26.8.2013(ascites) Flashcards
Abdominal distension with abdominal pain
Peritonitis
Pancreatitis
New onset umbilical or inguinal hernia
Ascites
6 Fs of abdominal swelling
Fluid Flatus Feces Foetus Fat Fatal growth
Normal volume of small intestine gas
200ml
Composition of intestinal gas
Aerophagy Nitrogen Oxygen Bacterial fermentation Hydrogen Methane
Cause of apparent abdominal distension
Increased lumbar lordosis
Pulsatile abdominal mass
Abdominal aortic aneurysm
Abdominal distension with nausea,vomiting,inability to pass feces or flatus
Intestinal obstruction
Severe constipation
Illeus
Increased eructation and Flatus with abdominal distension
Aerophagia
Increased intestinal production of gas
History taking in abdominal distension
Symptoms suggestive of malignancy Bowel obstruction Flatus Liver disease Heart failure TB
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
Auscultation in abdominal distension
Absent bowel sounds- illeus
High pitched localised bowel sounds- intestinal obstruction
Umbilical venous hum- portal hypertension
Bruit- HCC,alcoholic hepatitis
USG can detect _______ ml of Ascites
100
Lab tests in abdominal distension
Liver enzymes Serum albumin Prothrombin time Serum amylase and lipase Urinary protein quantitation
Blood count in cirrhosis
Cytopenias
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
Causes of Ascites in the absence of cirrhosis
Peritoneal carcinomatosis
Pancreatitis
Peritoneal infection
Causes of peritoneal carcinomatosis
Primary Mesothelioma Sarcoma Intraabdominal Gastric Colonic Metastasis Breast Lung Melanoma
Mechanism of non cirrhotic Ascites
Malignancy and TB - exudation of protein rich fluid
Pancreatitis- release of pancreatic enzymes
Cirrhosis accounts for _______ % of cases with Ascites
84
Infectious causes of Ascites
TB
Fitz Hugh Curtis
Chlamydia
Gonorrhoea
Rare causes of Ascites
Hypothyroidism
Familial Mediterranean fever
Quadrant preferred for paracentesis
Left lower quadrant
Complications of paracentesis
Rare even in the presence of coagulopathy Hypotension Infections Abdominal wall hematoma Hepatorenal syndrome
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
No
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
