Principales técnicas quirúrgicas para el médico general / Main surgical techniques for the general practitioner

Existen múltiples técnicas y procedimientos quirúrgicos en la práctica clínica que todo médico general debería conocer y manejar ante una situación de urgencia que involucre la resolución inmediata. El no actuar en una situación emergente, ya sea por inexperiencia o desconocimiento puede poner en riesgo la vida del paciente. Entre estos procedimientos, podemos encontrar las suturas (y sus distintos tipos), la paracentesis, la apendicectomía (abierta y laparoscópica), la punción lumbar y la cesárea. Es por esto que se creó este artículo de educación médica utilizando un método explicativo de las principales técnicas quirúrgicas de forma resumida y concisa, basado en la literatura disponible, con el fin de servir como guía de bolsillo y revisión rápida para estudiantes, internos y médicos que deben enfrentarse a un procedimiento quirúrgico que no puede ser diferido.

There are multiple surgical techniques and procedures in the day to day clinical practice that every general practitioner should know how to do and handle in an emergency situation that requires immediate resolution. Failure to act in an emergent situation, either due to inexperience or ignorance, can put a patient's life at risk. Between these procedures there are sutures (and its variations), paracentesis, appendectomy (open and laparoscopic), lumbar puncture and cesarean delivery. That is why this medical education article was developed using an explicative method of the main surgical techniques in a summarized and concise way, based on the available literature, in order to serve as a pocket guide and quick review for students, interns and doctors who must face a surgical procedure that cannot be deferred.

Assembly and use of a low-cost paracentesis simulator for the teaching of puncture and drainage of ascites / Montagem e uso de simulador de paracentese de baixo custo - aplicabilidade no ensino de punção e drenagem de ascite

ABSTRACT Objectives: to describe the assembly of a low-cost paracentesis simulator and evaluate its effectiveness, acceptance and impact on the learning of medical students. Methodology: a paracentesis simulator was built using a mannequin and materials such as plastic bottles, Velcro, polyvinyl chloride sheets and silicone were used. A cross-sectional and experimental study was carried out with undergraduate medical students without previous practical experience with paracentesis, which sought to validate the model, evaluating its benefits in learning and obtaining technical skills. Results: after using the simulator there was an increase of 82.4% in the level of confidence in performing paracentesis in a patient, with 98% of respondents considering that the model fulfilled the simulator function with satisfaction, and 100% considering it useful as a teaching tool. Conclusion: the built simulator was effective as an educational resource, serving as an alternative to high-cost commercial models, allowing for greater accessibility in the use of this tool in medical education.

RESUMO Objetivos: descrever a montagem de simulador de paracentese de baixo custo e avaliar eficácia, aceitação e impacto no aprendizado de acadêmicos do curso de medicina. Método: um simulador de paracentese foi construído a partir de manequim e de materiais como garrafas plásticas, velcro, folhas de policloreto de vinila e silicone. Foi feito estudo transversal com estudantes da graduação do curso de medicina sem experiência real prévia com paracentese, que buscou validar o modelo, por meio da análise de benefícios no aprendizado e na obtenção de habilidades técnicas. Resultados: após o uso do simulador, observou-se aumento de 82,4% no nível de segurança na realização da paracentese em paciente, 98% dos pesquisados consideraram que o uso do modelo cumpriu com satisfação a função de simulador e 100% definiram-no útil como ferramenta de ensino. Conclusão: a montagem do simulador mostrou-se factível e eficaz como recurso educacional. Serviu como alternativa aos modelos comerciais de alto custo e permitiu maior acessibilidade do uso dessa ferramenta na educação médica.

Paracentese de alívio no domicílio: uma prática assistencial possível / Home relief paracentesis: a possible care practice / Paracentesis evacuadora domiciliaria: una práctica posible de cuidado

