1. Abdominal Distension Flashcards
1
Q
What is useful to determine the etiology of ascites?
A
Paracentesis
2
Q
A serum to fluid albumin ratio greater than 11 g/l (mmol/L) suggests what etiology? And less than 11? (2)
A
- A serum to fluid albumin ratio greater than 11 g/l (mmol/L) suggests a transudative etiology, such as portal hypertension.
- Conversely, a ratio less than 11 g/L (mmol/L) suggests an exudative etiology, such as peritoneal carcinomatosis
3
Q
In an average-sized adult patient, ascites must be ___ L for clinical diagnosis.
A
> 1.5 L
4
Q
Name types of Bowel Dilatation (4)
A
- Mechanical obstruction
- Pseudo-obstruction
- Paralytic ileus
- Other
- Fecal impaction
- Irritable bowel syndrome
- Flatus
- Malabsorption
5
Q
Name examples: Mechanical obstruction (7)
A
- Adhesion
- Volvulus
- Malignancy (intraluminal or extraluminal mass)
- Intussusception
- Constipation
- Incarcerated/strangulated hernia
- Bowel stricture (i.e., Crohn or recurrent diverticulitis)
6
Q
Name examples: Pseudo-obstruction (4)
A
- Acute (such as Ogilvie’s, an acute pseudo-obstruction of the colon. May occur in postoperative patients)
- Myopathic (scleroderma, familial)
- Enteric neuropathic (diabetes, amyloid, paraneoplastic, narcotics)
- Extrinsic neuropathic (multiple sclerosis, spinal injury, stroke)
7
Q
Name examples: Paralytic ileus (5)
A
- C. difficile (do not miss Dx of toxic megacolon or necrotizing enterocolitis in infants)
- Peritonitis
- Postoperative
- Hypothyroidism
- Hypokalemia
8
Q
A
9
Q
Name examples Abdominal/pelvic Mass (9)
A
- Pregnancy
- Ovarian mass
- Fibroids
- Bladder tumor
- Hepatosplenomegaly
- Malignancy
- Inguinal hernia
- Femoral hernia (especially in women)
- Postoperatively (seromas/hematomas)
10
Q
Describe HX (3) and physical exam (4): Abdominal distension
A
- History
- Determine the onset, duration, and accompanying symptoms such as abdo tenderness, obstipation, nausea, or vomiting
- If the patient is vomiting, inquire about the color, frequency and odour/character
- Inquire about a medical Hx of abdo surgery, cirrhosis or liver failure, cancer, hernias, alcohol abuse, or hepatitis
- Physical exam
- Vital signs: A hypotensive, tachycardic, or febrile patient in the setting of abdo distension is concerning for ischemic bowel or spontaneous bacterial peritonitis.
- Surgical scars or signs of portal venous hypertension and cirrhosis such as caput medusae, spider nevi, palmar erythema, jaundice, icterus, etc.
- Auscultate the abdomen for hyperactive bowel sounds suggestive of mechanical bowel obstruction.
- Palpate the abdomen for any signs of guarding rebound or percussion tenderness. It is imperative to identify possible peritonitis. Assess for hepatosplenomegaly, hernias, and pelvic masses. Perform the shifting dullness test
11
Q
Describe investigations: Abdominal distension (6)
A
- Routine blood work: serum hemoglobin, white cell count, platelets, electrolytes, liver enzyme tests (AST, ALT, ALP, and GGT), liver function tests (bilirubin, INR, albumin), as well as lipase (amylase is less useful in modern clinical practice).
- Serum lactate should be ordered if ischemic bowel is suspected, but the results should be interpreted with caution in septic patients, patients with chronic liver or kidney disease, or those who are volume-contracted.
- Every female patient within childbearing age should have a b-hCG test to exclude pregnancy.
- If the shifting dullness test is positive and the patient’s clinical Hx is consistent with portal venous hypertension, then paracentesis should be ordered and the serum ascites albumin gradient (SAAG = albumin concentration of serum − albumin concentration of ascitic fluid) score should be calculated in addition to testing the fluid analyzed for albumin, white count, aerobic and anaerobic culture growth, and cytology
- Routine imaging: three-view abdo x-rays to inspect for subdiaphragmatic free air, air-fluid levels, small bowel dilatation (remember 3-6-9 rule for maximum diameters—30 mm for small bowel, 60 mm for large bowel, and 90 mm for cecum), colonic volvulus, or fecal impaction.
- An abdo U/S is the next imaging modality of choice to assess for organomegaly, ascites, and abdominopelvic masses. CT scans offer a greater sensitivity and specificity for differentiating abdo pathology with the drawback of radiation exposure.
12
Q
A
13
Q
Describe: Approach to patient with distended Abdo (Figure)
A
14
Q
Describe: Approach to patient with ascites (Figure)
A
15
Q
Describe management mechanical small bowel obstruction (3)
A
- Patients with mechanical small bowel obstruction should be promptly referred to a general surgeon. Most adhesive bowel obstructions will resolve with nonoperative management (typically “suck and drip,” nasogastric decompression, and intravenous fluid resuscitation), but incarcerated, nonreducible hernias are emergencies. Other relative surgical urgencies include high-grade adhesive bowel obstructions.
- Patients with spontaneous bacterial peritonitis require prompt antibiotic coverage and referral to an internal medicine specialist or gastroenterologist to optimize the management of their portal venous hypertension. Care should be taken when resuscitating with crystalloid solution due to third-spacing secondary to hypoalbuminemia in many of those patients.
- Otherwise asymptomatic patients can be managed in the outpatient clinic setting with further diagnostic tests and treatment plans.
20
Q
Describe Approach to patient with bowel dilatation (colicky pain/signs/sx/workup/management): Intussusception
A
- Colicky Pain: +
- Signs/Sx:
- Children may have current jelly stools, and a palpable mass.
- Adults do not have bloody stools as frequently, and may present indolently. Intussusception in adults is pathological until proven otherwise
- Workup:
- 1.U/S vs CT- Target sign
- Abdo x-ray
- Dance sign (RUQ mass with RLQ empty space movement of cecum).
- Management: Urgent pediatric gastroenterol- ogy/general surgery referral for endoscopic reduction
23
Q
Describe differences between Cirrhotic versus malignant ascites
- Tx aim
- Paracentesis
- Pharmacotherapy
- Lifestyle modifications
- Surgical intervention
- Liver transplant
A
