Diagnostic peritoneal fluid aspiration: a simple maneuver to diagnose a major question: a prospective study surgical point of view

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1 Interntionl Surgery Journl Mohmed AHH et l. Int Surg J Sep;4(9): pissn eissn Originl Reserch Article DOI: Dignostic peritonel fluid spirtion: simple mneuver to dignose mjor question: prospective study surgicl point of view Adel Hfeez Hosni Mohmed, Mgdy Khlil Ad Almgeed*, Men Zri Helmi, Mohmed El-Syed Adell Deprtment of Generl Surgery, Sohg University Hospitl, Egypt Received: 31 July 2017 Accepted: 03 August 2017 *Correspondence: Dr Mgdy Khlil Ad Almgeed, E-mil: Copyright: the uthor(s), pulisher nd licensee Medip Acdemy. This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution Non-Commercil License, which permits unrestricted non-commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. ABSTRACT Bckground: A vriety of fluids cn ccumulte in the peritonel nd pelvic cvities including scites, lood, pus, ile, urine, lymph, cererl spinl fluid, nd mucin. The ppernce of some of these fluids y imging my suggest specific etiology, ut dignostic spirtion must e performed in the mjority of cses. This review ims to ssess criticlly the vlue of peritonel fluid nlysis in the dignosis. Methods: There ws prospectively evluted 80 ptients presented with intrperitonel fluid collection t Sohg University Hospitl from July 2016 till July Physicl, chemicl, cteriologicl nd cytologicl properties of the spirted peritonel fluid ws studied. Results: The study included 80 ptients with intr-peritonel collection of surgicl importnce (due to trum, inflmmtion, mlignncy). Dignostic spirtion from intr-dominl collection ws routinely done in ll cses giving the following results: 20 cses (25%) showed lood in the spirte, 18 cses (22.5%) showed pus, 11 cses (13.75%) showed ile stined fluid, 9 cses (11.25%) showed gstric contents, 8 cses (10%) showed serosngenous spirte, 7 cses (8.75%) showed cler fluid spirte, 4 cses (5%) showed turid fluid nd 3 cses (3.75%) showed smll intestinl contents. Conclusions: Dignostic spirtion from intrperitonel fluid collection is considered simple ville test tht helps in dignosis of mjor prolemtic cses. Keywords: Aspirtion, Intrperitonel fluid collection, Peritonitis INTRODUCTION A vriety of fluids cn ccumulte in the peritonel nd pelvic cvities including scites, lood, pus, ile, urine, lymph, cererl spinl fluid, nd mucin. 1 The ppernce of some of these fluids y imging my suggest specific etiology, ut dignostic spirtion must e performed in the mjority of cses. 2 This review ims to ssess criticlly the vlue of peritonel fluid nlysis in the dignosis. Dignostic Aspirtion from intrperitonel fluid collection is considered simple ville test tht help in dignosis of mjor prolemtic cses. The initil evlution of the gross ppernce of peritonel fluid cn offer useful informtion in the differentil dignosis. Under norml conditions, peritonel fluid is cler to ple yellow. 3 Hemoperitoneum is chrcteristic of trum, Rupture ortic neurysm, hemorrhgic pncretitis, rupture spleen,or ectopic pregnncy. Bloody peritonel fluid serosnginous is chrcteristic of strngulted hernition, mlignncy, mesenteric vsculr occlusion or rupture ovrin cyst, wheres cler or strw-colored scites is often ssocited with cirrhosis. Therefore, the Interntionl Surgery Journl Septemer 2017 Vol 4 Issue 9 Pge 2952

