Ascitic fluid concentrations of fibronectin and cholesterol: comparison of differential diagnostic value with the conventional protein determination

Ascitic fluid concentrations of fibronectin, cholesterol and protein were determined in 95 patients: 38 with cirrhosis of the liver, 10 with miscellaneous nonmalignant diseases, 43 with peritoneal carcinomatosis and 4 with liver metastases or hepatocellular carcinoma. Fibronectin, cholesterol and protein at discrimination values of 7.5 mg/100 ml, 45 mg/100 ml and 3.0 g/100 ml, respectively, separated patients with peritoneal carcinomatosis from patients with cirrhosis with an efficiency of 94%, 90% and 85%, respectively. Thus, ascitic fluid determinations of fibronectin and cholesterol offer good discrimination of cirrhotic ascites from ascites related to peritoneal carcinomatosis, superior to the conventional protein determination. However, the failure of all parameters to distinguish ascites caused by miscellaneous nonmalignant diseases from malignancy-related ascites underscores the importance of highly specific methods to confirm a suspected diagnosis of malignancy-related ascites.     

Immunological parameters in the differential diagnosis of ascites secondary to peritoneal carcinomatosis, hepatic cirrhosis, and congestive heart failure]

As a contribution to the study of ascites in patients with liver cirrhosis, congestive heart failure and peritoneal carcinomatosis evaluate in serum and ascites the concentrations of alphafetoprotein, carcinoembryonic antigen and fibronectin, they might suggest a diagnosis for the basic pathology. Forty-seven patients were studied, from whom 23 with cirrhosis, 17 peritoneal carcinomatosis and 7 with congestive heart failure. We conclude that: a) none of the tools usually employed in the analysis of ascitic fluid alone can make the base pathological process responsible for producing ascites; b) fibronectins were more useful for differential diagnosis between cirrhosis and carcinomatosis; c) alpha-fetoprotein and carcinoembryonic antigen were not useful for the definition for differential diagnosis.     

腹腔镜检查在慢性肝病诊断中的意义

目的　评价腹腔镜在肝病诊断中的价值。方法　对１２６ 例肝病患者的腹腔镜检查作了回顾性综合分析。结果　确诊的主要病种为肝硬化５８ 例,慢性肝炎３０ 例,肝癌２１ 例（原发性１９ 例,继发性２ 例）,肝周围炎６例,其它５例;原发性肝癌合并肝硬化的有１３ 例（占６８％ ）,有肝周、脾周或腹腔内不同程度粘连者４１例。镜检的正确率（证实和修正临床诊断）达到９５．２％ 。对各病种在腹腔镜下的主要表现分别作了描述,并指出了镜检中应注意的问题。结论　腹腔镜检查并配合活检,作为肝脏疾病的较好诊断方法,具有实用价值。     

经胃腹腔内镜检查对原因不明腹水的诊断价值

目的探讨经自然腔道进行腹腔内镜检查对渗出性腹水病因的诊断价值。方法23例不明原因渗出性腹水患者经口腔穿胃壁行腹腔内镜检查及病理活检。结果23例中22例获得明确诊断,确诊率95．7％。明确病因诊断22例中,腹腔恶性肿瘤12例（54．6％）,结核性腹膜炎8例（36．4％）,肝硬化合并自发性腹膜炎1例（4．5％）,嗜酸性小肠炎1例（4．5％）。结论经自然腔道腹腔内镜检查及病理活检对原因不明渗出性腹水患者是一种安全、确诊率高的诊断方法。     

腹腔内镜检查对不明原因腹水的诊断价值

目的 探讨腹腔内镜检查及直视下腹膜活检对不明原因腹水的诊断价值,评价超细胃镜代替硬式腹腔镜检查的可行性。方法对35例不明原因腹水的患者进行腹腔内镜探查手术,并取可疑组织送病理检查。结果35例腹腔内镜探查确诊33例,确诊率94．3％,其中确诊结核性腹膜炎10例,转移性腹膜癌7例,肝癌5例,肝硬化3例,原发性腹膜癌3例,卵巢癌2例,肝血管肉瘤1例,脾淋巴瘤1例,嗜酸性肠炎1例,所有患者术后恢复顺利,无并发症。结论腹腔内镜检查安全,靶向性腹膜活检确诊率高,对不明原因腹水的诊断有重要价值。     

What is the role of diagnostic laparoscopy in a gastroenterology unit?

