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Harrison- Approach to Symptoms > 26.8.2013(ascites) > Flashcards

26.8.2013(ascites) Flashcards

0
Q

Abdominal distension with abdominal pain

A

Peritonitis

Pancreatitis

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1
Q

New onset umbilical or inguinal hernia

A

Ascites

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2
Q

6 Fs of abdominal swelling

A 
Fluid
Flatus
Feces
Foetus
Fat
Fatal growth
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3
Q

Normal volume of small intestine gas

A

200ml

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4
Q

Composition of intestinal gas

A 
Aerophagy
 Nitrogen
 Oxygen
Bacterial fermentation
 Hydrogen 
 Methane
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5
Q

Cause of apparent abdominal distension

A

Increased lumbar lordosis

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6
Q

Pulsatile abdominal mass

A

Abdominal aortic aneurysm

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7
Q

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

A

Intestinal obstruction
Severe constipation
Illeus

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8
Q

Increased eructation and Flatus with abdominal distension

A

Aerophagia

Increased intestinal production of gas

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9
Q

History taking in abdominal distension

A 
Symptoms suggestive of malignancy
Bowel obstruction
Flatus
Liver disease
Heart failure 
TB
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10
Q

General examination findings in abdominal distension

A 
Liver disease
 Dilated superficial abdominal veins
 Spider angioma
 Palmar erythema
 Gynacomastia
Virchow node
Elevated JVP,kussmaul sign,pericardial knock,TR
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11
Q

Auscultation in abdominal distension

A

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

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12
Q

USG can detect _______ ml of Ascites

A

100

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13
Q

Lab tests in abdominal distension

A 
Liver enzymes
Serum albumin
Prothrombin time
Serum amylase and lipase
Urinary protein quantitation
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14
Q

Blood count in cirrhosis

A

Cytopenias

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15
Q

Pathogenesis of Ascites in cirrhosis

A

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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16
Q

Causes of Ascites in the absence of cirrhosis

A

Peritoneal carcinomatosis
Pancreatitis
Peritoneal infection

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17
Q

Causes of peritoneal carcinomatosis

A 
Primary
 Mesothelioma 
 Sarcoma
Intraabdominal 
 Gastric
 Colonic
Metastasis
 Breast
 Lung 
 Melanoma
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18
Q

Mechanism of non cirrhotic Ascites

A

Malignancy and TB - exudation of protein rich fluid

Pancreatitis- release of pancreatic enzymes

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19
Q

Cirrhosis accounts for _______ % of cases with Ascites

A

84

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20
Q

Infectious causes of Ascites

A

TB
Fitz Hugh Curtis
Chlamydia
Gonorrhoea

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21
Q

Rare causes of Ascites

A

Hypothyroidism

Familial Mediterranean fever

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22
Q

Quadrant preferred for paracentesis

A

Left lower quadrant

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23
Q

Complications of paracentesis

A 
Rare even in the presence of coagulopathy
Hypotension
Infections
Abdominal wall hematoma
Hepatorenal syndrome
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24
Q

Hallmark of chylus Ascites

A

Triglycerides >200mg/dl

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25
Q

Dark brown ascitic fluid

A

High bilirubin concentration

Billiary tract perforation

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26
Q

Black color ascitic fluid

A

Pancreatic necrosis

Metastatic Melanoma

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27
Q

Turbid ascitic fluid

A

Infections

Malignancy

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28
Q

Measurements in ascitic fluid

A 
Albumin
Total protein levels
Cell and differential count
Gram stain and culture if infection is suspected
Serum albumin should also be sent
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29
Q

________ correlates with hepatic venous pressure gradient

A

SAAG

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30
Q

Does SAAG change with diuresis

A

No

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31
Q

Causes of low SAAG ascites

A 
TB
Billiary leak
Nephrotic syndrome 
Pancreatitis
Peritoneal carcinomatosis
32
Q

