Abdominal Distension

Question 1

What are the causes of ascites?

Answer 1

Portal hypertension
- Cirrhosis
- Alcoholic hepatitis
- Cardiac failure/pericarditis
- Budd-Chiari syndrome
- Massive hepatic metastasis
Peritoneal carcinomatosis, esp ovarian
Pancreatitis
Nephrotic syndrome
Peritoneal TB
Serositis

Question 2

What are the top four causes of cirrhosis in Australia?

Answer 2

1. Alcohol
2. Hep C
3. NASH
4. Hep B

Question 3

What can be concluded about ascites from a Doppler ultrasound?

Answer 3

Confirms presence, if in doubt
May diagnose cirrhosis
May confirm portal HTN
May diagnose portal vein thrombosis
May diagnose HCC

Question 4

What can be concluded about ascites from an ascitic tap?

Answer 4

Diagnostic

Can be therapeutic

Question 5

What tests are run on ascitic taps?

Answer 5

Microscopy
Culture
Sensitivity
Ascitic
- Albumin
- Protein concentration
Rarely cytology

Question 6

What is the pathogenesis of spontaneous bacterial peritonitis?

Answer 6

Leaky membranes
Poor opsonisation
Sub-optimal immune response

Question 7

How is spontaneous bacterial peritonitis diagnosed?

Answer 7

PMN cell count >250 cells/mL from tap

Detectable growth on culture

Question 8

What are the risk factors for spontaneous bacterial peritonitis, in the presence of ascites?

Answer 8

Low ascitic protein
High serum bilirubin
Prior spontaneous bacterial peritonitis
Variceal bleeding
Malnutrition
PPI therapy

Question 9

What is the management for a patient who is at high risk of spontaneous bacterial peritonitis?

Answer 9

Prophylactic antibiotics

Question 10

What is SAAG?

Answer 10

Serum albumin-ascites gradient
= [serum albumin] - [ascitic albumin]
IDs ascites due to portal HTN
- SAAG >11 g/L = portal HTN
- SAAG <11 g/L = non-portal HTN

Question 11

What is the management of ascites?

Answer 11

Treat underlying disease if possible
Avoid NSAIDs and ACE inhibition
Na restriction
Fluid restriction
Diuretics
- Watch serum K and renal function
Therapeutic ascitic tap > only if bothering patient

Question 12

Why restrict sodium in the presence of hyponatraemia?

Answer 12

Na diluted, not actually low

Question 13

What is the aetiology of varices?

Answer 13

Portal HTN > engorgement of collaterals and porto-systemic shunting

Question 14

What is the risk of variceal haemorrhage related to?

Answer 14

Varix size
Endoscopic stigmata
Previous bleeds
Hepato-venous portal pressure gradient >12 mmHg

Question 15

What are the common causes of upper GI bleeding?

Answer 15

Peptic ulcer disease
Varices
Oesophagitis
Mallory-Weiss tear

Question 16

What is the treatment for acutely bleeding oesophageal varices?

Answer 16

Endoscopically
- Band ligation
- Injection of glue/sclerosant
- Tamponade with Sengstake-Blakemore tube
Pharmacologically
- Splanchnic vasoconstrictor = terlipressin/somatostatin analogue
Radiological decompression/occlusion of varices
Surgical decompression

Question 17

What is the primary prophylaxis of variceal bleeding?

Answer 17

Non-selective beta-blockade
- Bradycardia and hypotension often poorly tolerated in advanced cirrhosis
Endoscopic band ligation if varices large and high risk/advanced cirrhosis

Question 18

What is the secondary prophylaxis of variceal bleeding?

Answer 18

Regular endoscopic band ligation/injection to eradicate varices