Development and validation of a deep learning system for ascites cytopathology interpretation.

BACKGROUND: Early diagnosis of Peritoneal metastasis (PM) is clinically significant regarding optimal treatment selection and avoidance of unnecessary surgical procedures. Cytopathology plays an important role in early screening of PM. We aimed to develop a deep learning (DL) system to achieve intelligent cytopathology interpretation, especially in ascites cytopathology. METHODS: The original ascites cytopathology image dataset consists of 139 patients' original hematoxylin-eosin (HE) and Papanicolaou (PAP) Staining images. DL system was developed using transfer learning (TL) to achieve cell detection and classification. Pre-trained alexnet, vgg16, goolenet, resnet18 and resnet50 models were studied. Cell detection dataset consists of 176 cropped images with 6573 annotated cell bounding boxes. Cell classification data set consists of 487 cropped images with 18,558 and 6089 annotated malignant and benign cells in total, respectively. RESULTS: We established a novel ascites cytopathology image dataset and achieved automatically cell detection and classification. DetectionNet based on Faster R-CNN using pre-trained resnet18 achieved cell detection with 87.22% of cells' Intersection of Union (IoU) bigger than the threshold of 0.5. The mean average precision (mAP) was 0.8316. The ClassificationNet based on resnet50 achieved the greatest performance in cell classification with AUC = 0.8851, Precision = 96.80%, FNR = 4.73%. The DL system integrating the separately trained DetectionNet and Classificationnet showed great performance in the cytopathology image interpretation. CONCLUSIONS: We demonstrate that the integration of DL can improve the efficiency of healthcare. The DL system we developed using TL techniques achieved accurate cytopathology interpretation, and had great potential to be integrated into clinician workflow.

The utility of texture-based classification of different types of ascites on magnetic resonance.

PURPOSE: To quantify specific characteristics of different types of ascitic fluid on magnetic resonance (MR) images and to determine their utility for computer-assisted lesion classification. METHODS: The MR images of 48 patients with intra-abdominal fluid were retrospectively analyzed. Patients were grouped according to the underlying disease and pathological outcomes. The fluid texture was analyzed on Breath Hold Axial T2 FatSat FIESTA sequence, using MaZda software. Most discriminative texture features for the classification of different types of ascites were selected based on Fisher coefficients (F) and the probability of classification error and average correlation coefficients (POE+ACC). Computer-assisted classification based on k-nearest-neighbor (k-NN) and artificial neural network (ANN) was performed and then accuracy, sensitivity and specificity were calculated. RESULTS: Adequate discriminative power for differentiating benign ascites from malignant ascites was achieved for two textural features, namely the Run Length Nonuniformity computed from both vertical and horizontal directions with 91.84% accuracy (sensitivity 100%; specificity 42.86%), and ten features for differentiating bland from hemorrhagic fluid with 90.00% accuracy (sensitivity 92.31%; specificity 85.71%), both for the ANN classifier. CONCLUSION: Texture analysis revealed several differences in signal characteristics of benign and malignant ascites. Computer-assisted pattern recognition algorithms may aid in the differential diagnosis of ascites types, especially in the early stages when there are few peritoneal modifications or when the cause is difficult to find.

[Management of ascites due to portal hypertension]. / Hypertension portale et prise en charge de l'ascite.

Portal hypertension is regularly encountered by the general practitioner. It is defined by an elevation of the porto-systemic pressure gradient, with complications such as ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, variceal bleeding, hypersplenism, hepatopulmonary syndrome or hepatic encephalopathy occuring when a significant elevation of this gradient is reached. Cirrhosis is the primary cause of portal hypertension in industrialized countries. Symptomatic portal hypertension carries a poor prognosis. Management should be initiated rapidly, including the identification and correction of any reversible underlying condition. Liver transplantation should be considered in advanced cases.