Introdução: A ascite é definida como um acúmulo de líquido na cavidade peritoneal e, em 75% dos casos, é causada por cirrose e hipertensão da veia porta de várias etiologias. Seu tratamento inclui restrição de fluidos, diurese e paracentese de grande volume. A paracentese de alívio é o procedimento de remoção de fluido ascítico da cavidade peritoneal com a finalidade de reduzir a pressão intra-abdominal e aliviar sintomas associados como dispneia, dor e desconforto abdominal. É uma técnica simples e segura que pode ser realizada em ambiente hospitalar e ambulatorial. A expansão dos Serviços de Atenção Domiciliar (SAD) no país oportunizou a realização de procedimentos de maior complexidade no domicílio podendo contribuir com o bem-estar de pacientes em cuidado paliativo domiciliar. Objetivo: Descrever o perfil de pacientes submetidos à paracentese de alívio em um SAD. Métodos: Estudo transversal, incluindo pacientes consecutivos que realizaram paracentese de alívio no domicílio entre os anos 2009 e 2017. Os dados foram coletados em prontuário. Para a análise descritiva dos dados estatísticos utilizou-se o Software Statistical Package for the Social Sciences v. 18.0 (SPSS). Resultados: A amostra foi composta por 15 pacientes, apresentando uma média do Índice de Comorbidade de Charlson de 8,1 (3-15). As neoplasias foram as principais causas de ascite nos pacientes acompanhados (80,2%). No período do estudo foram realizadas 48 paracenteses de alívio. Seis pacientes apresentaram sintomatologia clínica com necessidade de visita domiciliar (VD) não programada. Em relação às complicações do procedimento de paracentese, um paciente apresentou sangramento no local da punção. Todas as situações acima foram manejadas no domicílio. Em relação aos desfechos do atendimento no SAD, 53% dos pacientes necessitaram de reinternação hospitalar por piora clínica. Conclusões: A paracentese de alívio no domicílio mostra-se como uma prática segura, reduzindo idas desnecessárias a serviços de urgência/emergência e com bons índices de satisfação relatados pelos pacientes, desde que os profissionais sejam devidamente capacitados para realização do procedimento, com rotina e técnica instituída pelo SAD.

Introduction: Ascites can be defined as an accumulation of fluid in the peritoneal cavity and, in 75% of cases, is caused by cirrhosis and portal vein hypertension of different etiologies. Its treatment includes fluid restriction, diuresis and paracentesis. Relief paracentesis is a procedure that removes ascites fluid from peritoneal cavity, reduces intra-abdominal pressure and alleviate some symptoms such as dyspnea, pain, and abdominal discomfort. It is a simple and safe technique that can be performed in a hospital or outpatient setting. The expansion of home care services in our country has enabled the completion of more complex procedures at home and may contribute to the welfare of outpatients in palliative care. Objective: Describe the profile of outpatients undergoing relief paracentesis. Methods: Cross-sectional study, including consecutive patients of a public home care service who underwent home relief paracentesis between 2009 and 2017. Data were collected from medical records and the Software Statistical Package for the Social Sciences v. 18.0 (SPSS) was used for data analysis. Results: Sample consisted of 15 out patients. We observed an average of 8.1 (3-15) in Charlson Comorbidity Index and neoplasms were the main cause of ascites (80.2%). 48 relief paracenteses were performed during the period and six patients presented clinical symptomatology requiring unplanned home visit. Concerning complications of paracentesis procedure, only one patient had bleeding at the puncture site. All above situations were handled at home. Regarding outcomes of care, 53% of patients required hospital readmission because of clinical worsening. Conclusions: Home relief paracentesis is a safe practice and can reduce unnecessary procedures at an emergency room. It is important that professionals are properly trained to perform the procedure with routine and technique established by a home care service.

Introducción: La ascitis se define como una acumulación de líquido en la cavidad peritoneal y en el 75% de los casos es causada por cirrosis e hipertensión venosa portal de diversas etiologías. Su tratamiento incluye restricción de líquidos, diuresis y paracentesis de gran volumen. La paracentesis evacuadora es el procedimiento para eliminar el líquido ascítico de la cavidad peritoneal para reducir la presión intraabdominal y aliviar los síntomas asociados como disnea, dolor y molestias abdominales. Es una técnica simple y segura que se puede realizar en un hospital y en ambulatorio. La expansión de los Servicios de Atención Domiciliaria (SAD) en el país ha permitido completar procedimientos más complejos en el domicilio y puede contribuir al bienestar de los pacientes en cuidados paliativos domiciliarios. Objetivos: Describir el perfil de pacientes sometidos a paracentesis evacuadora en un SAD. Métodos: Estudio transversal, con pacientes consecutivos que se sometieron a paracentesis evacuadora en el domicilio entre 2009 y 2017. Los datos se obtuvieron de los registros médicos. Para el análisis descriptivo de los datos estadísticos utilizamos el Software Statistical Package for the Social Sciences v. 18.0 (SPSS). Resultados: La muestra consistió en 15 pacientes, con un índice de comorbilidad de Charlson promedio de 8,1 (3-15). Las neoplasias fueron las principales causas de ascitis en los pacientes seguidos (80,2%). Durante el período de estudio, se realizaron 48 paracentesis evacuadoras. Seis paracentesis presentaron sintomatología clínica que requería una visita domiciliaria (VD) no planificada. Con respecto a las complicaciones del procedimiento de paracentesis, un paciente tuvo sangrado en el sitio de punción. Todo lo anterior se manejó en el domicilio. En cuanto a los resultados de la atención en el SAD, el 53% de los pacientes requirieron reingreso hospitalario por empeoramiento clínico. Conclusiones: La paracentesis evacuadora en el domicilio es una práctica segura que reduce los viajes innecesarios a los servicios de urgencia/emergencia y con una alta satisfacción del paciente, siempre que los profesionales estén debidamente capacitados para realizar el procedimiento, con la rutina y la técnica establecidas por el SAD.

