major diseases after the first procedure were 25, 39, 31, 49, and 33 days, respectively. The mean survival time for all patients was 73.5 days, and 75.6 days for those with the five major diseases. All patients experienced symptomatic relief, and complications were rare. Repeated KM-CART was performed in 47.1% of the patients, most often in those with ovarian cancer (66.7%). Regarding the mGPS at the first CART procedure, 89% of patients were in the group with the poorest nutritional status. Patients who underwent KM-CART three or more times had longer survival than those who were treated once or twice. CONCLUSION: Repeated KM-CART provides a survival benefit for patients with malignant ascites, even in cases of poor nutritional status.