https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.20066

Management of adult patients with ascites caused by cirrhosis.

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the ‘Grading of Recommendations Assessment, Development and Evaluation (GRADE)’ system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years’ time.

https://gut.bmj.com/content/gutjnl/early/2020/10/15/gutjnl-2020-321790.full.pdf

Guidelines on the management of ascites in cirrhosis.

The peritoneum is one of the most common extrapulmonary sites of tuberculous infection. Peritoneal tuberculosis remains a significant problem in parts of the world where tuberculosis is prevalent. Increasing population migration, usage of more potent immunosuppressant therapy and the acquired immunodeficiency syndrome epidemic has contributed to a resurgence of this disease in regions where it had previously been largely controlled. Tuberculous peritonitis frequently complicates patients with underlying end-stage renal or liver disease that further adds to the diagnostic difficulty. The diagnosis of this disease, however, remains a challenge because of its insidious nature, the variability of its presentation and the limitations of available diagnostic tests. A high index of suspicion is needed whenever confronted with unexplained ascites, particularly in high-risk patients. Based on a systematic review of the literature, we recommend: tuberculous peritonitis should be considered in the differential diagnosis of all patients presenting with unexplained lymphocytic ascites and those with a serum-ascites albumin gradient (SAAG) of <11 g/L; culture growth of Mycobacterium of the ascitic fluid or peritoneal biopsy as the gold standard test; further studies to determine the role of polymerase chain reaction, ascitic adenosine deaminase and the BACTEC radiometric system for acceleration of mycobacterial identification as means of improving the diagnostic yield; increasing utilization of ultrasound and computerized tomographic scan for the diagnosis and as a guidance to obtain peritoneal biopsies; low threshold for diagnostic laparoscopy; treatment for 6 months with the first-line antituberculous drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) in uncomplicated cases.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2036.2005.02645.x

Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment.

We identified 60 cases of tuberculous peritonitis during the past 12 years at our health care center. Most of the patients had severe underlying medical conditions, such as cirrhosis, renal failure, diabetes mellitus, and malignancy. Abnormal chest radiograph findings, ascitic fluid lymphocytosis, and biochemical findings for exudates could only identify 33%, 37%, and 53% of the cases, respectively. On the other hand, peritoneal biopsy allowed early definitive diagnosis for 9 patients. Thirty-one patients died, 26 of whom died < or =6 weeks after their initial presentation, often before the result of mycobacterial culture was available. Only 8 patients died of advanced disease after antituberculous therapy was started. Univariate analysis showed that advanced age, underlying diagnosis, and delayed initiation of therapy were associated with higher mortality rates. Standard antituberculous chemotherapy is highly effective. However, conventional microbiologic diagnostic methods are slow and not sensitive enough for establishing a diagnosis of tuberculous peritonitis.

/pdf/tuberculous-peritonitis-associated-mortality-is-high-among-1e2excaqda.pdf

Tuberculous Peritonitis–Associated Mortality Is High among Patients Waiting for the Results of Mycobacterial Cultures of Ascitic Fluid Samples

Gastric dysplasia is believed to be the penultimate stage of gastric carcinogenesis. Its clinical importance has been underscored since its close association with gastric cancer was established. However, diagnostic criteria and grading schemes have evolved differently in different parts of the world. This has resulted in disagreement regarding differentiating features of both preinvasive and early gastric cancer between Western and Japanese histopathologists thereby preventing their direct comparison. Therapeutic guidelines are also controversial. On this background we review the current concepts and contemporary issues related to gastric dysplasia and early invasive carcinoma, their definition, classification, grading, natural history, potential therapy, and outline some of the recent efforts to harmonise the differences in terminology between Japanese and Western pathologists in order to produce a single classification system that would potentially be applicable throughout the gastrointestinal tract.

In the field of gastrointestinal pathology the term dysplasia is used by histopathologists to describe premalignant lesions.1-3 In the stomach, like any other segment of the gut, it is defined as an unequivocal neoplastic non-invasive epithelial alteration.1 4 The observation of gastric dysplasia as a precursor lesion of gastric cancer was made over a century ago, but it is only with the accrued use of upper endoscopy that its clinical significance has been stressed.5 Thus, the relevance of standardising the diagnostic criteria for gastric dysplasia and early invasive carcinoma, and of refining our understanding of its natural history have become increasingly important. However, to date, several unresolved issues pertain to gastric dysplasia: ( a ) lack of a uniformly recognised classification; ( b ) significant interobserver variability in microscopic diagnosis; ( c ) absence of well defined dysplastic features associated with the diffuse type of gastric carcinoma; ( d ) a limited understanding of the clinical significance of a diagnosis of dysplasia; and ( e ) variations in the therapeutic approach.

We therefore …

https://gut.bmj.com/content/gutjnl/45/5/784.full.pdf

Gastric epithelial dysplasia

This study analysed clinical features and laboratory investigations in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy at this hospital between 1984 and 1988. Tuberculous peritonitis was found in 2% of all patients with tuberculosis and in 59.8% of all those with abdominal tuberculosis admitted to the hospital during the study period. Tuberculous peritonitis was more common in women than men (1.4:1) and was most frequently encountered in the third and fourth decades of life. The commonest presenting symptoms were abdominal swelling (73.1%), fever and night sweats (53.8%), anorexia (46.9%), weight loss (44.1%), and abdominal pain (35.9%). The mean duration of symptoms was 1.5 months. Ascites was the commonest (95.2%) physical sign. Tuberculin skin testing was positive in 57.6% of patients (n = 118). The mean erythrocyte sedimentation rate was 75 mm/1st hour (n = 58). Chest radiography on 98 patients showed pleuropulmonary pathology in 40 patients (40.8%). Sputum examination confirmed active pulmonary tuberculosis in 26 patients. The ascitic fluid was an exudate in 96.4% and a transudate in 3.6% of patients, with 91.3% showing a straw coloured ascites. Cirrhosis, detected by biopsy specimen, was a finding in 6.2% of patients.

https://gut.bmj.com/content/gutjnl/31/10/1130.full.pdf

K E Pettengell

Papers

Symptoms and investigative findings in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy and biopsy over a five year period.