Background Diagnostic laparoscopy is known to be a relatively safe invasive procedure. However, its use has decreased owing to the development of imaging techniques, and fewer gastroenterologists now practice diagnostic laparoscopy. Our aim was to examine the role of diagnostic laparoscopy in a gastroenterology unit in the era of advanced imaging techniques. Methods We retrospectively reviewed 855 diagnostic laparoscopy cases. Its safety and efficacy were evaluated for various indications. Results No mortality was observed, and complications were noted in ten patients (1.2%). Among the indications were evaluation of chronic liver disease (n = 673), liver tumor (n = 15), ascites of unknown origin and peritoneal disease (n = 142), and staging of intra-abdominal malignancy (n = 25). In patients with chronic liver disease, 461 were diagnosed as having chronic viral hepatitis, based on clinical data including imaging studies, but the diagnosis was changed to cirrhosis after a laparoscopic exam in 69 patients (15.0%). In patients with ascites of unknown origin and peritoneal disease, the diagnostic yield was 87.2% (123/141). In 24 (19.5%) of the 123 patients, the diagnosis changed or the less probable diagnosis was confirmed after laparoscopic examination. The confirmed diagnoses were mainly primary peritoneal disease, including peritoneal tuberculosis, in 17 patients, peritoneal metastatic carcinoma in five, and mesothelioma in two. Conclusions Diagnostic laparoscopy in a gastroenterology unit is safe and useful, especially for confirmation of liver cirrhosis and primary peritoneal disease evaluation.     

Diagnostic value of fibrolaparoscopy and direct-vision peritoneal biopsy in atypical tuberculous peritonitis]

Fifty-three cases of atypical tuberculous peritonitis were diagnosed by Machida FLA-8 fibrolaparoscope and direct-vision peritoneal biopsy in our hospital during the last few years. The misdiagnosis rate of this disease is very high. The rate of accurate clinical diagnosis was only 39.6% in patients of this study, while 60.4% was misdiagnosed as other diseases, such as cirrhosis, chronic hepatitis, hepatic carcinoma ovarian cyst etc. In addition, many patients with other diseases were misdiagnosed as tuberculous peritonitis by clinical consideration, for instance, 56 cases who were diagnosed or doubted as tuberculous peritonitis by clinical consideration were diagnosed as other diseases by laparoscopy and liver and peritoneal biopsy under direct-vision. Among them chronic hepatitis accounted for 32 cases, peritoneal carcinoma 11 cases, cirrhosis 7 cases, normal peritoneum, liver, gall bladder and spleen 6 cases. Therefore, the patient who is presumptively diagnosed as tuberculous peritonitis by clinical consideration should have laparoscopy and direct-vision peritoneal biopsy performed.     

Genesis of fibronectin in ascites--detection of cellular and plasma fibronectin in portal and malignant ascites

Measurement of fibronectin in ascites has been proposed for the differentiation of ascites either due to malignant growth in the peritoneal cavity or liver cirrhosis with portal hypertension. The high ascitic fibronectin concentration in patients with peritoneal carcinomatosis was thought to be due to the synthesis of this protein by neoplastic cells. Therefore in ascites of malignant origin cellular fibronectin should be present as it is synthesized by neoplastic cells. On the other side the transsudative ascites due to liver cirrhosis with portal hypertension should mainly contain plasma-fibronectin, which is secreted by hepatocytes into the bloodstream. With the aid of two different monoclonal antibodies and immunoblotting of partially digested or intact ascitic fibronectin, cellular fibronectin could be demonstrated in ascitic fluid of 10 patients with peritoneal carcinomatosis, 13 patients with liver cirrhosis, one patient with right-sided heart failure and one patient with Budd-Chiari-Syndrome. As determined by a specific ELISA 8 out of 10 samples of malignant ascites contained more than 30 mg/l of cellular fibronectin, whereas 10 out of 13 samples of ascites due to liver cirrhosis contained less than 10 mg/l. Whereas in ascites of malignant origin cellular fibronectin represented about 20% of total fibronectin, in portal ascites fibronectin represented sometimes more than 50% of total fibronectin. Cellular fibronectin of non-malignant origin is probably produced by mesothelial cells or peritoneal macrophages. Therefore, fibronectin accumulating in peritoneal carcinomatosis is only to some extent locally produced, but mainly caused by an unhindered exsudation of plasma-fibronectin.     

