Abdominal Swelling and Ascites

Question 1

The normal small intestine contains ~_____ mL of gas made up of nitrogen, oxygen, carbon dioxide, hydrogen, and methane.

Answer 1

200

Question 2

Grade 2 ascites is detectable by _____

Answer 2

physical examination

Grade 1 by Ultrasound

Question 3

A minimum of ____mL of ascitic fluid is required for detection on physical examination.

Answer 3

1500

Question 4

[Paracentesis] The _____ is preferred because of the greater depth of ascites and the thinner abdominal wall.

Answer 4

left lower quadrant

Question 5

[Paracentesis] hallmark of chylous ascites.

Answer 5

White, milky fluid indicates a triglyceride level >200 mg/ dL (and often >1000 mg/dL)

Question 6

[Paracentesis] Dark brown fluid can reflect a high ____concentration and indicates _____

Answer 6

bilirubin

biliary tract perforation.

Question 7

[Paracentesis] Black fluid

Answer 7

Pancreatic necrosis or metastatic melanoma.

Question 7

[Paracentesis] Turbid Fluid

Answer 7

Infection or tumor cells

Question 8

A SAAG ≥1.1 g/dL reflects the presence of _____ and indicates that the ascites is due to increased pressure in the hepatic sinusoids.

Answer 8

portal hypertension

Question 9

A SAAG____g/dL indicates that the ascites is not related to portal hypertension, as in tuberculous peritonitis, peritoneal carcinomatosis, or pancreatic ascites.

Answer 9

<1.1

Question 10

An ascitic protein level of ____ g/dL indicates that the hepatic sinusoids are normal and are allowing passage of protein into the ascites, as occurs in cardiac ascites, early Budd-Chiari syndrome, or sinusoidal obstruction syndrome. A

Answer 10

≥2.5

Question 11

An ascitic protein level ____g/dL indicates that the hepatic sinusoids have been damaged and scarred and no longer allow passage of protein, as occurs with cirrhosis, late Budd-Chiari syndrome, or massive liver metastases.

Answer 11

<2.5

Question 12

When ____ is suspected, the ascitic amylase level should be measured and is typically >1000 mg/dL.

Answer 12

pancreatic ascites

Question 13

The initial treatment for cirrhotic ascites is _______

Answer 13

restriction of sodium intake to 2 g/d.

Question 14

Although β-adrenergic blocking agents (beta blockers) are often prescribed to prevent_____ in patients with cirrhosis, the use of beta blockers in patients with refractory ascites may be associated with _____

Answer 14

variceal hemorrhage

decreased survival rates

Question 15

Intravenous (IV) infusion of albumin accompanying LVP decreases the risk of “_____” and death.

Answer 15

postparacentesis circulatory dysfunction

Question 16

______ is superior to LVP in reducing the reaccumulation of ascites but is associated with an increased frequency of ______, with no difference in mortality rates.

Answer 16

TIPS placement

hepatic encephalopathy

Question 17

A 60-year-old male with cirrhosis and ascites presents for initial management. What is the first-line dietary intervention for this patient?

A) Fluid restriction
B) Sodium restriction to 2 g/day
C) High-protein diet
D) Potassium supplementation

Answer 17

B

Question 18

A patient with cirrhotic ascites is prescribed spironolactone but develops painful gynecomastia. What is the most appropriate substitution for spironolactone?

A) Furosemide
B) Amiloride
C) Midodrine
D) Clonidine

Answer 18

B

Question 19

A patient with refractory ascites undergoes large-volume paracentesis (LVP). What additional therapy should be administered to reduce the risk of postparacentesis circulatory dysfunction?

A) Midodrine
B) IV albumin infusion
C) Diuretics
D) Clonidine

Answer 19

B

Question 20

A 55-year-old male with refractory cirrhotic ascites is being considered for a procedure to reduce reaccumulation of ascites. Which of the following is associated with a higher frequency of hepatic encephalopathy?

A) Large-volume paracentesis (LVP)
B) Transjugular intrahepatic portosystemic shunt (TIPS)
C) Sodium restriction
D) Alfapump system

Answer 20

B

Question 21

A patient with malignant ascites is unresponsive to sodium restriction and diuretics. What is the most appropriate next step in management?

A) Serial large-volume paracentesis (LVP)
B) Midodrine
C) Standard antituberculosis therapy
D) Pro-brain-type natriuretic peptide (BNP) testing

Answer 21

A

Question 22

Which of the following patients with cirrhotic ascites should receive prophylactic antibiotics to prevent spontaneous bacterial peritonitis (SBP)?

A) A patient with ascitic fluid total protein concentration of 1.5 g/dL
B) A patient with active gastrointestinal bleeding
C) A patient with hepatic hydrothorax
D) A patient with ascitic PMN count of 100/μL

Answer 22

B

Question 23

A patient with cirrhosis presents with shortness of breath and hypoxia. Imaging reveals pleural fluid consistent with hepatic hydrothorax. Which of the following is an appropriate next step in management?

A) Chest tube placement
B) Sodium restriction and diuretics
C) Beta-blockers and thoracentesis
D) IV ciprofloxacin

Answer 23

B

Question 24

In hospitalized patients with ascites, paracentesis within _____ hours of admission reduces mortality because of early detection of SBP.

Answer 24

12

Question 25

SBP is defined by a polymorphonuclear neutrophil (PMN) count of ___/ μL in the ascitic fluid.

Answer 25

≥250

Question 26

The presence of multiple pathogens in the setting of an elevated ascitic PMN count suggests ____from a ruptured viscus or abscess

Answer 26

secondary peritonitis

Question 27

The presence of multiple pathogens without an elevated PMN count suggests _____

Answer 27

bowel perforation from the paracentesis needle.

Question 28

Treatment of SBP with an antibiotic such as____ is generally effective against gram-negative and gram-positive aerobes.

Answer 28

IV cefotaxime

Question 29

Who should receive prophylactic antibiotics to prevent SBP

Answer 29

Cirrhotic patients with a history of SBP

an ascitic fluid total protein concentration <1 g/dL

active gastrointestinal bleeding

Question 30

A patient with ascites has a serum-ascites albumin gradient (SAAG) of 1.2 g/dL and an ascitic protein level of 1.8 g/dL. Which of the following is the most likely cause of this patient’s ascites?

A) Cirrhosis
B) Heart failure
C) Peritoneal carcinomatosis
D) Early Budd-Chiari syndrome

Answer 30

A

Question 31

A patient presents with ascites and a SAAG of <1.1 g/dL. Which of the following conditions is the least likely cause of their ascites?

A) Tuberculosis
B) Peritoneal carcinomatosis
C) Heart failure
D) Biliary leak

Answer 31

C

Question 32

A patient with ascites has a SAAG ≥1.1 g/dL and an ascitic protein level ≥2.5 g/dL. Which of the following is the most likely diagnosis?

A) Cirrhosis
B) Heart failure
C) Late Budd-Chiari syndrome
D) Pancreatitis

Answer 32

B

Question 33

A patient with ascites has a SAAG ≥1.1 g/dL and an ascitic protein <2.5 g/dL. Which of the following conditions is the most likely cause of their ascites?

A) Cirrhosis
B) Heart failure
C) Early Budd-Chiari syndrome
D) IVC obstruction

Answer 33

A