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TITLE: Peritoneal fluid and blood lactate levels in acute abdomen disorders
Indu Verma*, Satinder Kaur*, A P S Narang*, Subash Goyal**, J S Multani**.
*Department of Biochemistry ** Department of Surgery, Dayanand Medical College and Hospital,
Ludhiana, Punjab, India.
Indu Verma*
M Sc, Phd Associate professor
Satinder Kaur*, M Sc, Phd Associate professor
A P S Narang,*
M Sc, Phd Professor
Subash Goyal**
MBBS, MS Professor
J S Multani**
MBBS, MS
Corresponding Author:
DR INDU VERMA
ASSOCIATE PROFESSOR
BIOCHEMISTRY DEPARTMENT
DAYANAND MEDICAL COLLEGE AND HOSPITAL
LUDHIANA, PUNJAB
E-mail: indubalasofat@yahoo.co.in
Mobile- 09814005249, 08146133511
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Peritoneal fluid and blood lactate levels in acute abdomen disorders
Abstract:
Lactate is end product of anaerobic metabolism of glucose .The supply of oxygen is limited in
certain intra abdominal conditions which are due to direct vascular invasion or inflammatory process.
Aim of our study was to find the predictive value by comparing the lactate levels in the peritoneal fluid
(PF) and in the blood of patients with acute abdomen. Our study comprised of 50 patients with acute
abdominal conditions, admitted in emergency ward, out of which 30 patients were with surgical
abdomen (Group I) and 20 patients with non surgical abdomen (Group II). Lactate was estimated in
peritoneal fluid and blood by Blood Gas Analyzer (NOVA M-7). The mean lactate levels in peritoneal
fluid (14.65±6.54 m mol/l) of group I which was significantly higher as compared to (5.92±4.34 m
mol/l) in group II (p<0.001). Blood lactate levels were also high in group I than group II but not
significantly. Ratio and difference of PF and blood lactate levels in group I was higher in comparison
to group II (p<0.001) which is potentially useful in patients with acute intra abdominal pathology. Our
study is not substitute for mandatory clinical methods. Its main purpose is to develop better approach
towards the acute abdomen with equivocal clinical features. This applies especially to clinically ill
patients or in whom physical examination is not yielding because of neurologic disorders or
unresponsiveness. Quick lactate estimation on Blood Gas Analyzer makes our study more significant
for sick patients with acute abdomen.
Key words: acute abdomen, blood, lactate, peritoneal fluid
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Introduction:
The acute abdomen is the sudden abdominal pain with associated signs and symptoms that
focus attention to abdominal reason. The proper management of patients with acute abdominal
conditions requires a timely decision of intervention. The decision, whether and when to operate a
patient with equivocal evidence of acute surgical abdomen still remains a challenge. The decision
depends upon the evaluation of patient’s history, physically findings, laboratory data and imaging
studies. The raised plasma lactate concentration is a sign of acute life threatening condition and known
to be best marker for mesenteric ischemia. Estimation of lactate has been more specific to acute
intestinal conditions like appenditis than C - reactive protein or leukocyte count
[1-2].
A high lactate
levels is an early sign of tissue hypoxia. The simultaneous estimation of peritoneal fluid and plasma
lactate is more helpful to detect the presence of acute intra abdominal pathology
[3]
. Normally lactate
levels in blood are 0.5-2.5 m mol/ L which are equal to lactate levels in peritoneal fluid. But in intra
abdominal disease conditions resulting into low oxygen tension, causes increased lactic acid in PF than
Blood. [4] The present study was planned to estimate the lactate in PF and blood in patients with acute
abdomen and to find their predictive value in correlation with severity of disease.
Material and Methods:
The present study was conducted in the department of Biochemistry in collaboration with
Surgery. The 50 patients presenting with acute abdominal problems in Emergency Ward were included
in the study and divided into two groups .Group I had 30 patients with acute surgical abdomen and
Group II had 20 patients with non surgical acute abdomen .Patients with age <15 years, burns or
trauma were excluded from the study. The approval from institutional ethic committee was taken for
our study.
Routine investigations like hemogram, RBS, RFT, LFT, urine routine, X-ray chest & abdomen
and ultrasound of whole abdomen were carried out. Arterial blood and peritoneal fluid samples were
collected simultaneously for lactate estimation in both the groups. In Group-I, the operating surgeon
aspirated peritoneal fluid immediately upon opening the peritoneum before manipulation of intra
abdominal contents whereas in Group-II patients abdominal paracentesis was used to obtain peritoneal
fluid by using 18 or 20 gauge disposable needles inserted aseptically just through abdominal wall in
right or left iliac fossa and fluid was withdrawn by simple and gentle suction .The blood and peritoneal
fluid lactate was analyzed on Blood Gas Analyzer (NOVA, M-7, Biomedical, USA).
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Results:
Group I included patients with gangrenous gut, perforation of hollow viscus and secondary
peritonitis. Lactate levels were significantly higher in PF than blood in Group I in all the patients.
