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Metabolic abnormalities in patients with cirrhosis and hepatic encephalopathy
538A
AASLD ABSTRACTS
HEPATOLOGYOctober 2001
1463
1464
EVALUATION OF THE ROLE OF TOTAL PARACENTESIS IN MANAGEMENT OF REFRACTORY ASCITES IN PATIENTS W I T H LIVER CIRRHOSIS. Maged T E1-Ghannam, Naema I E1-Ashry, Ahmed A El-Ray, Nadia Abu-
VALUE OF DUPLEX ULTRASOUND TO INVESTIGATE WItETHER LARGE VOLUME PARACENTESIS WITHOUT INFUSIONS IS SAFE, EASY AND ECONOMIC IN SELECTED CIRRHOTIC PATIENTS. Hesham
Zekri, Gamal El-Attar, Magdy M Yousef, Nadia El-Behairy, Theodor Bilharz Research Institute, Cairo, Egypt Egypt
A Yehia, Theodor Bilharz Research Institute, Cairo, Egypt Egypt
This study was designed to determine the safety and efficacy of total paracentesis without or with on demand fluid replacement therapy,as a method of management for refractory ascites.Thirty patients with refractory ascites were mcluded.The:y were divided into two groups according to their need to replacement therapy; group I with no replacement therapy (21 patients),and group ii needed replacement therapy(9 patients).Using thoraeocentesis needle and with the help of vacuum, ascttie fluid was totally removed.According to the CVP and blood pressure readings,patients were infused with plasma expanders (Dextran 70) if their readings were low.Hormonal assay for plasma renin activity, aldosterone andatria[ natriuretic peptide(ANP) were performed immediately before,immediately after,24 hours,48 hours,7days and 3 months after paracentesis. Hypovolemia,ehemically, occurred m all patients as judged from the elevation of renin and aldosterone and decreased ANP,The elevation reached the maximum level after 48 hours. All these changes came back to normal values after a week. It was found that the severity in changes was greater in the first group rather than the second group with r eplacement. Complications recorded during the procedure and the follow up period include:Muscla cramps in 6(20%) patients;encephalopathy in 4(13%) pa tients,hemateraesis and SBP in l (3.3%) patient and ascaes recured in 23 (76.6%).Most of the complications occurred in gpl.ln conclusion, we found that total paracentesis is safe and effective in patients with refractory ascites eompflcating liver cirrhosis and can be done in f~w hours with the help of genre suction. Replacement therapy using at least 3L of dextran 70 is vital to guard against hypovolemia and to prevent electrolyte disturbances. P~ma r~in agtfclty(PR~)aldeste~me(PA)a~ atrialnatduroc pep~det~IP)
;2.G"
3
#
83#
G~I~
157.5.9 932-~35.fi
4.~q,G
3
85.0.43 ~0~8÷43,
~7
~4
~7+5
81.~+21,~
97 5-50.
Ill /....
Fifty-eight cases with moderate or tense cirrhotic ascites were randomly allocated into two groups to investigate whether large volume paracentesis (LVP) without infusions is safe, easy and economic in some selected cirrhotic patients. They were selected according to certain criteria. The criteria were: moderate or tense ascites, absence of anuria, oliguria or polyuria, absence of hepatic encephalopathy, absence of active gastrointestinal hemorrhage or severe infection at entry, serum creatinine less than 1.5 mg/dl and no renal impairment. Twenty-eight patients (group 1) were not infused by infusions. Thirty patients (group 2) were infused by different infusions, 10 patients (a) were infused by saline solution at about 170 ml/L, 10 patients (b) were infused by hemaccel at about 150 m//L and 10 patients (c) were infused by human albumin at about 6-8 g/L ascites removed respectively. The amount of LVP was about 5-7 liters in 2 hours. The basal clinical features, laboratory data were similar in both groups. They were subjected to the routine examinations, investigations and duplex ultrasound. Velocity (V) and Flow volume rate (FVR) of portal vein (PV) before and after LVP, efficacy, safety, clinical outcome in both groups were compared. Duplex ultrasound was repeated at i and 7 days later. Results showed no significant changes were observed in liver and renal functions before and after LVP in both groups. Vs of PV in group 1, 2a, 2b and 2c before LVP were 17+3.3, 19+7.8, 27.2+ 19 and 16.3+ 4.2 respectively and one day after LVP they were 26.8+11.2, 22 + 7.4, 30.7+29.3 and 18.7+8.7 em/s. FVR of PV before and after LVP showed similar changes. Hemodynamic parameters were improved in all patients as regarding velocity and FVR after LVP especially in the group 1 not infused by infusions in a significant pattern. Few complications were detected in both groups. Two complications were detected in group 1 as hematemsis and encephalopathy and two complications were detected in group 2 as hematemsis and spontaneous bacterial peritonitis. Duplex ultrasound before and after LVP explains through hemodynamic changes why LVP without infusions is a good modality in selected cirrhotic patients. LVP reduces the mechanical effect and it improves hemodynamic status. These results indicate that LVP without infusions in selected patients are effective, safe, easy and economic as compared to costly infusions provided that we select probably the patients according to the criteria mentioned above.