Manejo de ascitis refractaria e hiponatremia dilucional en pacientes con cirrosis / Management of refractory ascites and dilutional hyponatremia in cirrhotic patient

Ascites and dilutional hyponatremia are frequent conditions in cirrhotic patients and its occurrence has a worse prognosis. Thus, patients with ascites should generally be considered for referral for liver transplantation. The present article explores issues related with ascites classification and the treatment corresponding to each of the 3 degrees of ascites. Regarding refractory ascites, recommendations are included on the use of diuretics, large volume paracentesis with the administration of intravenous albumin and use of transjugular intrahepatic portosystemic shunt (TIPS). Finally, physiopathological aspects involved in the development of dilutional hyponatremia and vaptans treatment, are presented, which are aquaretics that selectively blockade vasopressin V2 receptors in the principal cells of the collecting ducts, being one of the most innovative pharmacological interventions for the management of hyponatremia in cirrhotic patients, in the recent years.

La ascitis e hiponatremia dilucional son complicaciones frecuentes en pacientes con cirrosis avanzada y su aparición implica un peor pronóstico. Por ello, los pacientes con ascitis deberían ser referidos para trasplante hepático. El presente artículo explora los aspectos relacionados con la clasificación de la ascitis y el tratamiento correspondiente a cada uno de los 3 grados de ascitis. En relación al manejo de la ascitis refractaria, se incluyen recomendaciones respecto a la eficacia del uso de diuréticos, paracentesis evacuadora radical con reposición de albúmina intravenosa y uso de cortocircuito porto-sistémico intrahepático (TIPS). Finalmente, se abordan los aspectos fisiopatológicos involucrados en el desarrollo de hiponatremia dilucional y el tratamiento con vaptanes, que son acuaréticos que bloquean selectivamente los receptores V2 de vasopresina en las células principales del túbulo colector, constituyendo una de las intervenciones farmacológicas más innovadoras en el manejo de la hiponatremia en cirrosis en los últimos años.

Correlación clínica- para-clínica en un escolar con hipertensión porta de etiología a esclarecer / Clinical-paraclinical in a school with portal hypertension to determine

La hipertensión porta (HTP) es el resultado del incremento de la presión dentro del sistema venoso porta. Se presenta con poca frecuencia en el paciente pediátrico pero es una de las mayores causas de morbilidad y mortalidad en el niño con enfermedad hepática. La mayoría de los pacientes con http presentan un estado hiperdinámico, lo cual aumenta el flujo venoso porta y mantiene la hipertensión. Puede ser secundaria a obstrucción a nivel prehepático, intrahepático o extrahehepático.

Portal hypertension (PH) is the result of increased pressure within the portal venous system. It occurs infrequently in the pediatric patient but it is a major cause of morbidity and mortality in children with liver disease. Most patients with PH have a hyperdynamic state, which increases venous flow and portal hypertension remains. May be secondary to obstruction at prehepatic, intrahepatic or extrahehepatic.

Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: management and outcome.

BACKGROUND: Our purpose was to determine optimal management of and outcome after umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites. METHODS: A retrospective chart review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at The Mount Sinai Medical Center from 2002 to 2008. Univariate, multivariate, and Kaplan-Meier analysis was performed. RESULTS: Twenty-one patients had refractory ascites: 15 presented with incarceration and 6 with spontaneous umbilical rupture. The mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation, and 5 developed ascites-related wound complications. Follow-up at a mean of 36 months demonstrated a 20% mortality rate due to liver disease; 5% required liver transplantation and 6% had a recurrent hernia. In addition to diuretics and albumin, perioperative management of ascites consisted of preoperative transjugular intrahepatic portosystemic shunt (TIPS; n = 6), postoperative TIPS (n = 2), and closed-suction drains (n = 7). The wound complication rate was 17% in patients who underwent preoperative TIPS versus 27% in patients who did not undergo preoperative TIPS (P = NS). TIPS placement postoperatively controlled ascites adequately without additional complication in 2 patients. In this series, use of closed-suction drains did not appear to decrease ascites-related complications. Spontaneous umbilical rupture was an independent risk factor for adverse outcome. For patients presenting with umbilical rupture, preoperative TIPS and semi-elective repair appeared to improve perioperative and 36-month outcome as compared with emergent repair. CONCLUSION: Preoperative TIPS in conjunction with semi-elective repair when feasible appears preferable, particularly for patients with spontaneous umbilical rupture. The lower than anticipated mortality rate was attributed to institutional experience and to the multidisciplinary approach to patient care.