(Table I).The patients of group II were with acute gastroenteritis, pancreatitis and sub acute intestinal
obstruction; their Lactate levels in PF were also higher than blood but not significant. These patients
were with acute abdominal disorders without surgical emergencies (Table-II). Blood lactate levels
were not different significantly in these two groups. Difference and ratio of PF and blood lactate levels
was ≥3.0 in all patients in group I whereas not even a single patient in group II had ≥3.0 (Table III)
Discussion:
The routine preoperative evaluation in the patients with potential intra abdominal catastrophe
has led to invention of variety of diagnostic tests. The clinical parameters including physical
examination, various radiological and laboratory findings were done to detect intestinal strangulation.
None of the parameters alone or in combination proved to have predictive value. Increased plasma
lactate concentration is a recognized danger signal often found in cases of shock, septicemia, hepatic
and renal failure and diabetic ketoacidosis
[5-7]
.The peritoneal lavage has been reported to be useful
adjunct in the evaluation of patients with abdominal pain whereas ascitic fluid lactate for diagnosis of
spontaneous bacterial peritonitis has been observed.[8-9]
Normally lactate levels in blood are 0.5-2.2 mmol/l which is equal to lactate levels in peritoneal
fluids. But intra abdominal disease conditions results into low oxygen tension due to direct vascular
invasion or inflammatory process. Under anaerobic conditions, the cytochrome system is unable to
function as an intermediate in the transfer of hydrogen to molecular oxygen. So, reduced NADH
accumulates and oxidized with Lactate Dehydrogenase with production of lactate. This will lead to
lactate acidosis with significant increase in lactate/pyruvate ratio. Intra abdominal diseased conditions
resulting into low oxygen tension in the tissues, causes increased lactic acid value in PF than blood. As
there are chances of metabolic acidosis in these patients, hence the difference and ratio of PF to plasma
lactic acid is more significant. In previous studies Lactate was estimated in peritoneal fluid and plasma
in patients with acute abdomen and found that significant higher level of peritoneal lactate as compared
to plasma lactate in patients with gangrenous bowel, perforation of hollow viscus and peritonitis. They
also found that difference between PF and blood was ≥1.5 m mol/l, predicted the presence of acute
intra abdominal pathology with 100% accuracy. [4, 8, 10]
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In our study, the difference between the peritoneal fluid and the blood lactate was ≥3.0 m mol/l
in all the patients in group I whereas only one patient in group II. The ratio between PF to blood lactate
was also ≥ 3.0 in all the patients in group I as compared to group II. So, we concluded that if the
difference and ratio between the PF and blood lactate is ≥3.0 m, it signifies the presence of acute intra
abdominal pathology with surgical problems that needs urgent laprotomy. The purpose of this study is
not to diminish the importance of routine clinical assessment of the patients presented with acute intra
abdominal pathology but to augment their diagnostic accuracy.
Our findings suggest that the calculated difference and ratio between peritoneal and plasma
lactate values is a valuable diagnostic index for patients in whom the diagnosis of acute abdomen is not
obvious. Clinical trials in USA (2010), also showed that increased PF/serum lactate ratio is an
important marker even for relaprotomy and post surgical complications. [11]
Conclusion:
Although the decision, whether and when to perform surgery is largely subjective and based on
professional experience. Difference and ratio of PF/blood lactate is an easier, sensible, non invasive
and economical marker for acute abdominal disorders and could be useful tool for the surgeon in
decisional process.
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References:
1.
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2.
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3.
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4.
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5.
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7.
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8.
Baillay RL, Gildorf RB. Diagnostic peritoneal lavage in evaluation of acute abdominal disease.
South Med J 1990:83:422-427
9.
Ali Liker Filiz, Hakan aladag,Mehmet Levhi, Liker Sucuilu The role of D-lactate I differential
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10.
Demircan M, Cetin S, Uquralp S, Karaman, Sezgin N, Gozukara EM. Plasma D-Lactic acid
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11.
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Clinical Trials.2010.Philadelphia, USA.
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Table I-Lactate levels in acute abdominal disorders with surgical emergencies (Group I)
______________________________________________________________________________
Sub group
No of patients
Lactate levels mmol/L
Peritoneal fluid
Blood
______________________________________________________________________________
Gangrenous gut
4
13.52±7.00
3.77±2.85
Perforation
23
16.01±6.03
4.24±3.05
Secondary peritonitis
3
9.93±6.10
2.10±1.35
______________________________________________________________________________
Overall mean
30
14.65±6.54
3.85±2.96*
______________________________________________________________________________
*PF vs Blood lactate p<0.001
Table II- Lactate levels in acute abdominal disorders without surgical emergencies
(Group II)
______________________________________________________________________________
Sub group
No of patients
Lactate levels mmol/L
Peritoneal fluid
Blood
______________________________________________________________________________
Acute gastroenteritis
1
6.1
3.2
Pancreatitis
17
6.16±4.66
4.68±4.54
Sub acute intestinal obstruction
2
3.8±0.42
2.2±0.14
______________________________________________________________________________
Overall mean
20
5.92±4.34
4.36±4.24
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Table III-Difference and Ratio of mean Lactate levels in peritoneal fluid and blood
______________________________________________________________________________
Groups
Difference between PF & blood
Ratio of PF and blood
Lactate levels (mmol/L)
Lactate levels
______________________________________________________________________________
Group I
10.80±3.58
3.80
Group II
1.56±0.10*
1.37*
______________________________________________________________________________
*Difference Group I vs Group II p<0.001
*Ratio Group I vs Group II p<0.001