g~
1465
1466
THE RISING TIDE OF TUBERCULOSIS: PREVALENCE OF TUBERCULOUS PERITONITIS IN CHRONIC LIVER DISEASES PATIENTS. Naglaa
METABOLIC ABNORMALITIES IN PATIENTS W I T H CIRRHOSIS AND HEPATIC ENCEPBALOPATRY. Konstantinos J Dabos, Liver Unit, Univer-
H E1-Sherif, Mahmoud Romeih, Aesha Abu-Aitta, Einass E1-Defrawi, Yousry Abdel-Rahman, Hesham A Yehia, Moatez Hassan, Lila Aboul-Fadl, Soad Mokhtar, Theodor Bilharz Research Institute, Cairo, Egypt Egypt
sity of Edinburgh, Edinburgh Uk; Philip N Newsome, Liver Unit, Edinburgh Uk; John A Parkinson, Deaprtent of Chemistry, University of Edinburgh, Edinburgh Uk; Celine Fillippi, Liver Unit, University of Edinburgh, Edinburgh Uk; Ian Sadler, Deaprtent of Chemistry, University of Edinburgh, Edinburgh Uk; John Plevris, Peter C Hayes, Liver Unit, University of Edinburgh, Edinburgh Uk
Tfie ascitic fluid that complicates chronic liver disease (CLD) may not be simply a transudate secondary"to portal hypertension. It could be an exudate due to tuberculous (TB) peritonitis. The distinction between the two events is not an easy task in many instances. This work was designed to study the frequency of TB peritonitis in CLD patients showing toxic symptoms using the polymerase chain reaction (PCR) and the TB-Fast test for the diagnosis of Mycobacterium tuberculosis (MTB) in both blood and ascitic fluid samples. TB-Fastis an immunochemical test that detects MTB antigens using specific monoclona] antibodies. Forty-six chronic hepatic patients with suspected TB peritonitis were enrolled in this study. Two specimens (blood and ascitic fluid) were collected from each patient. Following clinical examination, routine laboratory investigations, chest x-ray and PPD skin tests, specimens were processed for chemical, pathological, bacteriological and molecular examinations. Laparoscopy and peritoneal biopsy were performed whenever possible. Smears for acid-fast bacilli and culture on Lowenstein medium were done for ascitic fluid specimens, while PCR analysis and TB-Fast test were performed for both blood and ascitic fluid. Depending on the clinical, laboratory and culture results, 18 patients were diagnosed as TB peritonitis, while 28 patients were suspicious of the disease. Among the 18 patients, posidve smears, culture, PCR and TB-Fast test were recorded in 4(22.2%), 8(44.4%), 16(88.9%) and 14(77.8%) respectively. While smears and culture were negative among the 28 patients with suspected TB peritonitis, PCR and TB-Fast test were positive in 14(50%) and 12(42.9%) respectively. TB-Fast test gave similar results in both ascitic fluid and blood samples while PCR showed higher positivity among ascitic fluid specimens. In conclusion, we report a considerable prevalence of TB peritonitis reaching more than 50% among patients with CLD showing toxic manifestations. PCR analysis and TB-Agdetection by TB-Fast testing of ascitic fluid (being the specimen of choice) provide rapid reliable means of diagnosis of TB peritonitis. Accordingly, a high index of clinical suspicion is recommended as being essential for the early diagnosis of such cases.
