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A. MLA Map Gastroenterology Including Liver > Ascites > Flashcards

Ascites Flashcards

1
Q

The portal vein drains all the blood from the GI tract through the liver. Which of the following is NOT a tributary of the portal vein?

1 - splenic vein
2 - inferior mesenteric vein
3 - coeliac vein
4 - superior mesenteric vein

A

3 - coeliac vein

  • portal venous system also contains toxins that can be excreted by the kidneys
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2
Q

Once the blood moves from the portal venous system through its tributaries into the liver, it is processed. What vessels does this then leave the liver by?

1 - inferior vena cava
2 - superior vena cava
3 - coeliac vein
4 - superior mesenteric vein

A

1 - inferior vena cava

  • travels up IVC to right atrium and into the systemic circulation
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3
Q

There are 3 locations where the portal venous system can be connected with the systemic venous system which collects blood from the rest of the body. Which of the following is NOT one of these?

1 - superior portion of the anal canal
2 - inferior portion of the esophagus
3 - renal veins
4 - round ligament (umbilical vein)

A

3 - renal veins

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4
Q

At birth the umbilical cord is cut causing the umbilical vein to collapse. It then becomes what?

1 - round ligament
2 - falciform ligament
3 - coronary ligament
4 - right triangular ligament

A

1 - round ligament

  • remains closed normally as portal venous system and systemic venous system are the same = 5-10mmHg
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5
Q

Organs in the body, including the cavities in the body contain a serous membrane. This serous membrane contains a lining of mesothelial cells that lubricate these organs and cavities and reduce friction. What are the 2 layers of this called?

1 - visceral layer
2 - endothelial layer
3 - parietal layer
4 - epithelial layer

A

1 - visceral layer
3 - parietal layer

  • fluid is contained between these layers
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6
Q

Is the accumulation of fluid in the parietal space between the visceral and parietal layers of the serosa always pathological?

A
  • yes

Examples of fluid accumulations in parietal space before fluid can be detected:
- Ascites 500ml
- Pleural effusions 300ml
- Pericardial effusion 50ml

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7
Q

What are ascites?

1 - accumulation of fluid in the pericardium
2 - accumulation of fluid in the testicles
3 - accumulation of fluid in the kidneys
4 - accumulation of fluid in the peritoneum cavity

A

4 - accumulation of fluid in the peritoneum cavity

  • diagnosis of ascites is generally when there is >1500ml
  • ascites = greek for bag of sac
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8
Q

Are ascites always pathological?

A
  • yes
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9
Q

This is the formula for calculating filtration/reabsorption rate:

Qf = Peff x Kf

  • Qf = filtration/reabsorption rate
  • Peff = effective filtration pressure, which is the difference between hydrostatic and oncotic pressure
  • Kf = filtration coefficient, which is the permeability and surface area of biological membranes to water

Based on the above, which of the following is important when considering the filtration re-absorption rate?

1 - hydrostatic pressure
2 - oncotic pressure
3 - membrane permeability
4 - membrane surface area
5 - all of the above

A

5 - all of the above

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10
Q

Which of the following is NOT likely to cause effusions?

1 - decreased hydrostatic pressure
2 - decreased oncotic pressure
3 - increased membrane permeability
4 - modulated surface area exchange

A

1 - decreased hydrostatic pressure
- an increase would cause effusions

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11
Q

Which of the following is NOT a cause of portal hypertension that increases hydrostatic pressure, forcing fluid out of blood vessels and can lead to ascites?

1 - liver cirrhosis
2 - alcoholic hepatitis
3 - chronic cardiac failure
4 - constrictive pericarditis
5 - nephrotic syndrome
6 - large PE

A

5 - nephrotic syndrome

  • can cause hepatorenal failure in rare cases
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12
Q

Which of the following is NOT a cause of hypoalbuminemia that reduces oncotic pressure, leading to fluid leaking out of blood vessels and can lead to ascites?

1 - liver cirrhosis
2 - nephrotic syndrome
3 - protein losing enteropathy
4 - malnutrition

A

1 - liver cirrhosis

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13
Q

Which of the following is NOT a cause of peritoneal disease that affects the perfusion and surface area of membranes, leading to fluid leaking out of blood vessels and can lead to ascites?

