26.8.2013(ascites) Flashcards by Rakesh durai

Abdominal distension with abdominal pain

Peritonitis

Pancreatitis

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New onset umbilical or inguinal hernia

Ascites

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6 Fs of abdominal swelling

Fluid
Flatus
Feces
Foetus
Fat
Fatal growth

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Normal volume of small intestine gas

200ml

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Composition of intestinal gas

Aerophagy
 Nitrogen
 Oxygen
Bacterial fermentation
 Hydrogen 
 Methane

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Cause of apparent abdominal distension

Increased lumbar lordosis

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Pulsatile abdominal mass

Abdominal aortic aneurysm

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Abdominal distension with nausea,vomiting,inability to pass feces or flatus

Intestinal obstruction
Severe constipation
Illeus

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Increased eructation and Flatus with abdominal distension

Aerophagia

Increased intestinal production of gas

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History taking in abdominal distension

Symptoms suggestive of malignancy
Bowel obstruction
Flatus
Liver disease
Heart failure 
TB

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General examination findings in abdominal distension

Liver disease
 Dilated superficial abdominal veins
 Spider angioma
 Palmar erythema
 Gynacomastia
Virchow node
Elevated JVP,kussmaul sign,pericardial knock,TR

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Auscultation in abdominal distension

Absent bowel sounds- illeus
High pitched localised bowel sounds- intestinal obstruction
Umbilical venous hum- portal hypertension
Bruit- HCC,alcoholic hepatitis

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USG can detect _______ ml of Ascites

100

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Lab tests in abdominal distension

Liver enzymes
Serum albumin
Prothrombin time
Serum amylase and lipase
Urinary protein quantitation

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Blood count in cirrhosis

Cytopenias

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Pathogenesis of Ascites in cirrhosis

Resistance to blood flow
Hepatic fibrosis- disruption of hepatic sinusoids
Activation of hepatic stellate cells
Decreased eNOS
Splanchnic vasodilation
Increased systemic NO,TNF,VEGF
Decreased effective circulating volume sensed as hypovolemia by kidneys

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Causes of Ascites in the absence of cirrhosis

Peritoneal carcinomatosis
Pancreatitis
Peritoneal infection

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Causes of peritoneal carcinomatosis

Primary
 Mesothelioma 
 Sarcoma
Intraabdominal 
 Gastric
 Colonic
Metastasis
 Breast
 Lung 
 Melanoma

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Mechanism of non cirrhotic Ascites

Malignancy and TB - exudation of protein rich fluid

Pancreatitis- release of pancreatic enzymes

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Cirrhosis accounts for _______ % of cases with Ascites

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Infectious causes of Ascites

TB
Fitz Hugh Curtis
Chlamydia
Gonorrhoea

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Rare causes of Ascites

Hypothyroidism

Familial Mediterranean fever

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Quadrant preferred for paracentesis

Left lower quadrant

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Complications of paracentesis

Rare even in the presence of coagulopathy
Hypotension
Infections
Abdominal wall hematoma
Hepatorenal syndrome

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Hallmark of chylus Ascites

Triglycerides >200mg/dl

Dark brown ascitic fluid

High bilirubin concentration | Billiary tract perforation

Black color ascitic fluid

Pancreatic necrosis | Metastatic Melanoma

Turbid ascitic fluid

Infections | Malignancy

Measurements in ascitic fluid

``` Albumin Total protein levels Cell and differential count Gram stain and culture if infection is suspected Serum albumin should also be sent ```

________ correlates with hepatic venous pressure gradient

SAAG

Does SAAG change with diuresis

Causes of low SAAG ascites

``` TB Billiary leak Nephrotic syndrome Pancreatitis Peritoneal carcinomatosis ```

