Ascites and Jaundice

Question 1

Portal HTN

Answer 1

Cirrhosis accounts ofr 85%.

Cardiac ascites ocurs in setting of RHF…most common causes of this are LHF and constrictive pericarditis

Inc CVP that is trnasmitted back to liver

Cancers and infiltrative dz can also obstruct

Question 2

Primary peritoneal dz

Answer 2

Peritoneal carcinomatosis secrete protein rich fluid that draws fluid from EC space into peritoneum

Infectious causes are uncommon - typically from TB of fungi

TB - hematogenous spread to peritonuem

Question 3

Other causes

Answer 3

Pancreatisis - leakage of enzymes

Nephrotic syndrome - hypoalbuminemia

Lymphomas - lymphatic obstruction leading to chylous ascities

Question 4

Features of cirrhosis, cardiac ascitses, periotneal mesothelioma

Answer 4

Cirr - alcohol abuse, IV durug abuse, liver dz

Card - hx of HF or pericarditis…dyspnea, chest pain, LE edema, renal probs

perit - hx of asbestos expsorue…weigth loss, crampy pain, small to mod ascites with inc girth

Question 5

Bulging flank
Flank dullness
Shifting dullness
Fluid wave

Answer 5

Supine - sides bulge outward

Horizonal border of flank sep areas of dullness and tympany

Perc of abdomen procudes dulllness that shifts as pt rolls

With on hand on either, tapping against lat wall will produce fluid wave that is felt as tap by other hand

Almost all will also have peripheral edema

Question 6

Dx of ascites by appearance

Answer 6

Normal appearance of straw yellow/clear with portal HTN

Turbin or cloudy = infection

Milky - inc TGs…chylous ascites

Pink or bloody - inc erythrocyte, traumatic paracentesis but also amybe peritoneal mesothelioma

Question 7

SAAG and ascitic fluid protein

Answer 7

Under 2.5 and over 1 - cirrhosis and non-cirrhotic portal HTN

UNder 2.5 and under 1 - neprhtoic syndrome

Over 2.5 and over 1.1 - cardiac ascities or infiltrative dz

Over 2.5 and under 1 - peritoneal carciomatosis, chylous, pancreatitis, TB

Fluid with high neutros - infection

High lymphos - TB or malignancy

Question 8

MG of ascites

Answer 8

If cirrhosis - sodium restriction

If that does not work - spironolactoen and furosemide

Slow titration up to prevent IV volume depletion

Question 9

Path of jaundice up to excretion of liver

Answer 9

Heme oxygnase breaks down heme into CO and biliverdin

Biliverdin to bilirubin by biliverdin reductase

Bilirubin insoluble so bound to albumin and taken to liver

Within hepatocytes, bilirubin conjugated by UGT1A! to form water soluble conjugated bilirubin….then excreted by ABC-C2

Question 10

Bilirubin after excretion from liver

Answer 10

Bac in colon reduce conjugated to unconjugated and then to urobilinogen and stercorbilinogen

Unconjugated can be reabsored back into portal along with urobilinogen and

Remianing fecal urobilinogens and stercobiliigens excreted in stool

Question 11

Jaundice process

Answer 11

Inc bilirubin production
Dec conjugation of bilirubin in hepatocytes
Cholestasis previting excretion
inc enteroheptic circulation

Common in newborn infants due to hsort RBC lifespan which inc heme degradation, enzymatic process of conj slow and inc circulation

Any processes that slows colonic passage of bile increase enterohepatic circulation

Question 12

Gilbert syndrome/Crigler=najjar
Dubin-johnson yndrome/rotor
Others in infants

Answer 12

Look for hemoglobinopathies or immune mediated hemolysis

Gil - def of bili metab….mut in promoter of UGT1A1…diff from Crigler-Najjar where mutations in UGT1A1 gene its which is worse

D-J - mut in ABC-C2 membrane protein so dec excretion….rotor - gene mutations in hepatocyte transport proteins so less eff uptake and excretion

Most serious is biliary atresia

Question 13

unconjugated and conjugated hyperbili in adults

Answer 13

Un - hemolysis, crticial illness, or impaired conjugated

Conj - anything that disrupts bile cnalaliculus or bilary system…common causes of intra includie damage….extra most lilely from gallstones or other cholestasis

Question 14

CM of jaundice in infants

Answer 14

Progresses from head to toe

3-7 - icterus

15 - entire skin

Neurotoxin so may get acute bili encephalopathy….inititally hypotonia and progress to get severe hypertonia

Shrill cry…can progress to resp failure and status epilepticus

biliary atreia is fibroinflam desturction of extrahep biliary tract….jaundice bt birht and 2mos…may have acholic stools and dark urine

Question 15

Dx of jaundice in infants

Answer 15

Check within 2 days

If abnormally high, do a blood type and Coombs test along with CBC and smear

Check for conjugated hyperbili….if pos, then get US of liver and biliary sx….biliary atresia if gallbladder not visualized or if inc echogeneiticy in periportal area

Question 16

CM of jaundice in children/adults

Answer 16

Rarely sx

Cong disorders also normally asx

Gilbert - IM episdoes of jaundice

Crigler-Najjar - verying degrees of jaundice ranging from isolated icertus

Dubin and rotor - mild jaundice iwth isolated icuters

Question 17

Dx of jaundice in children and adults

Answer 17

If isolated hyperbilirubinemia - then think non hepatic dz like hemolysis or drug effecct

Gilbert - noram llevel during periods of healthy and only jaundice in periods of stress

Crgiler - wide range but higher during stress

Crigler and gilbert - normal conjugated

Others - abnormal conjugated