2 gross ppernce of peritonel fluid cn provide preliminry clues regrding the etiology of the underlying disese. 3 Dignostic peritonel spirtion is highly sensitive to help us mking good ide out the dignosis, detecting its etiology nd method of mngement. 4 The im of the study is Evlute the sensitivity nd vlue of peritonel fluid spirtion in dignosis of peritonel collection. METHODS This prospective study ws conducted in generl surgery deprtment t Sohg University Hospitl t the period from July 2016 till July The study included 80 ptients with suspected intrperitonel collection of surgicl importnce t ny ge nd sex presented with cute domen, history of trum or previous opertion. Ptients with intr-peritonel collection due to liver cirrhosis, crdic or renl diseses were excluded from the study. Dt on dmission included history tking, clinicl exmintion, lortory investigtions, nd imging. Dignostic peritonel fluid spirtion under US guide ws done to detect the cuse nd nture of peritonel collection, physicl, chemicl, cteriologicl nd cytologicl properties of the spirte ws studied. Technique The spirtion done under US Guide Positioning of the ptient ws ccording to the site of collection; hed up or down, right tilt or left tilt Select n pproprite point on the dominl wll in the right or left qudrnts, lterl to the rectus sheth under ultrsound guide to mrk spot Clen the site nd surrounding re with 2% Chlorhexdine nd pply sterile drpe Anesthetise the skin nd deeper tissue with Lidocine Tke clen needle nd 20ml syringe nd insert through the skin dvncing nd spirting until fluid is withdrwn Aspirte Remove needle nd pply sterile dressing. RESULTS The study included 80 ptients with intr-peritonel collection of surgicl importnce (due to trum, inflmmtion, mlignncy). 65% were mles nd 35% were femles. The ge rnged from 6 months to 70 yers old Tle1: Numer nd percent of cses ccording to spirtion nd dignosis. Aspirtion Numer 80 cse Pthologicl dignosis No (%) Splenic injury 13 (16.2%) Blood 20 cses Liver injury 5 (6.2%) Mlignncy 1 (1.2%) poplexy 1 (1.2%) Strngulted intestinl ostruction 4 (4.8%) Serosnguinous 8 cses Rupture ovrin cyst 2 (2.4%) Mlignncy 1 (1.2%) Acute hemorrhgic pncretitis 1 (1.2%) Pus 16 cses Appendiculr scess 10 (12.5%) scess 6 (7.5%) Bile 11 cses Biliry lekge post-opertive 11 (13.7 %) Gstric contents 9 cses Perforted peptic ulcer 9 (11.2%) Cler Fluid 6 cses Urinry ldder injury 5 (6.2%) Acute pncretitis 2 (2.4%) Strngulted Intestinl ostruction 2 (2.4%) Turid Fluid 7 cses Acute pncretitis 3 (3.6%) Appendiculr scess 1 (1.2%) TB peritonitis 1 (1.2%) Smll intestinl contents 3 cses Fecl peritonitis 3 (3.6%) Dignostic spirtion from intr-dominl collection ws routinely done in ll cses. The spirte ws lood in 20 cses (25%), pus in 16 cses (20%), ile in 11 cses (13.75), gstric content in 9 cses (11.25%), Interntionl Surgery Journl Septemer 2017 Vol 4 Issue 9 Pge 2953

3 serosnginous in 8 cses (10%), cler fluid in 7 cses (8.75%), turid fluid in 6 cses (7.5%) nd smll intestinl content in 3 cses (3.75%). Tle 2: Different dignostic methods proved y the results. Method of dignosis No.(percentge of cses) Aspirtion 28 cses (35%) plin X-ry US CT Dignosis Perforted peptic ulcer Fecl peritonitis Biliry lekge Urinry ldder injury 7 cses (8.75%) Intestinl ostruction 25 cses (31.25%) 15 cses (18.7%) Splenic injury Appendiculr scess scess Liver injury Acute pncretitis, pncretic cyst Mlignncy Dignostic 3 cses (3.75%) Mlignncy lproscopy Intr-opertiv Intestinl injury 5 cses (6.25%) dignosis Rupture ovrin cyst Numer of cses dignosed y spirtion 28 cse (35%). There re 25 cses (31.25%) dignosed y domen ultrsound US, 15 cses (18.7%) dignosed y CT domen, 7 cses (8.75%) dignosed y X-ry, only 5 cses (6.25%) dignosed intr-opertive, dignostic lproscopy ws used in 3 cses (3.75%) to dignose scites of unknown etiology. Cytology of mlignnt peritonel fluid y ppniculou stin Figure 3 ) nd ): Microscopic picture of mlignnt peritonel fluid using ppniculou stin showing cells with mlignnt criteri (pleomorphism, lrge nuclei, norml shpe nuclei nd high nucler cytoplsmic rtio. c d e f Figure 2: Gross picture of intr-peritonel fluid; ) Cler fluid; ) Turid fluid; c) Turid ile; d) Pus; e) Serosngenous (loody); f) Blood. Figure 4 ) nd ): Microscopic picture of Hodgkin Lymphom showing the lue cells tht hve the ppernce of owl's eyes re clled Reed-Sternerg cells re the hllmrk cells of Hodgkin lymphom. Interntionl Surgery Journl Septemer 2017 Vol 4 Issue 9 Pge 2954