Little is known about the functions of cellular pathways in patients with cirrhosis and chronic hepatic encephalopathy (CHE).As the aetiology of CHE remains unclear we investigated differences in redox potential and amino acid concentrations between stable cirrhotics and cirrhotics during an episode of CHE. Methods Using 1H Nuclear Magnetic Resonance Spectroscopy we looked at indices of glycolysis, branch chain amino acids (BCAA), aromatic amino acids (AAA) and ketone bodies in the plasma of non-fasting stable "cirrhotics (n= 23), cirrhotics with CHE (n = 26) and controls (n= 17). Results There were no differences in the lactate/pyruvate ratio, the b-hydroxybutyrate /acetoacetate ratio and the malate/aspartate shuttle redox potential comparing controls and cirrhoties. The Fischer's index (BCAA/AAA)in controls was 3.92 and significantly (p<0.012) less at 1.59 in stable cirrhotics.This was a reflection of mainly an increase in AAA. In CHE patients the lactate/pyruvate ratio was significantly lower compared to the other two groups (p<0.035 on both measurements), the b-hydroxybutyrate/acetoacetate ratio was significantly lower compared to the other two groups (p<0.01 on both measurements), and the malate/aspartate shuttle was significantly higher (p<0.005 on both measurements). The Fischer's index of CHE patients was 2.55 and not statistically diferent from the other two groups.There was though a statistically significant increase of BCAA compared to the other two groups (p<0.03 on both measurements) and a statistically significant increase of AAA compared to controls (p<0.01). Conclusions .Ketogeuesis and the branch chain amino acid metabolism are impaired in CHE patients coupled with low intraeellular energy levels. This might have implications in the pathogenesis of the condition.
AASLD ABSTRACTS
HEPATOLOGYOctober 2001
1463
1464
EVALUATION OF THE ROLE OF TOTAL PARACENTESIS IN MANAGEMENT OF REFRACTORY ASCITES IN PATIENTS W I T H LIVER CIRRHOSIS. Maged T E1-Ghannam, Naema I E1-Ashry, Ahmed A El-Ray, Nadia Abu-
VALUE OF DUPLEX ULTRASOUND TO INVESTIGATE WItETHER LARGE VOLUME PARACENTESIS WITHOUT INFUSIONS IS SAFE, EASY AND ECONOMIC IN SELECTED CIRRHOTIC PATIENTS. Hesham
Zekri, Gamal El-Attar, Magdy M Yousef, Nadia El-Behairy, Theodor Bilharz Research Institute, Cairo, Egypt Egypt
A Yehia, Theodor Bilharz Research Institute, Cairo, Egypt Egypt
This study was designed to determine the safety and efficacy of total paracentesis without or with on demand fluid replacement therapy,as a method of management for refractory ascites.Thirty patients with refractory ascites were mcluded.The:y were divided into two groups according to their need to replacement therapy; group I with no replacement therapy (21 patients),and group ii needed replacement therapy(9 patients).Using thoraeocentesis needle and with the help of vacuum, ascttie fluid was totally removed.According to the CVP and blood pressure readings,patients were infused with plasma expanders (Dextran 70) if their readings were low.Hormonal assay for plasma renin activity, aldosterone andatria[ natriuretic peptide(ANP) were performed immediately before,immediately after,24 hours,48 hours,7days and 3 months after paracentesis. Hypovolemia,ehemically, occurred m all patients as judged from the elevation of renin and aldosterone and decreased ANP,The elevation reached the maximum level after 48 hours. All these changes came back to normal values after a week. It was found that the severity in changes was greater in the first group rather than the second group with r eplacement. Complications recorded during the procedure and the follow up period include:Muscla cramps in 6(20%) patients;encephalopathy in 4(13%) pa tients,hemateraesis and SBP in l (3.3%) patient and ascaes recured in 23 (76.6%).Most of the complications occurred in gpl.ln conclusion, we found that total paracentesis is safe and effective in patients with refractory ascites eompflcating liver cirrhosis and can be done in f~w hours with the help of genre suction. Replacement therapy using at least 3L of dextran 70 is vital to guard against hypovolemia and to prevent electrolyte disturbances. P~ma r~in agtfclty(PR~)aldeste~me(PA)a~ atrialnatduroc pep~det~IP)
;2.G"
3
#
83#
G~I~
157.5.9 932-~35.fi
4.~q,G
3
85.0.43 ~0~8÷43,
~7
~4
~7+5
81.~+21,~
97 5-50.