1 - malignancy/carcinomatosis
2 - Iinfections (TB, fungal)
3 - nephrotic syndrome
4 - vasculitis
5 - peritonitis
6 - lymphoproliferative malignancies

A

3 - nephrotic syndrome

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14
Q

Ascites is the accumulation of excessive fluid in the peritoneal space, generally >1500ml. This can be further subdivided into 3 categories. What is grade 1 ascites?

1 - moderate ascites causing moderate symmetrical distension of the abdomen
2 - mild ascites and is only detectable by ultrasound examination
3 - large ascites causing marked abdominal distension
4 - low fluid that is undetectable

A

2 - mild ascites and is only detectable by ultrasound examination

  • ultrasound is able to detect <500ml of fluid
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15
Q

Ascites is the accumulation of excessive fluid in the peritoneal space, generally >1500ml. This can be further subdivided into 3 categories. What is grade 2 ascites?

1 - moderate ascites causing moderate symmetrical distension of the abdomen
2 - mild ascites and is only detectable by ultrasound examination
3 - large ascites causing marked abdominal distension
4 - low fluid that is undetectable

A

1 - moderate ascites causing moderate symmetrical distension of the abdomen

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16
Q

Ascites is the accumulation of excessive fluid in the peritoneal space, generally >1500ml. This can be further subdivided into 3 categories. What is grade 2 ascites?

1 - moderate ascites causing moderate symmetrical distension of the abdomen
2 - mild ascites and is only detectable by ultrasound examination
3 - large ascites causing marked abdominal distension
4 - low fluid that is undetectable

A

3 - large ascites causing marked abdominal distension

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17
Q

Ascites can be subdivided into uncomplicated and refractory ascites. Which of these is easier to treat?

A
  • uncomplicated ascites
  • refractory ascites is hard to treat and has increased mortality
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18
Q

Ascites can be subdivided into uncomplicated and refractory ascites. Which of these is more common?

A
  • uncomplicated ascites
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19
Q

All of the following are causes of ascites, but which is the most common?

1 - alcoholic hepatitis
2 - liver cirrhosis
3 - viral hepatitis
4 - malignancy
5 - heart failure

A

2 - liver cirrhosis
- accounts for 80% of ascites

  • closely followed by viral and alcoholic hepatitis
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20
Q

A problem with the portal venous systems ability to drain into the liver, generally due to a cirrhotic liver can lead to a build up of blood in the portal venous system, causing portal hypertension. What pressure is diagnostic of portal hypertension?

1 - >120mmHg
2 - >70mmHg
3 - >30-50mmHg
4 - >5-10mmHg

A

4 - >5-10mmHg

Features of portal hypertension:
- A = Ascites
- B = Bleeding
- C = Caput medusae
- D = Diminished liver function
- E = Enlarged spleen.

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21
Q

If a patient develops portal hypertension (>5-10mmHg) this can cause portosystemic shunts. If the toxins in the blood are not filter in the liver, what can this lead to?

1 - liver failure
2 - liver hepatitis
3 - hepatic encephalopathy

A

3 - hepatic encephalopathy

  • toxins in the blood like ammonia can pass blood brain barrier
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22
Q

If a patient develops portal hypertension (>5-10mmHg) this can cause portosystemic shunts. The 3 main places this occurs are superior portion of the anal canal, inferior portion of the esophagus and then round ligament (umbilical vein). What can portosystemic cause in the inferior portion of the esophagus?

1 - barretts esophagus
2 - achalasia
3 - metaplasia
4 - varices

A

4 - varices

  • essentially enlarged esophageal veins
  • very fragile and can cause extensive upper GI bleed
  • portal hypertension is the most common cause
  • treated with endoscopic banding and beta blockers or if these fail, then TIPSS (Trans intrahepatic portosystemic shunt) or surgery (venous shunts)
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23
Q

If a patient develops portal hypertension (>5-10mmHg) this can cause portosystemic shunts. The 3 main places this occurs are superior portion of the anal canal, inferior portion of the esophagus and then round ligament (umbilical vein). What can portosystemic cause in the superior portion of the anal canal?

1 - fistula formation
2 - pilonidal sinus
3 - haemorrhoids
4 - diverticulitis

A

3 - haemorrhoids

  • enlarged veins that can bleed
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24
Q

If a patient develops portal hypertension (>5-10mmHg) this can cause portosystemic shunts. The 3 main places this occurs are superior portion of the anal canal, inferior portion of the esophagus and then round ligament (umbilical vein). What can portosystemic cause in the round ligament (umbilical vein?

