3.4. Liver + Biliary Tree Disease - Ascites and Spontaneous Bacterial Peritonitis Flashcards
What are the causes of Ascites divided into?
- Haemorrhagic Ascitic Fluid
- Chylous (Milky) Ascitic Fluid
- Straw-Coloured Ascitic Fluid
What are the causes of a Haemorrhagic Ascitic Fluid?
- Malignancy
- Abdominal Trauma (e.g. Ruptured Exctopic Pregnancy)
- Acute Pancreatitis
What are the causes of a Chylous (Milky) Ascitic Fluid?
Cirrhosis / Obstruction of the main Lymphatic Duct
What are the causes of a Straw-Coloured Ascitic Fluid?
- Liver conditions
- Infections
- Systemic Conditions
- Congenital Syndromes
What Liver Conditions can cause Straw-Coloured Ascitic Fluid?
- Malignancy
- Cirrhosis
- Hepatic Vein Obstruction
What Infections can cause Straw-Coloured Ascitic Fluid?
- Tuberculosis
2. Following Intra-abdominal perforation (e.g. E. Coli)
What does Intra-Abdominal Perforation usually end up causing?
Spontaneous Bacterial Peritonitis
What Systemic Conditions can cause Straw-Coloured Ascitic Fluid?
- Chronic Pancreatitis
2. Congestive Heart Failure
What Congenital Syndromes can cause Straw-Coloured Ascitic Fluid?
- Meigs’ Syndrome
2. Nephrotic Syndrome
What is Ascites?
Fluid within the Peritoneal Cavity
What is Ascites a common complication of?
- Cirrhosis
2. Renal Sodium and Water Retention (Secondary to this)
What is the Mechanism for Renal Sodium and Water Retention?
- Urine excretion is low due to the Renal Aetiology
2. This results in a Positive Sodium Gradient (so more water is retained)
What causes the Sodium and Water Retention in the Kidney?
- Peripheral Arterial Vasodilation occurs (reducing the effective blood volume)
- This creates the sensation of Hypotension, which activates the RAAS system of the Kidneys to retain more Sodium and Water
What is the effect of Portal Hypertension on Ascitic Fluid Build-Up?
- This exerts a local hydrostatic pressure, which leads to the increased Hepatic and Splanchnic production of Lymph (and Transudate)
- The excess production of Lymph (and Transudate) then begins to leak and fill up the Peritoneal Cavity
What is the effect of Low Serum Albumin on Ascitic Fluid Build-Up?
- Due to the poor Liver Synthesis of Albumin, there is Hypoalbuminaemia
- Hypoalbuminaemia results in a loss of Oncotic pressure, so there is a Greater Hydrostatic pressure pushing the water out into the Peritoneal Cavity
What is the Pathology of Spontaneous Bacterial Peritonitis?
The infecting organisms enter into the peritoneum via haematological spread
What are the Clinical Features of Ascites / Spontaneous Bacterial Peritonitis?
- Abdominal Swelling
- Abdominal Pain
- Respiratory Distress
- Pyrexia
- Infectious Markers
Why does the Abdominal Swelling occur?
Due to the fluid being present in the Paritoneal Cavity
How does the Abdominal Swelling present?
As a shifting Dullness
How severe is the pain in Ascites?
Mild - it is more of a Discomfort
How sever is the pain in Spontaneous Bacterial Peritonitis?
Severe
Why can Respiratory Distress occur?
Due to the potential Right Sided Pleural Effusion, which can occur due to the Livers proximity
When does Pyrexia and other Infectious Markers occur?
In cases of Spontaneous Bacterial Peritonitis, due to the infection
What investigations are needed for Ascites / Spontaneous Bacterial Peritonitis?
Diagnostic Aspiration
What is included in the Diagnostic Aspiration?
- White Cell Count
- Gram Stain and Culture
- Protein Count
- Cytology
- Amylase
Why is the White Cell Count of the Ascitic Fluid examined
To deduce is it is Spontaneous Bacterial Peritonitis
Why is there a Gram Stain and Culture?
For Bacteria and Acid’Fast Bacilli - to deduce if it is Spontaneous Bacterial Peritonitis
Why is there a Protein Count?
To assess the causation of the Ascites
What does a High Serum-Albumin Gradient of the Ascitic Fluid suggest?
The cause is Portal Hypertension
What does a Low Serum-Albumin Gradient of the Ascitic Fluid suggest?
The cause is Peritoneal Abnormalities
Why is Cytology needed?
To assess for Malignant Cells
Why is Amylase tested for?
To exclude Pancreatic Ascites
What is the Treatment of Ascites?
- Reduce Sodium Intake
- Diuretics
- Paracentesis
- Transjugular Intrahepatic Portocaval Shunting
- Antibiotics
What is the purpose of reducing the dietary Sodium?
As this helps tackle the initial problem of Sodium Retention causing excess Water retention
Why are Diuretics used?
Aldosterone Antagonists are used to reduce the Salt-Water Re-absorption (and hence retention)
What is Paracentesis?
The Perforation and Drainage of the Ascitic Fluid from the Peritoneal Cavity
When is Paracentesis used?
When the Diuretics are not effective enough
What is the function of Paracentesis?
Symptomatic Relief
When would a Transjugular Intrahepatic Portocaval Shunt be used?
When appropriate, if Portal Hypertension was the cause
When would Antibiotics be used?
To treat the Spontaneous Bacterial Peritonitis
Which type of Antibiotic is used?
Treatment - 3rd Generation Cephalosporin
Prophylaxis - Quinolone