Laparoscopic findings in aged patients (author's transl)]

A group of 165 geriatric patients is compared with a control group of 114 younger patients concerning different frequency of laparoscopic diagnoses. As it was suspected from the clinical view aged patients predominently suffered from posthepatic cirrhosis and from cirrhosis of unknown origin, from recurrent cholecystitis, obstructive jaundice, metastases and carcinosis of peritoneal cavity. Younger patients much more frequently showed toxic liver damage starting from fatty liver and ending up with fatty liver cirrhosis. Persistent acute hepatitis non associated with HBSAg was scarcely seen with the aged group. It was a frequent diagnosis with the younger control group. There are explanations given for the differing endoscopic results concerning aged persons and younger control persons.     

Ascitic fluid analysis in malignancy-related ascites

A prospective study identified 45 patients with malignancy-related ascites among 448 ascites patients (10% of the total). Patients were categorized into five subgroups based on the pathophysiology of ascites formation. Each subgroup had a distinctive ascitic fluid analysis. Patients with peritoneal carcinomatosis but without massive liver metastases (53.3% of the patients with malignancy-related ascites) had a uniformly positive ascitic fluid cytology, high ascitic fluid protein concentration and low serum-ascites albumin gradient. Patients with massive liver metastases and no other cause for ascites formation (13.3% of the series) had a negative cytology, low ascitic fluid protein concentration, high serum-ascites albumin gradient and markedly elevated serum alkaline phosphatase. Those with peritoneal carcinomatosis and massive liver metastases (13.3% of the series) had a nearly uniformly positive ascitic fluid cytology, variable protein concentration, high serum-ascites albumin gradient and markedly elevated serum alkaline phosphatase. Chylous ascites (6.7%) was characterized by a milky appearance, negative cytology and an elevated ascitic fluid triglyceride concentration. Patients with hepatocellular carcinoma superimposed on cirrhosis (13.3%) had negative ascitic fluid cytology, low ascitic fluid protein concentration, high serum-ascites albumin gradient and elevated serum and ascitic fluid alpha-fetoprotein concentration. Two-thirds of patients with malignancy-related ascites had peritoneal carcinomatosis; 96.7% of patients with peritoneal carcinomatosis had positive ascitic fluid cytology. Ascitic fluid analysis is helpful in identifying and distinguishing the subgroups of malignancy-related ascites.     

Renal diseases and the liver

Many liver diseases coexist with chronic renal disease, because many systemic conditions affect both the liver and the kidneys. Certain liver diseases are also common in patients with chronic renal disease, especially viral hepatitis, either because the renal disease occurs as a complication of viral hepatitis, or the viral hepatitis is acquired as a result of dialysis. Renal tubular dysfunction is also frequently observed with cholestasis. However, liver complications of renal diseases are extremely uncommon, notable examples include nephrogenic ascites and nephrogenic hepatic dysfunction. Nephrogenic ascites can mimic liver cirrhosis with ascites, and it improves with renal transplantation. Nephrogenic hepatic dysfunction is a manifestation of renal cell carcinoma, which settles with the removal of the renal cell carcinoma, but returns with the recurrence of the tumor. In general, the presence of liver disease in patients with chronic renal disease makes management of both conditions more challenging. Viral hepatitis should be treated, if possible, before renal transplant. If cirrhosis is present, renal transplant alone is contraindicated; combined liver and kidney transplantation is indicated in patients with end-stage renal disease and advanced cirrhosis.     

Biochemical evaluation of processed ascites in patients undergoing cell‐free and concentrated ascites reinfusion therapy

The biochemical composition of processed ascites is not well researched and may differ among institutions. This prospective study was conducted to evaluate the biochemical characteristics of processed ascites of 11 patients with liver cirrhosis and carcinoma who underwent cell‐free and concentrated ascites reinfusion therapy. The ascites due to carcinoma were more acidic and had higher lactate dehydrogenase activity than those due to liver cirrhosis. The ascites due to liver cirrhosis contained a higher amount of immunoglobulin than those due to carcinoma. Immunoglobulin preparations were approximately 2.95% IgG in liver cirrhosis ascites and 2.25% IgG in carcinoma ascites. Moreover, the concern about IgA infusion in the patient with IgA deficiency made it important to identify the source of the ascites. The present study provided fundamental information regarding the safety of cell‐free and concentrated ascites reinfusion therapy.     