Ill /....
Fifty-eight cases with moderate or tense cirrhotic ascites were randomly allocated into two groups to investigate whether large volume paracentesis (LVP) without infusions is safe, easy and economic in some selected cirrhotic patients. They were selected according to certain criteria. The criteria were: moderate or tense ascites, absence of anuria, oliguria or polyuria, absence of hepatic encephalopathy, absence of active gastrointestinal hemorrhage or severe infection at entry, serum creatinine less than 1.5 mg/dl and no renal impairment. Twenty-eight patients (group 1) were not infused by infusions. Thirty patients (group 2) were infused by different infusions, 10 patients (a) were infused by saline solution at about 170 ml/L, 10 patients (b) were infused by hemaccel at about 150 m//L and 10 patients (c) were infused by human albumin at about 6-8 g/L ascites removed respectively. The amount of LVP was about 5-7 liters in 2 hours. The basal clinical features, laboratory data were similar in both groups. They were subjected to the routine examinations, investigations and duplex ultrasound. Velocity (V) and Flow volume rate (FVR) of portal vein (PV) before and after LVP, efficacy, safety, clinical outcome in both groups were compared. Duplex ultrasound was repeated at i and 7 days later. Results showed no significant changes were observed in liver and renal functions before and after LVP in both groups. Vs of PV in group 1, 2a, 2b and 2c before LVP were 17+3.3, 19+7.8, 27.2+ 19 and 16.3+ 4.2 respectively and one day after LVP they were 26.8+11.2, 22 + 7.4, 30.7+29.3 and 18.7+8.7 em/s. FVR of PV before and after LVP showed similar changes. Hemodynamic parameters were improved in all patients as regarding velocity and FVR after LVP especially in the group 1 not infused by infusions in a significant pattern. Few complications were detected in both groups. Two complications were detected in group 1 as hematemsis and encephalopathy and two complications were detected in group 2 as hematemsis and spontaneous bacterial peritonitis. Duplex ultrasound before and after LVP explains through hemodynamic changes why LVP without infusions is a good modality in selected cirrhotic patients. LVP reduces the mechanical effect and it improves hemodynamic status. These results indicate that LVP without infusions in selected patients are effective, safe, easy and economic as compared to costly infusions provided that we select probably the patients according to the criteria mentioned above.