Causes of high SAAG Ascites

A 
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
33
Q

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

A

Intact hepatic sinusoids

34
Q

Indication for ascitic glucose and LDH levels

A

Secondary peritonitis from perforated viscus

35
Q

Diff btw SBP and secondary peritonitis

A

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

36
Q

Ascitic amylase in pancreatic Ascites

A

> 1000mg/dl

37
Q

How much ascitic fluid should be sent for cytology

A

50ml

38
Q

ADA level in Ascites

A

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

39
Q

Initial treatment of cirrhotic Ascites

A

Restriction of sodium intake

40
Q

Drug to be used when painful gynacomastia develops due to spironolactone

A

Amiloride 5-40mg/day

41
Q

Ratio of frusemide:spironolactone in Ascites

A

40:100

42
Q

Maximum dose of spironolactone and frusemide

A

Spironolactone 400mg

Frusemide 160mg

43
Q

Refractory Ascites

A

Persistence of Ascites despite sodium restriction and maximal diuretic therapy

44
Q

Rx of refractory ascites

A

Large volume paracentesis

TIPS

45
Q

Comparison of TIPS over LVP for refractory Ascites

A

Decreased reoccurrence
No difference in mortality
Increased risk of hepatic encephalopathy

46
Q

Rx of malignant Ascites

A

serial LVP
Transcutaneous drainage catheter
Peritoneovenous shunt

47
Q

Causes of SBP

A 
Cirrhosis
Cardiac
Nephrotic
Acute hepatitis
Acute liver failure
Rare in malignant ascites
48
Q

Presentation of SBP

A 
Increase in abdominal girth
Abdominal tenderness(40%)
Rebound tenderness is rare
Fever 
Nausea
Vomiting
Exacerbation of preexisting hepatic encephalopathy
49
Q

Common pathogens in SBP

A

E.coli
Klebsiella
Streptococci
Enterococci

50
Q

Presence of multiple pathogens in ascitic fluid without elevated polymorphs

A

Bowel perforation by paracentesis needle

51
Q

Rx of SBP

A

IV Cefotaxime for 5 days if pt improves

52
Q

SBP prophylaxis

A

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

53
Q

Prophylaxis of SBP

A

Oral norfloxacin

54
Q

How diuresis decreases the risk of SBP?

A

Increases the activity of ascitic fluid protein opsonins

55
Q

Chest tube placement in heptic Hydrothorax

A

Avoided

56
Q

Three most common causes of cirrhosis

A

Alcoholism
Hepatitis C
NASH

57
Q

NASH with decompensation and body weight

A

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

58
Q

Pt with long history of stable cirrhosis with sudden Ascites

A

HCC

59
Q

Pain in Ascites

A

Malignancy related Ascites
Alcoholic hepatitis
SBP

60
Q

Manifestation of tuberculous peritonitis

A

Fever

Abdominal pain

61
Q

Ascites and anasarca developing in setting of DM

A

Nephrotic ascites

62
Q

Ascites due to pancreatitis

A

Acute pancreatitis with necrosis

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

63
Q

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

A

1500ml

64
Q

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

A

100 ml

65
Q

Ascites mimics

A 
Gaseous distension(tympanitic)
Panniculus(develops over months or years)
Ovarian mass(flank resonance,central dullness)
66
Q

Important historical question helpful in differentiating Ascites from panniculus

A

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

67
Q

Sites of mechanoreceptors mediating Dyspnea

A

Face

Upper airway

68
Q

Hyperventilation syndrome

A

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

69
Q

Breathing discomfort at rest that disappears with activity

A

Anxiety

70
Q

Cause of sensation of chest tightness

A

Stimulation of Vagal irritant receptors

71
Q

Chest tightness is seen in

A

Asthma

MI

72
Q

Pts with pulmonary Edema suffer from a sensation of

A

Air hunger

73
Q

Pts with COPD and hyperinflation complain of

A

Inability to take a deep satisfying breath

74
Q

Causes of acute Dyspnea

A 
Acute LVF
Pulmonary Edema
Thromboembolic event
Pneumonia
Spontaneous pneumothorax
Asthma
Injury to chest wall or intra thoracic structures
ARDS
pleural effusion
Pulmonary hemorrhage
75
Q

Causes of chronic progressive Dyspnea

A 
COPD
LVF
Diffuse interstitial fibrosis
Asthma 
Pleural effusions
Pulmonary thromboembolic disease
Pulmonary vascular disease
Psychogenic Dyspnea
Severe Anemia
Post intubation tracheal stenosis
Hypersensitivity disorders
76
Q

Physiological correlates of Dyspnea

A

Ventilatory performance
Minute ventilation
Maximal voluntary ventilation
Breathing reserve

77
Q

Which is a stronger stimulus for Dyspnea? Hypercapnia or hypoxia

A

Acute Hypercapnia

Harrison- Approach to Symptoms (11 decks)

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