Ascitic fluid α1-antitrypsin

Ascitic fluid alpha 1-antitrypsin (AF-AAT) was compared with ascitic fluid total protein (AF-TP) and the serum-ascites albumin gradient (SAAG) in the differential diagnosis of ascites. The study included 82 consecutive patients of which 42 had cirrhosis, 8 hepatoma (with cirrhosis), and 27 malignant ascites (peritoneal 18, liver 9). The concentration of AF-AAT (milligrams per deciliter) was significantly elevated (P less than 0.001) in hepatoma (174 +/- 123), malignant liver disease (232 +/- 119) and peritoneal neoplasms (376 +/- 106) in comparison with cirrhotics (66 +/- 33). In separating ascites caused by cirrhosis or malignancy, AF-AAT (discriminating limit of 120 mg/dl) had a 96% sensitivity, 95% specificity, and 96% diagnostic efficacy, which was superior to the 87% observed for AF-TP and 86% for the SAAG. Similar results were obtained for the A/S AAT ratio but this test was not available in all patients. AF-AAT was particularly useful in patients with malignancy causing portal hypertension as assessed by SAAG (hepatoma, malignant liver disease). We conclude that AF-AAT may be a valuable parameter in the differential diagnosis of ascites.     

Main causes of death in cirrhosis

The main causes of 436 deaths among 532 patients with cirrhosis followed up for up to 16 years constituted liver failure (24%), liver failure with gastrointestinal bleeding (13%), gastrointestinal bleeding (14%), primary liver cell carcinoma (4%), other liver-related causes (2%), infections (7%), cardiovascular diseases (22%), extrahepatic malignancies (9%), and other non-liver-related causes (5%). Totally, 57% died of liver-related causes. A high frequency of liver-related death was found among patients with a short observation time, high biochemical activity, pronounced change in liver architecture, ascites, and other signs of a poor prognosis at the time of diagnosis. The findings favoured the hypothesis that cirrhosis of the liver is a disease with an initial active and a subsequent inactive phase. Half of the patients were treated with prednisone, but this had no detectable influence on the distribution of causes of or on the frequency of single causes of death as infections or gastrointestinal bleeding. The group of patients responding favourably to prednisone treatment with regard to survival (non-alcoholic women without ascites) showed causes of death not different from those of the total material.     

Role of peritoneal ultrasonography and ultrasound-guided fine needle aspiration cytology/biopsy of extravisceral masses in the diagnosis of ascites of undetermined origin

Background and study aimsAscites may be of undetermined origin despite comprehensive study. This study aimed to assess the accuracy and safety of conventional and interventional high-frequency peritoneal ultrasound in the diagnosis of patients with ascites of unclear origin.Patients and methodsA total of 62 patients were prospectively enrolled; they underwent conventional (3.5–5 MHz) and high-frequency (6–8 MHz) transabdominal peritoneal ultrasound to suggest the nature of ascites supplemented by fine needle aspiration cytology (FNAC) of ascites and/or core biopsy of the omentum or other extra-visceral masses for final histopathologic diagnosis. Laparoscopy or laparotomy was needed if biopsy was inconclusive.ResultsUltrasound-guided procedures were diagnostic in 55 (87.7%) patients. Thirty-six (58.1%) were benign, of whom 86% had tuberculous peritonitis, 26 (41.9%) were malignant, of whom 76.9% had peritoneal metastasis. High-frequency ultrasound was able to propose ultrasonographic criteria in a trial to diagnose the nature of ascites. Our proposed ultrasonographic criteria were based on the amount and texture of ascites in addition to the omental and mesenteric features. These were able to suggest the diagnosis with 80.7% sensitivity for malignant ascites and 75% specificity for benign ascites. Moreover, histopathological examination of tissues obtained by ultrasound-guided procedures increased the sensitivity to 88.5% and the specificity to 88.9% in diagnosing malignant and benign disease, respectively, with an overall diagnostic accuracy of 88.6%. These procedures were considered to be safe as only one major (haemoperitoneum) and two minor complications (temporary ascitic fistula) were reported.ConclusionHigh-frequency peritoneal ultrasound together with the minimally invasive ultrasound-guided FNAC/biopsy of extra-visceral lesions may be considered an effective and safe tool in the diagnosis of ascites of undetermined origin.     

Adenosine deaminase (ADA) in peritoneal tuberculosis: diagnostic value in ascitic fluid and serum

Simultaneous determination of ascitic fluid and serum adenosine deaminase (ADA) activity was evaluated as a diagnostic aid in peritoneal tuberculosis. The ascites was due to peritoneal tuberculosis (group 1), cirrhosis of the liver (group 2), cirrhosis of the liver with spontaneous bacterial peritonitis (group 3), peritoneal malignancy (group 4), Budd-Chiari Syndrome (group 5) and miscellaneous conditions (group 6). Serum from patients of pulmonary tuberculosis and healthy volunteers was analysed for enzyme activity. In patients with peritoneal tuberculosis the ascitic fluid and serum ADA activity was significantly higher than for the other groups (P less than 0.001). Levels above 36 u/l in ascitic fluid and above 54 u/l in the serum suggest tuberculosis. The ascitic fluid/serum ADA ratio was also higher in patients with peritoneal tuberculosis than with other causes of ascites (P less than 0.01). A ratio of more than 0.984 was suggestive of tuberculosis.     