Epstein-Barr Virus-related Corneal Endotheliitis Accompanied with Secondary Glaucoma

PURPOSE: To report a case of Epstein-Barr virus-related corneal endotheliitis accompanied by secondary glaucoma.CASE SUMMARY: A 73-year-old male presented with blurred vision in his right eye. In the ophthalmic evaluation, there were dispersed keratic precipitates overlying corneal edema. The anterior chamber showed trace ~1+ graded inflammation and an endothelial density decrease. His best-corrected visual acuity and intraocular pressure in the right eye were 0.2 and 34 mmHg, respectively. Paracentesis was performed on the anterior chamber of the right eye to confirm the diagnosis under the suspicion of corneal endotheliitis with trabeculectomy for the intraocular pressure control. Epstein-Barr virus was confirmed using a multiplex polymerase chain reaction (PCR), and oral and eye drops of Acyclovir were used to treat the patient. There was no evidence of a recurrence over 2 years and his intraocular pressure was 12 mmHg and best-corrected visual acuity was maintained at 0.5.CONCLUSIONS: A case of Epstein-Barr virus-related corneal endotheliitis was diagnosed using PCR of the aqueous humor. The patient was treated with an oral antiviral agent and eyedrops without a recurrence.

A dúvida: tireotoxicose versus hipertireoidismo descompensado / The doubt: Thyrotoxicosis X Decompensated Hyperthyroidism

Relata-se o caso de paciente do sexo masculino, atendido em um hospital universitário, após quadro duvidoso e arrastado de alteração cardíaca e hipertireoidiana, com a propedêutica sequencial própria para crise tireotóxica. Destaca-se a necessidade de identificação precoce da apresentação clínica, com atendimento de emergência, e a capacidade da realização de diagnósticos diferenciais com alterações cardíacas primárias, evitando-se sequelas e desfechos inesperados.

We report the case of a male patient seen in a University Hospital after a dubious and protracted picture of cardiac and hyperthyroid alteration, with adequate sequential propaedeutic for thyrotoxic crisis. The need for early identification of clinical presentation with emergency care, and the ability to perform differential diagnoses with primary cardiac changes are highlighted, to avoid unexpected sequelae and outcomes.

Development and evaluation of a training model for paracentetic suprapubic cystostomy and catheterization

OBJECTIVES: Minimally invasive paracentetic suprapubic cystostomy is a technique that should be learned by all surgical trainees and residents. This study aimed to develop a self-made training model for paracentetic suprapubic cystostomy and placement of the suprapubic catheter and then to evaluate its effectiveness in training fourth-year medical students. METHODS: Medical students were divided into an experimental group receiving comprehensive training involving literature, video, and model use and a control group receiving all the same training protocols as the experimental group except without hands-on practice using the model. Each student's performance was video-recorded, followed by subjective and objective evaluations by urology experts and statistical analysis. RESULTS: All students completed the surgical procedures successfully. The experimental group's performance scores were significantly higher than those of the control group (median final performance scores of 91.0 vs. 86.8, respectively). Excellent scores were achieved by more students in the experimental group than in the control group (55% vs. 20%), and fewer poor scores were observed in the experimental group than in the control group (5% vs. 30%). CONCLUSIONS: Based on its cost-effectiveness, reusability, and training effectiveness, this paracentetic suprapubic cystostomy training model is able to achieve goals in teaching practice quickly and easily. Use of the model should be encouraged for training senior medical students and resident physicians who may be expected to perform emergent suprapubic catheter insertion at some time.

