===== ascites ====== Flashcards
what are the different causes of ascites ?
1) PORTAL HYPERTENSION
presinusoidal
splenic/ portal vein thrombosis
splenic vein thrombosis
sinusoidal Hepatic (common) Cirrhosis Alcohol-related liver disease Liver metastases
post sinusoidal
Right heart failure
budd chiari syndrome
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infection and inflammation - pancreatitis / TB
decrease in albumin level - nephrotic syndrome , protein losing enteropathy such as celiac disease or inflammatory bowl disease , or liver problems malnutrition
malignancy
myxoedema
clinical features of ascites ?
Progressive abdominal distension ; symptoms associated with increased abdominal distention include
Early satiety
Weight gain
Dyspnea
Fluid wave test: wave produced by tapping one side of the abdomen in a patient in supine position; this wave will be transmitted to the other side via ascitic fluid.
Shifting dullness: change of resonance from dull to tympanic resonance when patient changes from supine to lateral decubitus position.
Flank dullness: typically elicited only if > 1.5 L of ascitic fluid is present
Abdominal pain may be present
Abdominal wall hernias
what are the signs of underlying disease in ascites ?
Signs of underlying disease
Enlarged liver, jaundice, spider angioma, palmar erythema: chronic liver disease
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Elevated jugular venous pressure, edema , hepatomegaly : heart failure
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Virchow’s node and weight loss: upper abdominal malignancy
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it is chronic pancreatitis - that most often causes ascites
epigastric Pain radiates to the back, is relieved on bending forward, and is exacerbated after eating.
Pain is initially episodic and becomes persistent as the disease progresses.
Often associated with nausea and vomiting
Features of pancreatic insufficiency: late manifestation (after 90% of the pancreatic parenchyma is destroyed)
Steatorrhea (exocrine enzyme deficiency)
Malabsorption and weight loss
Pancreatic diabetes
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acute pancreatitis : Constant, severe epigastric pain Classically radiating towards the back Worse after meals and when supine Improves on leaning forwards
Signs of shock: tachycardia, hypotension, oliguria/anuria
Possibly jaundice in patients with biliary pancreatitis
diagnosis of ascites ?
paracentesis
- performed even if coagulopathy present
calculate Serum ascites albumin gradient
SAAG
1.1 g/dl or more = transudative = portal hypertension
<1.1g/dl = exudative - caused by the rest
other test of ascitic fluid - red and white cell cunt
culture - for spontaneous bacterial peritonitis
glucose low - peritoneal cancer or bowel perf
LDH high in peritonitis and bowel perf
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us
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liver disease
CBC - thrombocytopenia - liver disease LFT - Elevated transaminases - serum albumin low ALP high undone bilirubin - high AST AND ALT HIGH
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chronic pancreatitis
Lipase (specific) and amylase (nonspecific) are often normal in chronic
ndirect tests
Fecal elastase-1
Direct tests [10]
Cholecystokinin test: Cholecystokinin analog (cerulein) is administered intravenously, which stimulates pancreatic enzyme and bicarbonate secretion. This secretion is collected in a tube placed in the duodenum during endoscopy and analyzed
CT
path-physio of Spon , bacterial peritonitis
portal hypertension
weak gut mucosal flora and defence
ecoli colonisation
= COMPLICATION OF ASCITIS
signs and symptoms od SBP
asymptomatic
fever vomiting abdominal pain
diagnostic of SBP
ascitic fluid has >250 neutrophil /ul
causes of acute pancreatitis
get smashed
gallstones ethanol trauma steroids / sulfonamides / furosemide mumps autoimmune sphincter of oddi dysfunction hypercalecmia from hyperparathyroidims ERCP surgery and procedures
strict diet followed by rapid intro of fattty food
god , sat , meha
diagnosis of acute pancreatitis
2 of 3
pain suggestive of pancreatitis
elevated serum lipase above 3 x ULN (amylase is also rised but non specific)
charecteristic findings on imaging
abdominal US - gallbladder stones and biliary obstruction
CONTRAST ENHANCED CT -
when necrotic pancreatitis suspected
72 hrs after onset of attack
MRI
MRCP , ERCP
blood test ncreased crp wbc hyperglycemia and glucosurea , protein urea , increased creatinin , increased urea hct high
gallstone pancreatitis - cholestatsic parameters
do ECG = = 30 percent changes in S-T segmnet
diffuse t wave inversion and ST elevation
management of ascites ?
identify cause and exclude spontaneous bacterial peritonitis
sodium and fluid RESTRICTION
diuretic - spiranoactone and furosemide
diagnostic ascitic tap
therapeutic paracentesis -with volume expansion using synthetic plasma expander or human albumin solution (20 percent)
for refectory ascites - transjugular intrahepatic protosystemic shunt
USS abdomen
consider liver transplant
high protein diet
management of SBP
PO co-amoxiclav
ecooli - ciprofloxacin / cefotaxime
or severe piperocillin tazobactum
management of hepatoenal syndrome
kidney failure in presence of severe liver disease - terlipressin
liver transplantation
management of acute pancreatitis
early and aggressive hydration 4-6 l / daily to get a 0.5ml/k/h with urine output and decreased urea level
enteric feeding
low fat liquid and go to low fat regular diet
severe pancreatitis = naso jejunal tube enetral feeding
analgesics - fentanyl and metamizole
imipenem in patients with necrotising pancreatitis = reduce infection
Severe pancreatitis with infected necrosis or persistent fluid collections should be treated with percutaneous US or CT-guided aspiration/ drainage
o surgical detriment
gall stone affected pancreatitis = laproscopic cholescystectomy
ERCP and spincterotomy = acute galstone with acute cholangitis
or unresolved billary obstruction