Ascites: diagnosis and management.

Ascites is the pathologic accumulation of fluid in the peritoneal cavity and is a common manifestation of liver failure, being one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its cause by determining the serum-ascites albumin gradient and the exclusion of complications eg, spontaneous bacterial peritonitis. Although sodium restriction and diuretics remain the cornerstone of ascites management, many patients require additional therapy when they become refractory to such medical treatment. These include repeated large volume paracentesis and transjugular intrahepatic portosystemic shunts. This review article summarizes diagnostic tools and provides an evidence-based approach to the management of ascites.

The Role of 18F-FDG PET/CT in the evaluation of Ascites of Undetermined Origin.

UNLABELLED: The first aim of our study was to compare the role of (18)F-FDG PET/CT with that of CT alone in detecting the primary cause of ascites. A secondary aim was to compare the value of (18)F-FDG PET/CT with that of CT alone in detecting abdominal cavity metastasis. Finally, we analyzed the receiver-operating-characteristic (ROC) curves of maximal standardized uptake values (SUVmax), serum carcinoembryonic antigen, CA19-9, and CA12-5 for differential diagnostic abilities. METHODS: The (18)F-FDG PET/CT scans of 40 patients with ascites of undetermined origin, including 30 patients with malignant diseases and 10 with benign lesions, were reviewed for the presence of ascites. Among the 40 patients, 34 had received their diagnosis by pathologic examination and 6 by clinical follow-up. We also assessed the (18)F-FDG PET/CT scans of 20 healthy volunteers for comparison. All (18)F-FDG PET/CT images were visually interpreted, and the SUVmax was measured. We compared the mean diameter of true-positive lesions with that of false-negative lesions. The diagnostic abilities of SUVmax, serum carcinoembryonic antigen, CA19-9, and CA12-5 were compared using the ROC curve. RESULTS: The sensitivity, specificity, and accuracy of PET/CT in detecting the primary cause of ascites were 63.3% (19/30), 70.0% (7/10), and 65.0% (26/40), respectively, and those of CT alone were 36.7% (11/30), 80% (8/10), and 47.5% (19/40), respectively (sensitivity, P < 0.05). The sensitivity of PET/CT was higher than that of CT alone for detecting abdominal cavity metastasis (86.4% vs. 27.3%, P < 0.01). The SUVmax in patients with malignant primary and metastatic lesions was significantly higher than that in healthy volunteers and in patients with benign ascites (P < 0.05). The mean maximal diameter of false-negative lesions was significantly smaller than that of true-positive lesions (P < 0.05). In ROC analysis, the areas under the curve of SUVmax, serum carcinoembryonic antigen, CA19-9, and CA12-5 were 0.803 (P < 0.01), 0.773 (P < 0.05), 0.552 (P > 0.05), and 0.220 (P < 0.01), respectively. CONCLUSION: (18)F-FDG PET/CT assisted in detecting the original cause of ascites. The differential diagnostic ability of (18)F-FDG PET/CT was superior to that of CT alone, tumor markers, and cytology. More attention should be paid to peritoneal tuberculosis, which can markedly accumulate (18)F-FDG and mimic peritoneal carcinoma.

Cytomorphological and immunocytochemical study of non-Hodgkin's lymphoma in pleural effusion and ascitic fluid.