Does the large amount of ascites lateralize the inferior epigastric artery in liver cirrhosis?

OBJECTIVE: The most common cause of hemorrhage after paracentesis is direct needle puncture of the inferior epigastric artery (IEA). This study examined the relationship between the amount of the ascites and the location of the IEA in liver cirrhosis. METHODS: Abdominal computed tomography (CT) examinations of patients with liver cirrhosis were reviewed retrospectively and divided into two groups according to the amount of ascites. The distances between the midline and the IEAs of both sides were measured at the umbilicus, McBurney's point, anterior superior iliac spine, and mid-inguinal level. Branching of the IEAs, abdominal wall and mesenteric varices in the abdomen below the umbilicus level were recorded. RESULTS: A total of 120 abdominal CTs were reviewed. The distances from the midline to the IEA in the large ascites group were longer than those in the small ascites group at the level of the right McBurney's point (44.5±14.6 mm vs. 39.6±11.8 mm, P=0.043) and left McBurney's point (48.6±15.3 mm vs. 43.3±11.5 mm, P=0.035). The incidence of abdominal wall varices was higher in the large ascites group (21.7% vs. 5.0%, P=0.014). CONCLUSION: In patients with liver cirrhosis, the large amount of ascites might be associated with lateralizing the location of the IEA. Moreover, it may be necessary to confirm the blood vessels in the abdominal wall and mesentery near the puncture site by bedside ultrasound before the paracentesis.

Eosinophilic Enteritis Presenting as Massive Ascites after Influenza A Virus Infection in a Young Female / 대한소화기병학회잡지

Eosinophilic gastrointestinal disorder (EGID) is an uncommon disease that is accompanied by intestinal eosinophil infiltration without a secondary cause of eosinophilia. Eosinophilic enteritis is a secondary portion of EGID that can present a range of gastrointestinal symptoms according to the affected depth of the intestinal layer. The subserosal type of eosinophilic enteritis presenting as ascites is relatively rarer than the mucosal type. In general, eosinophilic enteritis occurs in patients with food allergies, but its mechanism is unclear. The authors experienced a 29-year-old female patient with a large amount of ascites with diarrhea and abdominal pain. The patient was diagnosed with an influenza A infection one week earlier. Peripheral eosinophilia (absolute eosinophil count: 6,351 cells/mm³) and eosinophilic ascites (97% of white blood cells in the ascites are eosinophil) were present. Abdominal CT revealed a large amount of ascites and edematous changes in the ileum and ascending colon wall. A diagnosis of eosinophilic enteritis was confirmed as eosinophilic ascites by paracentesis, with eosinophil infiltration of the bowel wall by an endoscopic biopsy. The patient's symptoms improved rapidly after using steroids. To the best of the author's knowledge, this is the first report of eosinophilic enteritis with massive ascites after an influenza A virus infection in a Korean adult.

Eosinophilic Enteritis Presenting as Massive Ascites after Influenza A Virus Infection in a Young Female / 대한소화기학회지

Eosinophilic gastrointestinal disorder (EGID) is an uncommon disease that is accompanied by intestinal eosinophil infiltration without a secondary cause of eosinophilia. Eosinophilic enteritis is a secondary portion of EGID that can present a range of gastrointestinal symptoms according to the affected depth of the intestinal layer. The subserosal type of eosinophilic enteritis presenting as ascites is relatively rarer than the mucosal type. In general, eosinophilic enteritis occurs in patients with food allergies, but its mechanism is unclear. The authors experienced a 29-year-old female patient with a large amount of ascites with diarrhea and abdominal pain. The patient was diagnosed with an influenza A infection one week earlier. Peripheral eosinophilia (absolute eosinophil count: 6,351 cells/mm³) and eosinophilic ascites (97% of white blood cells in the ascites are eosinophil) were present. Abdominal CT revealed a large amount of ascites and edematous changes in the ileum and ascending colon wall. A diagnosis of eosinophilic enteritis was confirmed as eosinophilic ascites by paracentesis, with eosinophil infiltration of the bowel wall by an endoscopic biopsy. The patient's symptoms improved rapidly after using steroids. To the best of the author's knowledge, this is the first report of eosinophilic enteritis with massive ascites after an influenza A virus infection in a Korean adult.