g~
1465
1466
THE RISING TIDE OF TUBERCULOSIS: PREVALENCE OF TUBERCULOUS PERITONITIS IN CHRONIC LIVER DISEASES PATIENTS. Naglaa
METABOLIC ABNORMALITIES IN PATIENTS W I T H CIRRHOSIS AND HEPATIC ENCEPBALOPATRY. Konstantinos J Dabos, Liver Unit, Univer-
H E1-Sherif, Mahmoud Romeih, Aesha Abu-Aitta, Einass E1-Defrawi, Yousry Abdel-Rahman, Hesham A Yehia, Moatez Hassan, Lila Aboul-Fadl, Soad Mokhtar, Theodor Bilharz Research Institute, Cairo, Egypt Egypt
sity of Edinburgh, Edinburgh Uk; Philip N Newsome, Liver Unit, Edinburgh Uk; John A Parkinson, Deaprtent of Chemistry, University of Edinburgh, Edinburgh Uk; Celine Fillippi, Liver Unit, University of Edinburgh, Edinburgh Uk; Ian Sadler, Deaprtent of Chemistry, University of Edinburgh, Edinburgh Uk; John Plevris, Peter C Hayes, Liver Unit, University of Edinburgh, Edinburgh Uk
Tfie ascitic fluid that complicates chronic liver disease (CLD) may not be simply a transudate secondary"to portal hypertension. It could be an exudate due to tuberculous (TB) peritonitis. The distinction between the two events is not an easy task in many instances. This work was designed to study the frequency of TB peritonitis in CLD patients showing toxic symptoms using the polymerase chain reaction (PCR) and the TB-Fast test for the diagnosis of Mycobacterium tuberculosis (MTB) in both blood and ascitic fluid samples. TB-Fastis an immunochemical test that detects MTB antigens using specific monoclona] antibodies. Forty-six chronic hepatic patients with suspected TB peritonitis were enrolled in this study. Two specimens (blood and ascitic fluid) were collected from each patient. Following clinical examination, routine laboratory investigations, chest x-ray and PPD skin tests, specimens were processed for chemical, pathological, bacteriological and molecular examinations. Laparoscopy and peritoneal biopsy were performed whenever possible. Smears for acid-fast bacilli and culture on Lowenstein medium were done for ascitic fluid specimens, while PCR analysis and TB-Fast test were performed for both blood and ascitic fluid. Depending on the clinical, laboratory and culture results, 18 patients were diagnosed as TB peritonitis, while 28 patients were suspicious of the disease. Among the 18 patients, posidve smears, culture, PCR and TB-Fast test were recorded in 4(22.2%), 8(44.4%), 16(88.9%) and 14(77.8%) respectively. While smears and culture were negative among the 28 patients with suspected TB peritonitis, PCR and TB-Fast test were positive in 14(50%) and 12(42.9%) respectively. TB-Fast test gave similar results in both ascitic fluid and blood samples while PCR showed higher positivity among ascitic fluid specimens. In conclusion, we report a considerable prevalence of TB peritonitis reaching more than 50% among patients with CLD showing toxic manifestations. PCR analysis and TB-Agdetection by TB-Fast testing of ascitic fluid (being the specimen of choice) provide rapid reliable means of diagnosis of TB peritonitis. Accordingly, a high index of clinical suspicion is recommended as being essential for the early diagnosis of such cases.
Little is known about the functions of cellular pathways in patients with cirrhosis and chronic hepatic encephalopathy (CHE).As the aetiology of CHE remains unclear we investigated differences in redox potential and amino acid concentrations between stable cirrhotics and cirrhotics during an episode of CHE. Methods Using 1H Nuclear Magnetic Resonance Spectroscopy we looked at indices of glycolysis, branch chain amino acids (BCAA), aromatic amino acids (AAA) and ketone bodies in the plasma of non-fasting stable "cirrhotics (n= 23), cirrhotics with CHE (n = 26) and controls (n= 17). Results There were no differences in the lactate/pyruvate ratio, the b-hydroxybutyrate /acetoacetate ratio and the malate/aspartate shuttle redox potential comparing controls and cirrhoties. The Fischer's index (BCAA/AAA)in controls was 3.92 and significantly (p<0.012) less at 1.59 in stable cirrhotics.This was a reflection of mainly an increase in AAA. In CHE patients the lactate/pyruvate ratio was significantly lower compared to the other two groups (p<0.035 on both measurements), the b-hydroxybutyrate/acetoacetate ratio was significantly lower compared to the other two groups (p<0.01 on both measurements), and the malate/aspartate shuttle was significantly higher (p<0.005 on both measurements). The Fischer's index of CHE patients was 2.55 and not statistically diferent from the other two groups.There was though a statistically significant increase of BCAA compared to the other two groups (p<0.03 on both measurements) and a statistically significant increase of AAA compared to controls (p<0.01). Conclusions .Ketogeuesis and the branch chain amino acid metabolism are impaired in CHE patients coupled with low intraeellular energy levels. This might have implications in the pathogenesis of the condition.