4 DISCUSSION Peritonel fluid is liquid mde in the dominl cvity which lurictes the surfce of tissue tht lines the dominl wll nd pelvic cvity. It covers most of the orgns in the domen nd prevents dhesions. 5 The peritoneum consists of serous memrnes tht line the peritonel cvity through network of mesothelil cells nd collgen. Intrperitonel collection is consequence or compliction of numer of diseses, including heptic, crdic, nd renl diseses, infection, nd mlignncy or trum or rupture ortic neurysm. 1 The study evluted ll cses presented with intrperitonel collection presented in surgery emergency room, in the form of studying the presenttion, spirtion, investigtions nd mngement. In this study, group of 80 ptients with vrile types of peritonel collection were discussed, ptients were on ll ge groups rnged from 6 months to 70 yers. Dignostic spirtion from intrperitonel fluid collection hs routinely done to ll cses included in the study s it is considered simple ville test tht help in dignosis of mjor prolemtic cses. The most common cuse of peritonel collection in our surgery deprtment is inflmmtion in the form of ppendiculr scess, dominl scess, perforted peptic ulcer nd Acute pncretitis, usully the common presenttion is cute domen, spirtion under US guide gives pus which is golden yellow, thick, offensive odour with high totl leukocytic count, if the Aspirtion shows gstric content it is dignostic to perforted peptic ulcer,inflmmtion mngement is either opertive or conservtive or pig til insertion to drin pus in cse of d generl condition ptients. Mssimo et l, mentioned tht Inflmmtion nd intrdominl scess re the most common cuse for intrperitonel collection in surgery. 6 Currently the commonest etiology of intr-dominl scess is postsurgery. The su-phrenic scesses in one series, 85% occurred in postopertive ptients. Ascesses cn e locted in ny prt of the domen nd pelvis. Fluid in the domen moves long predictle pthwys. Certin recesses nd pouches in the domen re more likely to collect fluid or scesses thn other res ecuse of their size nd dependent grvittionl position. Dougls' pouch in the pelvis nd the right posterior su-heptic spce (Morison's pouch) re common sites. 7 The second most common cuse of intrperitonel collection in our emergency room is trum (27.5%) due to motor cr ccident, flling from height, lunt dominl trum, firerm or st. The commonest presenttion is cute domen. Dignostic spirtion under ultrsound guidnce is mndtory especilly if the US showed collection with no evident orgn injury. The spirtion is mostly lood due to orgn injury (spleen or liver). 5 cses (6.2%) in our series presented y nuri nd the fluid spirte ws mer yellow nd showed high cretinine level (urine). This cse scenrio is common in cse of rupture urinry ldder due to dominl trum. CTU is importnt to ensure the dignosis showing extrvstion or not. Bldder injuries fter lunt or penetrting trum re rre, constituting less thn 2% of dominl injuries requiring surgery. Such rrity owes to the protected position of the ldder deep in the ony pelvis. 8 Post-opertive complictions in the form of intrperitonel collection represents 15% of cses in our study. It is usully iliry lekge or fecl peritonitis. Biliry lekge occurs post cholecystectomy or post repir of liver injury giving greenish ile in the drin in the first 48 hours postopertive. Totl iliruin in the drin is significntly high which is dignostic for ile. Fecl peritonitis my occur post ny resection nstomosis opertion presented in the form of lekge of smll intestinl content in the drin. Significnt postopertive ile leks occur in up to 1% of ptients undergoing lproscopic cholecystectomy compred to 0.5% in open cholecystectomy. Usully present within first week ut cn mnifest up to 30 dys fter surgery. 