A antiga técnica em um novo estilo: desenvolvendo habilidades procedimentais em paracentese em simulador de baixo custo / The old one technique in a new style: developing procedural skills in paracentesis in a low cost simulator model

ABSTRACT BACKGROUND: Paracentesis is a routine medical procedure quite relevant in clinical practice. There are risks of complications related to paracentesis, so it is essential a proper trainee for the younger practicer. OBJECTIVE: The article describes the construction and the application of a low cost paracentesis simulator for undergraduate medical students and it also describes the perception of students about the simulator as well. METHODS: A low-cost model was developed by the Program of Tutorial Education for training medical students during three editions of an undergraduate theoretical-practical course of bedside invasive procedures. The authors constructed a model from very low-cost and easily accessible materials, such as commercial dummy plus wooden and plastic supports to represent the abdomen, synthetic leather fabric for the skin, upholstered sponge coated with plastic film to represent the abdominal wall and procedure gloves with water mixed with paint to simulate the ascitic fluid and other abdominal structures. One semi-structured form with quantitative and qualitative questions was applied for medical specialists and students in order to evaluate the paracentesis simulator. RESULTS: The paracentesis model has an initial cost of US$22.00 / R$70.00 for 30 simulations and US$16.00 / R$50.00 for every 30 additional simulations. It was tested by eight medical doctors, including clinical medicine, general surgeons and gastroenterologists, and all of them fully agreed that the procedure should be performed on the manikin before in the actual patient, and they all approved the model for undergraduate education. A total of 87 undergraduate medical students (56% male) individually performed the procedure in our simulator. Regarding the steps of the procedure, 80.5% identified the appropriate place for needle puncture and 75.9% proceeded with the Z or traction technique. An amount of 80.5% of the students were able to aspire the fluid and another 80.5% of students correctly performed the bandage at the end of the procedure. All the students fully agreed that simulated paracentesis training should be performed prior to performing the procedure on a real patient. CONCLUSION: The elaboration of a teaching model in paracentesis provided unique experience to authors and participants, allowing a visible correlation of the human anatomy with synthetic materials, deepening knowledge of this basic science and developing creative skills, which enhances clinical practice. There are no data on the use of paracentesis simulation models in Brazilian universities. However, the procedure is quite accomplished in health services and needs to be trained. The model described above was presented as qualified with low cost and easily reproducible.

RESUMO CONTEXTO: A paracentese é um procedimento médico de rotina bastante relevante na prática clínica. Devido à sua importância na assistência médica diária e seus riscos de complicações, o treino do procedimento é essencial em currículos médicos reconhecidos. OBJETIVO: Descrever a construção de um simulador de paracentese de baixo custo, destacando a percepção de estudantes sobre o seu uso para treinamento na graduação em Medicina. MÉTODOS: Um modelo de baixo custo foi desenvolvido pelo Programa de Educação Tutorial para treinamento de estudantes de Medicina durante três edições de um curso teórico-prático de procedimentos invasivos à beira do leito. Os autores construíram um modelo a partir de materiais comuns e de fácil acesso, como manequim comercial e suportes de madeira e plástico para representar o abdômen, tecido de couro sintético para a pele, esponja revestida com filme plástico para representar a parede abdominal e luvas de procedimento com água misturada com tinta para simular o líquido ascítico e outras estruturas abdominais. Para avaliar o modelo, aplicou-se um questionário semiestruturado com aspectos quantitativos e qualitativos para médicos especialistas e estudantes. RESULTADOS: O modelo para paracentese tem orçamento inicial de US$22.00 / R$70,00 para 30 simulações e US$16.00 / R$50,00 para cada 30 simulações adicionais. Foi testado por oito especialistas (clínico geral, cirurgião geral e gastroenterologista), dos quais quatro são gastroenterologistas, e todos concordaram plenamente que o procedimento deve ser realizado no manequim antes de ser feito no paciente real, e todos eles aprovaram o modelo para o ensino de graduação. Durante as edições do curso, um total de 87 estudantes de graduação em Medicina (56% homens) realizaram individualmente o procedimento. Em relação às etapas do procedimento, do total de alunos avaliados, 80,5% identificaram o local apropriado para a punção e 75,9% procederam com a técnica Z ou tração. Ao final, 80,5% dos alunos conseguiram aspirar ao conteúdo ascítico, com 80,5% realizando o curativo e finalizando o procedimento. Todos os alunos concordaram plenamente que o treinamento com paracentese simulada deve ser feito antes de se realizar o procedimento em um paciente real. CONCLUSÃO: A elaboração de um modelo de ensino em paracentese proporcionou experiência única a autores e participantes, permitindo uma visível correlação da anatomia humana com materiais sintéticos, aprofundando o conhecimento desta ciência básica e desenvolvendo habilidades criativas, o que potencializa a prática clínica. Não há dados sobre o uso de modelos de simulação de paracentese em universidades brasileiras. No entanto, o procedimento é bastante realizado nos serviços de saúde e precisa ser treinado. O modelo descrito acima foi apresentado como de qualidade, baixo custo e de fácil reprodutibilidade, sendo inédito no cenário da educação médica nacional, mostrando-se uma ferramenta complementar de ensino na graduação e preparando os alunos para o procedimento in vivo.

