Abdominal Distension Flashcards
What are the causes of ascites?
Portal hypertension - Cirrhosis - Alcoholic hepatitis - Cardiac failure/pericarditis - Budd-Chiari syndrome - Massive hepatic metastasis Peritoneal carcinomatosis, esp ovarian Pancreatitis Nephrotic syndrome Peritoneal TB Serositis
What are the top four causes of cirrhosis in Australia?
- Alcohol
- Hep C
- NASH
- Hep B
What can be concluded about ascites from a Doppler ultrasound?
Confirms presence, if in doubt May diagnose cirrhosis May confirm portal HTN May diagnose portal vein thrombosis May diagnose HCC
What can be concluded about ascites from an ascitic tap?
Diagnostic
Can be therapeutic
What tests are run on ascitic taps?
Microscopy Culture Sensitivity Ascitic - Albumin - Protein concentration Rarely cytology
What is the pathogenesis of spontaneous bacterial peritonitis?
Leaky membranes
Poor opsonisation
Sub-optimal immune response
How is spontaneous bacterial peritonitis diagnosed?
PMN cell count >250 cells/mL from tap
Detectable growth on culture
What are the risk factors for spontaneous bacterial peritonitis, in the presence of ascites?
Low ascitic protein High serum bilirubin Prior spontaneous bacterial peritonitis Variceal bleeding Malnutrition PPI therapy
What is the management for a patient who is at high risk of spontaneous bacterial peritonitis?
Prophylactic antibiotics
What is SAAG?
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
What is the management of ascites?
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
Why restrict sodium in the presence of hyponatraemia?
Na diluted, not actually low
What is the aetiology of varices?
Portal HTN > engorgement of collaterals and porto-systemic shunting
What is the risk of variceal haemorrhage related to?
Varix size
Endoscopic stigmata
Previous bleeds
Hepato-venous portal pressure gradient >12 mmHg
What are the common causes of upper GI bleeding?
Peptic ulcer disease
Varices
Oesophagitis
Mallory-Weiss tear
What is the treatment for acutely bleeding oesophageal varices?
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
What is the primary prophylaxis of variceal bleeding?
Non-selective beta-blockade
- Bradycardia and hypotension often poorly tolerated in advanced cirrhosis
Endoscopic band ligation if varices large and high risk/advanced cirrhosis
What is the secondary prophylaxis of variceal bleeding?
Regular endoscopic band ligation/injection to eradicate varices