INTRODUCTION: Non-Hodgkin's lymphoma (NHL) is often complicated by pleural effusion and ascites. The present study is an attempt to categorize the lymphomatous effusions according to the WHO classification, using archival material. METHODS: May-Grünwald-Giemsa and Papanicolaou-stained smears of 31 lymphomatous effusion specimens were reviewed. Of these, detailed cytological assessment was done on 12 pleural effusions and ten ascitic fluid specimens from 22 patients using the WHO lymphoma classification system. Immunocytochemical studies were performed in 21 specimens. RESULTS: Based on cytomorphological features, the 22 lymphomatous effusion specimens were categorized into lymphoplasmacytoid lymphoma (1), follicle centre cell (FCC) grade-1 (centrocytic) lymphoma (3), FCC grade-2 (centrocytic-centroblastic) lymphoma (3), FCC grade-3 (centroblastic) lymphoma (4), large cell immunoblastic lymphoma (4), lymphoblastic lymphoma (2), anaplastic large cell lymphoma (3) and miscellaneous types (2). Immunocytochemically, the lymphoma cells were T-cell (positive for CD3) and B-cell type (CD20 positive) in five and six cases respectively. CONCLUSION: Cytological examination of pleural effusion and ascitic fluid samples, supported by immunocytochemical studies, may be useful for the classification of lymphomas under the WHO system.

Evaluation of hernia repair operation in Child-Turcotte-Pugh class C cirrhosis and refractory ascites.

BACKGROUND AND AIM: Abdominal wall hernia is a common feature of decompensated liver cirrhosis and frequently causes life-threatening complications or severe pain. However, there have been no data reported on postoperative mortality, hepatic functional deterioration and recurrence rate according to Child-Turcotte-Pugh (CTP) class and to the presence of refractory ascites. METHODS: The study population comprised 53 liver cirrhosis patients who underwent hernia repair operation. Comparisons were made of 30-day mortality among the different CTP classes, and between those with or without refractory ascites. Liver function was also analyzed just before the operation, in the immediate postoperative period, and in the remote postoperative period. RESULTS: Seventeen patients were in CTP class A, 27 patients in class B, and 9 patients in class C. The median follow-up duration was 24 months. There was single 30-day postoperative mortality in class C, and no CTP class deterioration after 30 days of operation. There was no mortality or recurrences in 17 patients with medically refractory ascites. The difference in 30-day mortality according to CTP class and the presence of refractory ascites did not show statistical significance (P = 0.17 and 0.97, respectively). CONCLUSION: Hernia operation could be done safely in CTP class A and B with low rate of recurrences, and there was no definitive increase in the operative risk in class C. In addition, refractory ascites did not increase operative risk and recurrence rate. Therefore, surgical repair might be recommended even in patients with refractory ascites and poor hepatic function to prevent life-threatening complications or severe pain.

Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status.

The transjugular intrahepatic portosystemic shunt (TIPS) procedure has a well-established role in the management of patients with complications of portal hypertension such as variceal bleeding or refractory ascites. Several clinical variables have been described to be associated with a poor prognosis after a TIPS procedure, including the presence of uncontrollable ascites, the number of sclerotherapy sessions to control a bleeding episode, the use of drugs for hemodynamic support, the use of balloon tamponade to control bleeding, the need for an emergency TIPS procedure, the need for mechanical ventilation, prothrombin time, increased serum creatinine, increased serum bilirubin, encephalopathy, and sepsis. In addition, several scoring systems have been developed and applied to patients undergoing TIPS procedures in an attempt to improve patient selection criteria for this invasive procedure. This article reviews the most important scoring systems that have been developed and applied to patients undergoing emergency or elective TIPS procedures, with particular emphasis on the prognostic index designed for patients undergoing emergency TIPS procedures and the Model for End-stage Liver Disease score designed for patients undergoing elective TIPS procedures. The most practical application of these scoring systems is probably that, with the information provided, the operator is able to discuss with referring physicians, patients, and family members the expected outcomes of this challenging procedure.

[Diagnosis effectiveness of albumin in ascitic fluid]. / Eficacia diagnóstica de la albúmina en líquido ascítico.