Terapia intraperitoneal paliativa en ascitis maligna fîlcrossMark refractaria / Intraperitoneal palliative therapy in refractory malignant ascites

Resumen El tratamiento convencional de la ascitis maligna refractaria es un reto oncológico pues provee mejoría sintomática poco duradera. La terapia intraperitoneal ha sido evaluada principalmente en reportes y series de casos, y en algunos ensayos clínicos, estudiados principalmente en la ascitis por cáncer ovárico y gastrointestinal. Esta terapia incluye: isótopos radioactivos, quimioterapia con hipertermia y sin esta, terapia inmunológica, biológica y otras. Los tratamientos más exitosos con respuestas variables, y aunque la comparación directa no es posible, son: la quimioterapia intraperitoneal hipertérmica (respuesta global entre 85,7% y 100%) y el catumaxomab, que frente a la paracentesis demostró una supervivencia libre de punción de 46 vs 11 días (HR 0,254) y una mediana a la próxima paracentesis de 77 vs 13 días (HR 0,169), con impacto positivo en la calidad de vida, principal fin en el escenario paliativo. La investigación en este campo continúa buscando resultados más duraderos, seguros y costo-efectivos.

Abstract Conventional treatment of refractory malignant ascites is an oncological challenge since it provides little lasting symptomatic improvement. Intraperitoneal therapy, evaluated mainly through series and case reports, and some clinical trials include the use of radioisotopes, chemotherapy, with and without hyperthermia, immunological and biological therapy and others. It has been studied mainly in ascites from ovarian and gastrointestinal cancer. With variable response rates, and although direct comparison is not possible, the most successfully treatments are hyperthermic intraperitoneal chemotherapy (overall response rate between 85.7% and 100%), and catumaxomab, which compared to paracentesis, demonstrated a puncture-free survival of 46 vs. 11 days (HR 0.254) and a median time to next paracentesis of 77 vs. 13 days (HR 0.169). This had a positive impact on quality of life, which is the main goal in the palliative setting. Research in this field continues looking for more lasting, safe, and cost-effective results.

Ascites / 대한소화기학회지

Ascites is the most common cause of decompensation in cirrhosis, and 5% to 10% of patients with compensated cirrhosis develop ascites each year. The main factor of ascites formation is renal sodium retention due to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system by the reduced effective volume secondary to splanchnic arterial vasodilation. Diagnostic paracentesis is indicated in all patients with a new onset of grade 2 or 3 ascites and in those admitted to hospital for any complication of cirrhosis. A serum-ascites albumin gradient of ≥1.1 g/dL indicates portal hypertension with an accuracy of approximately 97%. Sodium restriction, diuretics, and large volume paracentesis are the mainstay of treatment in grade 1 to 3 ascites. The refractoriness of ascites is associated with a poor prognosis with a median survival of approximately six months. Repeated large volume paracentesis plus albumin is the first line treatment, and liver transplantation is recommended in patients with refractory ascites. A careful selection of patients is also important to obtain the beneficial effects of transjugular intrahepatic portosystemic shunts in refractory ascites. This review details the recent diagnosis and treatment of cirrhotic ascites.

Spontaneous Bacterial Peritonitis / 대한소화기학회지

Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any significant intraperitoneal infection, accounting for approximately 10–30% of bacterial infections in hospitalized patients. SBP develops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm³ in ascites after paracentesis. If SBP is diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review describes the pathophysiology, diagnosis, treatment, and prevention of SBP.