9 Willims et l, sid tht iliry leks fter cholecystectomy include itrogenic injury to the common ile duct, insufficient mngement of the cystic duct stump, or ntomic vrints, including the ccessory ducts of Luschk, which re smll iliry ducts in the gllldder foss tht drin into the iliry system. 10 Biliry lekge isn t only itrogenic ut lso my e due trum to gll ldder or CBD or inflmmtory perfortion of gll ldder due to cute gngrenous cholecystitis. 10 Mlignncy represents 3.7 % of intrperitonel collection cses: the spirte is serosnguinous, cytology ws positive for mlignnt cells: dignostic lproscopy identified the tumour with iopsy tken from the dominl mss. Lter on, the iopsy showed lymphom in one cse nd denocrcinom in the other. Usully the presenttion of the ptient is scites of unknown etiology. Ayntunde et l, reported tht intrperitonel collection is the first detected sign in mlignncy. 11 Mlignncy ccounts for pproximtely 10% of ll cses of intrperitonel collection. 12 Interntionl Surgery Journl Septemer 2017 Vol 4 Issue 9 Pge 2955

5 Aspirtion from intrperitonel collection proved to e dignostic in 35% of studied popultions especilly those with perforted peptic ulcer, fecl fistul, iliry lekge, the gross picture, physicl nd chemicl chrcters of the spirte will give us gret ide out the dignosis. Gerzof et l, reported tht spirtion under US guide is mndtory either s dignostic tool or even therpeutic in certin situtions. 13 Aspirtion is ccurte, rpid nd sfe for the dignosis of dominl collections. 4 CONCLUSION Dignostic spirtion from intrperitonel fluid collection is considered simple ville test tht help in dignosis of mjor prolemtic cses. Funding: No funding sources Conflict of interest: None declred Ethicl pprovl: The study ws pproved y the institutionl ethics committee REFERENCES 1. Hung L, Jmin K, Mrli A. Ascites cuses nd comoridity review nd met-nlysis. World J Surg. 2014;607: Meyers MA. Dynmic rdiology of the domen. norml nd pthologic ntomy. 21th ed. Intrperitonel Spred of Infections. New York, Springer-Verlg; 2012;2: Runyon BA, Hoefs JC, Morgn TR. Ascitic fluid nlysis in mlignncy-relted scites. Heptol. 2005;8: Kuncir EJ, Velmhos GC. Dignostic peritonel spirtion the foster child of DPL: prospective oservtionl study. Int J Surg. 2007;5: Kurek, Stnley J. Peritonel fluid. J Trum Acute Cre Surg. 2016;81(1): Mssimo S, Pierluigi V, Cten F. WSES guidelines for mngement of intr-dominl infections. World J Emerg Surg. 2013;8:3;1186: Altemeier WA, Culertson WR, Fuller WD. Intrdominl scesses. Am Surg. 2012;125: Crroll PR, McAninch JW. Mjor ldder trum: Mechnisms of injury nd unified method of dignosis nd repir. J Urol. 2006;132: Soto EA. Reduce sequele of CBD injuries. Surg Endosc. 1996;10(12): Willims EJ, Green J, Beckinghm I, Prks R, Mrtin D, Lomrd M. British Society of Gstroenterology: Guidelines on the mngement of common ile duct stones (CBDS). Gut. 2008;57: Ayntunde AA, Prsons SL. Pttern nd prognostic fctors in ptients with mlignnt scites: retrospective study. Ann Oncol. 2007;18: Runyon BA. Cre of ptients with scites. N Engl J Med. 2006;330: Gerzof SG, Roins AH, Johnsen WC. Percutneous ctheter dringe of dominl scesses. A five-yer experience. N Engl I Med. 2008;305: Cite this rticle s: Mohmed AHH, Almgeed MKA, Helmi MZ, Adell MS. Dignostic peritonel fluid spirtion: simple mneuver to dignose mjor question: prospective study surgicl point of view. Int Surg J 2017;4: Interntionl Surgery Journl Septemer 2017 Vol 4 Issue 9 Pge 2956