Causes of high SAAG Ascites

``` Ascitic protein >= 2.5g/dl Congestive heart failure Constrictive pericarditis Early budd chiari Venoocclusive disease IVC obstruction Ascitic protein <2.5g/dl Cirrhosis Late budd chiari Massive liver metastasis ```

What does an ascitic fluid protein count of >=2.5g/dl indicate?

Intact hepatic sinusoids

Indication for ascitic glucose and LDH levels

Secondary peritonitis from perforated viscus

Diff btw SBP and secondary peritonitis

Secondary peritonitis Glucose< 50mg/dl Ascitic LDH>serum LDH Multiple pathogens on ascitic fluid culture

Ascitic amylase in pancreatic Ascites

>1000mg/dl

How much ascitic fluid should be sent for cytology

50ml

ADA level in Ascites

In the absence of cirrhosis,ADA level of more than 30-45 U/L has a sensitivity of 90% for TB

Initial treatment of cirrhotic Ascites

Restriction of sodium intake

Drug to be used when painful gynacomastia develops due to spironolactone

Amiloride 5-40mg/day

Ratio of frusemide:spironolactone in Ascites

40:100

Maximum dose of spironolactone and frusemide

Spironolactone 400mg | Frusemide 160mg

Refractory Ascites

Persistence of Ascites despite sodium restriction and maximal diuretic therapy

Rx of refractory ascites

Large volume paracentesis | TIPS

Comparison of TIPS over LVP for refractory Ascites

Decreased reoccurrence No difference in mortality Increased risk of hepatic encephalopathy

Rx of malignant Ascites

serial LVP Transcutaneous drainage catheter Peritoneovenous shunt

Causes of SBP

``` Cirrhosis Cardiac Nephrotic Acute hepatitis Acute liver failure Rare in malignant ascites ```

Presentation of SBP

``` Increase in abdominal girth Abdominal tenderness(40%) Rebound tenderness is rare Fever Nausea Vomiting Exacerbation of preexisting hepatic encephalopathy ```

Common pathogens in SBP

E.coli Klebsiella Streptococci Enterococci

Presence of multiple pathogens in ascitic fluid without elevated polymorphs

Bowel perforation by paracentesis needle

Rx of SBP

IV Cefotaxime for 5 days if pt improves

SBP prophylaxis

Previous H/O SBP Ascitic fluid protein <1g/dl Active GI bleeding

Prophylaxis of SBP

Oral norfloxacin

How diuresis decreases the risk of SBP?

Increases the activity of ascitic fluid protein opsonins

Chest tube placement in heptic Hydrothorax

Avoided

Three most common causes of cirrhosis

Alcoholism Hepatitis C NASH

NASH with decompensation and body weight

Patient loses weight..hence previous h/o obesity must be sought for

Pt with long history of stable cirrhosis with sudden Ascites

HCC

Pain in Ascites

Malignancy related Ascites Alcoholic hepatitis SBP

Manifestation of tuberculous peritonitis

Fever | Abdominal pain

Ascites and anasarca developing in setting of DM

Nephrotic ascites

Ascites due to pancreatitis

Acute pancreatitis with necrosis | Chronic pancreatitis with rupture of duct (also due to trauma)

Amount of fluid that must be present in Ascites for flank dullness

1500ml

USG can detect as little as ____ ml of fluid in abdomen

100 ml

Ascites mimics

``` Gaseous distension(tympanitic) Panniculus(develops over months or years) Ovarian mass(flank resonance,central dullness) ```

Important historical question helpful in differentiating Ascites from panniculus

Rate of increase of abdominal girth- days to weeks in ascites

Sites of mechanoreceptors mediating Dyspnea

Face | Upper airway

Hyperventilation syndrome

Light headedness Tingling of hands and feet Tachycardia Inversion of T waves in ECG

Breathing discomfort at rest that disappears with activity

Anxiety

Cause of sensation of chest tightness

Stimulation of Vagal irritant receptors

Chest tightness is seen in

Asthma | MI

Pts with pulmonary Edema suffer from a sensation of

Air hunger

Pts with COPD and hyperinflation complain of

Inability to take a deep satisfying breath

Causes of acute Dyspnea

``` Acute LVF Pulmonary Edema Thromboembolic event Pneumonia Spontaneous pneumothorax Asthma Injury to chest wall or intra thoracic structures ARDS pleural effusion Pulmonary hemorrhage ```

Causes of chronic progressive Dyspnea

``` COPD LVF Diffuse interstitial fibrosis Asthma Pleural effusions Pulmonary thromboembolic disease Pulmonary vascular disease Psychogenic Dyspnea Severe Anemia Post intubation tracheal stenosis Hypersensitivity disorders ```

Physiological correlates of Dyspnea

Ventilatory performance Minute ventilation Maximal voluntary ventilation Breathing reserve

Which is a stronger stimulus for Dyspnea? Hypercapnia or hypoxia

Acute Hypercapnia