Diagnostic Value of Carcinoembryonic Antigen in Ascites for Colorectal Cancer with Peritoneal Carcinomatosis / 대한소화기학회지

BACKGROUND/AIMS: Diagnostic tests for carcinoembryonic antigen (CEA) in ascites have been performed in various malignant cases, but there is only few data on the applicability of CEA for colorectal cancer (CRC) patients with peritoneal carcinomatosis. We aimed to determine the usefulness of CEA in ascites (aCEA) as a diagnostic parameter for CRC with peritoneal carcinomatosis. METHODS: Between January 2000 and May 2013, the medical records of 259 patients who underwent paracentesis for the evaluation of ascites were retrospectively reviewed. CRC patients with ascites (n=82) and patients with non-malignant ascites (n=177) were evaluated. Patients who had other malignancies, including gastric or ovarian cancer, with ascites were excluded. The optimal diagnostic cut-off value of aCEA for CRC with peritoneal carcinomatosis was determined using receiver operating characteristic curve analysis. The value of aCEA for predicting the occurrence of peritoneal carcinomatosis was evaluated using a logistic regression model. RESULTS: The optimal cut-off value of aCEA to diagnose CRC with peritoneal carcinomatosis was 3.89 ng/mL, and the area under the curve for aCEA was 0.996 (sensitivity 96.3%, specificity 100%, positive predictive value 100%, negative predictive value 98.3%). Multivariate logistic regression analysis showed that aCEA was an independent factor predicting the occurrence of peritoneal carcinomatosis. CONCLUSIONS: In this study, we showed that aCEA may be a useful parameter for diagnosing CRC with peritoneal carcinomatosis, and we propose an optimal aCEA cut-off value of 3.89 ng/mL. Further study that includes patients with other malignant ascites may be necessary to validate these findings.

Factors Associated with Pain Following Intravitreal Injections

PURPOSE: To investigate factors associated with pain intensity following intravitreal injection and factors that might be associated with changes in pain intensity in patients who received repeated injections. METHODS: A total of 172 eyes (147 patients) were prospectively enrolled. Patients rated their pain from 0 to 10 using a visual analogue scale. Multiple linear regression analysis was used to evaluate factors associated with pain score. Sixty-eight patients evaluated their degree of pain more than once and were divided into three groups according to changes in pain during repeated injections. Clinical factors were compared among the three groups. RESULTS: Pain scores of women (women, 3.1 ± 1.5 vs. men, 2.4 ± 1.2; p = 0.003), those who received dexamethasone implant injection (dexamethasone implant, 3.5 ± 1.1 vs. anti-vascular endothelial growth factor, 2.7 ± 1.4; p = 0.028), and those who did not undergo anterior chamber paracentesis (ACP) (ACP, 2.6 ± 1.3 vs. no ACP, 3.0 ± 1.6; p = 0.047) were significantly higher than those of the other groups. On multiple linear regression analysis, only female sex and ACP were significantly associated with degree of pain. The waiting time during the second injection was significantly associated with change in degree of pain in patients who received repeated injections. CONCLUSIONS: Women were more prone to perceive pain, and the ACP procedure reduced pain during intravitreal injections. Most patients who received repeated injections felt that pain was similar or decreased compared to that experienced during the previous injection. However, increased waiting time might have been associated with increased discomfort for patients who received repeated injections.

Severe Intraperitoneal Hemorrhage from Pseudoaneurysm after a Large-volume Paracentesis, Successfully Treated with Microcoil Embolization / 대한소화기학회지

Large-volume paracentesis-induced intraperitoneal hemorrhage due to pseudoaneurysm formation is rarely reported. Here, we present a 56-year-old man with alcoholic liver cirrhosis admitted for massive ascites. Large-volume paracentesis was performed. Three days later, he became pale and complained of dyspnea and abdominal distention with hypotension. Percutaneous iliac angiography revealed contrast media leakage from a branch of the left circumflex iliac artery with pseudoaneurysm. He was successfully treated with microcoil embolization. Several days later, ascitic fluid increased and large-volume paracentesis was performed again. Two days later, his hemoglobin level suddenly decreased. An abdominal computed tomography scan showed new active bleeding at the left lower lateral peritoneal cavity, just anterior to the metalic coils. Percutaneous iliac angiography revealed contrast media extravasation from a branch of the left inferior epigastric artery with formation of collateral vessel. Percutaneous embolization was successfully performed again. After coil embolization, there were no further bleeding episodes.