Albumin in ascitic fluid has been evaluated as a discriminative diagnosis test, based on an observation and retrospective study, comparing it to that of total ascitis protein and albumin gradient, which are the most clinically used tests nowadays. The study involved a total of 45 patients, predominantly women, averaging 54 years of age, who were diagnosed through laparoscopy in a public hospital. The evaluation included: 19 patients suffering transudate type ascitis (chronic liver disease, n = 18), 23 patients with exudates type ascitis (peritoneal carcinomatosis, n = 12, tuberculous peritonitis, n = 11), and patients with mixedascitis. Sensibility, specificity and predictive values were obtained from the analysis of the tests, and they were represented through the distribution of averages and ROC curves, showing every time that these tests can be used in clinical practice because they have comparable sensibility and specificity values. As a new discriminative test of transudates and exudates the albumin test in ascitis proved to have a sensibility comparable to that of the protein in ascitic fluid but discreetly lower to that of albumin gradient. However, the ascitis albumin showed a better relation between the sensibility and specificity in the area under the ROC curves. Based on this study, the usefulness of the concentration of albumin in ascitic fluid is highlighted as a new test to discriminate exudates from transudates, which has been reported by very few authors in writing. In addition, this study shows that the albumin gradient can also be applied in the discrimination of exudates and transudates with efficacy comparable to its use in the discrimination of ascitis with or without portal hypertension.

[The validity of the proteins concentrations in the ascitic liquid and serum for the differential diagnosis of the ascitis]. / La validez de la concentración de proteínas en el líquido ascítico y suero para el diagnóstico diferencial de las asctitis.

Prospective evaluation was performed in 60 in-patients, carriers of ascites of different etiologies, analyzing the validity of the parameters depending on protein and albumin dosage, both in the ascitic serum and fluid, for the discrimination of possible etiological causes of ascites, including in these parameters Protein Concentration in the Ascitic Fluid, the Serum-Ascites Albumin Gradient, the Protein Ascites/Serum Ratio, and the Albumin Concentration in the ascitic fluid. Average age was 46.9 +/- 19.6, all female; 21 cases were associated with Chronic Hepatic Disease, 14 to Tuberculosis, 11 to Malignant Neoplasia, 7 to Nephrotic syndrome, 4 to Congestive Heart Failure, 2 to Collagen Disease, and 1 to a severe Malnutrition case. The evaluation parameters correlate with the oncotic and hydrostatic pressures of the Starling Law, on the basis of what they could be compared with, demonstrating that their sensitivity levels and their specificity may be used as positive or negative predictive values in the discriminative evaluations of ascites in relation to its probable etiological causes. Even though the Serum-Ascites Albumin Gradient may be useful in the separation of ascites cases with portal hypertension, it is also useful for classifying exudates and transudates. However, the other parameters must not be excluded for the evaluation of those cases, aiming at establishing whether the peritoneum has been affected and hence the terms transudates and exudates should still be used on the basis of the high sensitivity value and specificity of theses tests, which do not differentiate them statistically from the Serum-Ascites Albumin Gradient. Using the cut-off points for each parameter, the most adequate for our population would be 1.5 gr/dl for Albumin and 2.5 gr/dl for protein, with the additional lower cost benefit.

Ascitic fluid analysis: the role of biochemistry and haematology.

In specific settings, biochemical and haematological analysis of ascitic fluid may provide answers to important clinical questions. This review seeks to outline the value and limitations of ascitic fluid analysis and the main clinical scenarios in which it may be useful.

Meconium peritonitis in utero.

To clarify the relationship between clinical features in utero and postnatal prognosis, 20 fetuses who underwent ultrasonic (US) evaluation for meconium peritonitis (MP) over a 17-year period were reviewed. According to final US findings in utero, patients were classified into three types. Type I (massive meconium ascites) was noted is 5 cases, type II (giant pseudocyst) in 4, and the other 11 were classified as type III (calcification and/or small pseudocyst). Abdominal calcifications were identified in only 5 cases (2 type I, 1 type II, 2 type III). Seven fetuses who had associated polyhydramnios (1 Type I, 1 Type II, 2 Type III) and fetal hydrops (3 Type II) were delivered before 36 weeks' gestation. Cardiopulmonary resuscitation at birth was required in 9 cases (5 type I, 4 type II) who underwent abdominal drainage before delivery and/or immediately after birth. Although dilatation of the intestine was identified in 10 fetuses (2 type II, 8 Type III), 18 had intestinal atresia and 2 had fecal obstruction of the distal ileum. Four infants (2 type I, 1 type II, 1 type III) died of respiratory failure and postoperative complications. These results indicated that careful fetal US may be useful for perinatal management of MP.