ABSTRACT
Abdominal paracentesis is an old medical procedure for treatment of tense ascites. Paracentesis induced circulatory dysfunction [PICD] is a complication that can be prevented with the administration of intravenous albumin. The aim of this work is to assess the effects of a single large volume paracentesis [LVP] on portal venous hemodynamics and cardiopulmonary functions in cirrhotic patients with tense ascites. Also, to compare between dextran-70 and albumin as a replacement therapy. Thirty adult patients from either sex with cirrhosis and intractable ascites were randomly allocated into one of three groups subjected to LVP, group I: include 10 patients received human albumin infusion 20%, group II: include 10 patients received dextran -70 infusions and group III: include 10 patients with no replacement therapy. Patients had undergone blood urea blood urea nitrogen [BUN], liver function tests. serum electrolytes [Na+ and K+], ascetic fluid analysis, arterial blood gases [ABG], duplex ultra-sonographic examination of the portal [PV] and splenic veins [SV] with calculation of their velocity and congestive index [CI], standard pulmonary functions tests and echocardiographic estimation of right and Left atrial areas and cardiac output [COP]. Effective arterial blood volume was assessed by measuring plasma renin activity [PRA] and aldosterone concentrations [PAC]. All measurements were done at baseline, 48 hours [hrs.] and on the six day after LVP. All patients reported improvement of their clinical manifestation. Urine output increased in all groups with significant difference between group I and groups II and III at 48 hrs and between group I and III at 6th day. Heart rate slightly increased 48 hrs and then decreased on the 6th day with no significant difference between studied groups while the mean arterial blood pressure slightly decreased in dl groups with only significant difference between pre-tape and 48 hrs and 6th day results in-group III. The mean right and left AA and COP significantly increased in the all groups Right AA was lower in-group III at 48 hrs compared to other two groups. There was significant difference between pre-tape and 48 hrs results of left AA in-group III. At 48 hrs left AA was significantly lower in group III compared to other two groups and in group II compared to group I. On the 6th day, left AA was significantly lower in group III compared to other two groups. The mean FEVI and FVC increased in all groups, while the mean FEVI/FVC showed no significant change. The mean PaO2 increased significantly in all groups. Oxygen saturation increased significantly in all groups at 48 hrs then decreased on the 6th day but still above pre-tape results with significant difference between 48 hrs and 6th day values. PaCO2 decreased significantly in all groups. There was a significant increase in mean PV and SV velocity 48 hrs after LVP with non-significant reduction of their congestion index. BUN significantly increased in group III compared to groups I and II. Serum sodium markedly decreased in group III compared to groups I and II with significant difference between pre-tape, 48 hrs and 6th day results of group III. PRA and PAC non significantly increased in all groups before LVP, in group I, PRA showed no significant changes after LVP, while PAC initially increased after LVP then significantly decreased on the 6th day. In-group II, PRA and PAC significantly increased after LVP with significant difference between pre-tape, 48 hrs and 6th day results of PAC. In-group III there was significant increase in PRA and PAC. As regard PRA, there was significant difference between groups I and II and group III, also between group III and group II at 48 hrs while on the 6th day there was significant difference between groups I and II and group III. As regard, PAC there was significant difference between group I and groups II and III on the 6th day. There was non-significant increased incidence of hyponatremia, hyperkalemia and incidence of PICD in group III. So, we can conclude that LVP with concomitant infusion with appropriate plasma volume expander is quite safe, palliative, and cost effective in patients with advanced cirrhosis and has a fewer complications in comparison to conventional diuretic therapy. LVP has an immediate beneficial effect on arteria blood oxygenation, cardiac functions, provides rapid improvement of lung volumes and improve portal venous dynamics. The low cost, the good tolerance and the safety of the plasma expander, dextran justify its therapeutic usage as useful alternative to human albumin in the management of intractable ascites especially small volume [<5 liter]. Also therapeutic paracentesis without replacement is effective as with albumin or dextran infusion on the outcome of cardiopulmonary functions and portal venous dynamics