Paracentesis: datos sobre la correcta utilización / Paracentesis, Appropriate Technique and Clinical Application

La paracentesis es un procedimiento con fines diagnósticos en pacientes con ascitis de novo. Permite detectar la presencia de infección en pacientes con ascitis de larga data. En casos de ascitis a tensión, ascitis refractaria y disnea por restricción es ampliamente utilizada como terapia. El conocimiento general de este procedimiento y de los pormenores de su técnica son de gran importancia, ya que su utilización viene en aumento en los servicios de urgencias, hospitalización general e incluso, en la unidad de cuidados intensivos. Teniendo en cuenta lo anterior, se hace hincapié en la correcta utilización de esta técnica por parte del personal médico. Métodos: Se realizó una búsqueda de la literatura científica en las bases de datos Pubmed y SciELO de artículos con una estrategia definida, limitada a idiomas español e inglés, utilizando una combinación de términos libres y MeSH que incluyeron paracentesis, ascitis, cirrosis hepática y malignidad.

Paracentesis is a diagnostic procedure used in patients with new-onset ascites. It can detect the presence of infection in patients with longstanding ascites. In cases of tense ascites, refractory ascites or restriction dyspnea it is widely used for therapeutical purposes. General knowledge of this procedure is of great importance as well as a detailed understanding of the technique, because its use is increasing in the emergency department, general hospitalization, and even in the intensive care unit. Taking all this into consideration we aim to emphasize on the proper use of this technique by the medical staff.

Clinical Features of Refractory Ascites in Outpatients

OBJECTIVES: To present the clinical features and outcomes of outpatients who suffer from refractory ascites. METHODS: This prospective observational study consecutively enrolled patients with cirrhotic ascites who submitted to a clinical evaluation, a sodium restriction diet, biochemical blood tests, 24 hour urine tests and an ascitic fluid analysis. All patients received a multidisciplinary evaluation and diuretic treatment. Patients who did not respond to the diuretic treatment were controlled by therapeutic serial paracentesis, and a transjugular intrahepatic portosystemic shunt was indicated for patients who required therapeutic serial paracentesis up to twice a month. RESULTS: The most common etiology of cirrhosis in both groups was alcoholism [49 refractory (R) and 11 non-refractory ascites (NR)]. The majority of patients in the refractory group had Child-Pugh class B cirrhosis (p=0.034). The nutritional assessment showed protein-energy malnutrition in 81.6% of the patients in the R group and 35.5% of the patients in the NR group, while hepatic encephalopathy, hernia, spontaneous bacterial peritonitis, upper digestive hemorrhage and type 2 hepatorenal syndrome were present in 51%, 44.9%, 38.8%, 38.8% and 26.5% of the patients in the R group and 9.1%, 18.2%, 0%, 0% and 0% of the patients in the NR group, respectively (p=0.016, p=0.173, p=0.012, p=0.012, and p=0.100, respectively). Mortality occurred in 28.6% of the patients in the R group and in 9.1% of the patients in the NR group (p=0.262). CONCLUSION: Patients with refractory ascites were malnourished, suffered from hernias, had a high prevalence of complications and had a high postoperative death frequency, which was mostly due to infectious processes.

A Randomized Controlled Trial of Procedural Techniques for Large Volume Paracentesis

ABSTRACT Introduction. The aim of this study is to investigate large volume therapeutic paracentesis using either a z-tract or axial (coxial) technique in a randomized controlled trial. Materials and methods. In this randomized, single blind study, patients with cirrhosis undergoing outpatient therapeutic paracentesis were randomized to the z-tract or the modified angular (coaxial) needle insertion technique. Subject and procedure characteristics were compared between the groups with ascites leakage as quantified by need for dressing changes with standardized sized gauze pads as a primary endpoint and subject procedural discomfort, operator preference, and procedure complications as secondary endpoints. Results. 72 paracenteses were performed during the study period: 34 to the z-tract and 38 to the coaxial insertion technique. Following exclusions, a total of 61 paracenteses were analyzed: 30 using the z-tract technique and 31 using the coaxial technique. There were equal rates of post-procedural leakage of ascites between groups (13% in both groups, p = 1.00). Using the visual analog scale (0 - 100), there was a statistically significant increase in the subject reported pain score with the z-tract compared with the coaxial method [26.4 (95% CI 18.7 - 34.1) vs. 17.2 (95% CI 10.6 - 23.8), p = 0.04]. Mean physician rated procedure difficulty (1 - 5) was significantly higher for the z-tract vs. the coaxial technique [2.1 (95% CI 1.6 - 2.6) vs. 1.5 (95% CI 1.2 - 1.8), p = 0.04]. Conclusion. When compared to the z-tract technique, the coaxial insertion technique is superior during large volume paracentesis in cirrhosis patients.