Multiport staging laparoscopy in esophageal and cardiac carcinoma

Between February 1993 and September 2000, 320 patients with esophageal cancer were referred to our oesophagogastric unit. One hundred and thirty-three consecutive patients with histologically proven carcinoma of the esophagus were assessed with a view to resection using multiport staging laparoscopy. Multiport staging laparoscopy was performed as a short stay/day case procedure in 133 patients with esophageal and oesophagogastric junctional carcinoma. Multiple ports were used to inspect the liver, omentum, peritoneal surfaces, coeliac/left gastric lymph nodes and obtain biopsies and cytology. Satisfactory assessment was possible in 127 cases (95%). Laparoscopy detected incurable disease in 31 patients (24%), some of whom had more than one contraindication to surgery, including hepatic metastases (n = 10), peritoneal metastases (n = 12) and malignant small volume ascites (n = 5). Lymph node metastases were confirmed histologically by biopsy at laparoscopy in 26 patients (fixed nodes, n = 14; mobile nodes, n = 12). Sensitivity for the detection of liver and peritoneal metastases was 100%, and lymph node metastases were 83%. Specificity for detection of hepatic metastases was 99%, 100% for peritoneal metastases and 82% for lymph node metastases. Ninety-nine patients proceeded to definitive surgery and only two were unresectable. Multiport laparoscopic assessment of metastases in patients with esophageal carcinoma avoids unnecessary surgery and allows for more efficient use of theatre and intensive care time.     

诊断性腹腔镜的临床应用研究

目的：评价诊断性腹腔镜的检查方法、效果及安全性，提高腹部疑难疾病的早期诊断率。方法：回顾分析58例腹部疑难疾病患者的腹腔镜检查情况，其中腹水原因待查35例，腹水＋腹部包块23例。结果：58例患者中诊断为结核性腹膜炎31例，恶性腹膜间皮瘤23例，腹膜转移癌2例，盆腔结核及慢性盆腔炎各1例。不同疾病在腹腔镜下有不同表现。操作时间25－70min，平均38min。并发症为活检处出血4例，其中3例为自限性因，1例经局部喷洒凝血酶后停止，术后伤口漏水5例。对腹腔镜下有肯定判断的12例患者同时进行治疗。结论；腹腔镜检查具有安全、简便、微创、痛苦小、确诊率高等优点。诊断性腹腔镜值得进一步推广应用。     

The diagnosis of tuberculous ascites in a rural African community

Tuberculous ascites can be a difficult condition to diagnose. In the rural African population served by Jane Furse Hospital both tuberculosis and ascites are common conditions. Between 1 November 1982 and 31 October 1983, 80 patients were admitted with ascites. Open peritoneal biopsy was used in 18 patients in whom the cause was uncertain. In 5, biopsy showed caseating tuberculosis in the absence of any other evidence of active disease. In 6 the biopsy showed non specific changes which may be associated with tuberculosis or cirrhosis of the liver. No significant complications were encountered and it was concluded that this procedure was a useful, safe and rapid means of diagnosing tuberculous peritonitis.     

Laparoscopy as a diagnostic method in internal medicine: experiences with 168 procedures at Kilimanjaro Christian Medical Centre, Moshi, Tanzania.

One hundred and sixty-eight laparoscopies, performed for various indications between 1985 and 1989, were studied retrospectively and the findings and experiences are reported. The most frequent diagnoses were hepatocellular carcinoma (20%) and liver cirrhosis (18%). Correlation of macroscopic and histopathological diagnosis was satisfactory in hepatocellular carcinoma (74%) and poor in liver cirrhosis (38%). Laparoscopy was judged diagnostic in 45%, diagnostically helpful in 20% and non-contributory in 35% of all cases. The highest yield was obtained in hepatocellular carcinoma and liver cirrhosis, the poorest results in obstructive jaundice. It is concluded that for optimum diagnostic outcome the indication for laparoscopy should be strict and that it should be practised only in those centres where experienced clinicians and competent histopathologists are available.