1 - striae (stretch marks)
2 - caput medusae
3 - cullen’s sign (blood around umbilicus)
4 - grey-Turner’s sign (bruising in the flanks)

A

2 - caput medusae

  • round ligament becomes patent due to pressure changes
  • blood flows into abdominal veins that are visible on abdomen
  • cullen’s sign (blood around umbilicus) and grey-Turner’s sign (bruising in the flanks) are both signs of pancreatitis
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25
Q

If a patient develops portal hypertension (>5-10mmHg) this can cause portosystemic shunts. This can cause blood to back up into the spleen, causing splenomegaly, leading to trapper blood contents in the spleen. Which of the following is NOT caused by splenomegaly?

1 - anaemia
2 - hyponatraemia
3 - leukopenia
4 - thrombocytopenia

A

2 - hyponatraemia

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26
Q

Patients with portal hypertension seem to create more nitric oxide, potentially due to bacteria causing peripheral arteries to vasodilate and blood pressure drops. What is then the MAIN triggered in response?

1 - vasovagal response
2 - chemoreceptors fire
3 - renin-angiotensin aldosterone system fires
4 - shock

A

3 - renin-angiotensin aldosterone system fires

  • ## Na+ and H2O are retained to increase BP
27
Q

Patients with portal hypertension seem to create more nitric oxide causing peripheral arteries to vasodilate, blood pressure drops, triggering the renin angiotensin aldosterone system to retain Na+ and H2O. What does this then lead to?

1 - fluid pushed into tissues and large open spaces
2 - BP normalises
3 - patient becomes hypotensive
4 - patient becomes hypertensive

A

1 - fluid pushed into tissues and large open spaces

  • this is the cause of ascites
28
Q

In addition to portal hypertension, ascites can be group into 3 other categories. Which of the following is NOT one of these categories?

1 - Hypertension
2 - Other aetiologies
3 - Peritoneal disease
4 - hypoalbuminaemia

A

1 - Hypertension

29
Q

Ascites can present clinically in a variety of ways. Which of the following is NOT a typical presentation?

1 - abdominal distension
2 - mesenteric ischaemia
3 - weight gain
4 - nausea and pain
5 - dyspnoea

A

2 - mesenteric ischaemia

  • dyspnoea is due to limited venous return from the lower limbs (pressure on the inferior vena cava) and impaired expansion of the lungs (pressure on the diaphragm)
30
Q

When examining a patients abdomen with suspected ascites, should their abdomen be typically dull or resonant?

A
  • resonant as no solid organs
  • with ascites there will be shifting dullness, mainly flank dullness
31
Q

When examining a patient with suspected ascites, we may see palmer erythema. This is causes as the liver is unable to metabolise a specific hormone. The inability to metabolise which hormone by the liver causes palmer erythema?

1 - growth hormone
2 - estradiol
3 - follicular stimulating hormone
4 - thyroxine (T4)

A

2 - estradiol

  • essentially estrogen
32
Q

When examining a patient with suspected ascites, we may see leukonychia. What is the cause of this in association with ascites?

1 - too much iron absorbed
2 - too little iron absorbed
3 - hypoalbuminaemia
4 - excessive estradiol

A

3 - hypoalbuminaemia

  • liver cannot make sufficient albumin
33
Q

On physical examination, how can we identify the cause of ascites as portal hypertension and not heart failure?

1 - no increased JVP
2 - tachycardia
3 - peripheral oedema
4 - raised JVP

A

1 - no increased JVP

  • will only be raised in heart failure
34
Q

Which of the following is NOT a typical symptom presenting a patient with suspected ascites?

1 - gynaecomastia
2 - spider naevus
3 - jaundice/itching skin
4 - muscle wasting
5 - bowel obstruction
6 - hernias
7 - nausea

A

5 - bowel obstruction

  • spider naevus are likely due to excessive estrogen, similar to palmer erythema
  • hernias may present due to increased intra-abdominal pressure
35
Q

Which of the following is NOT a true complication of ascites?

1 - spontaneous bacterial peritonitis
2 - upper GI bleeding only
3 - malnutrition
4 - hepatorenal syndrome
5 - pleural effusion
6 - budd chiari syndrome

A

2 - upper GI bleeding only

  • can be anywhere in GIT
  • pleural effusion occurs as fluid builds up in peritoneal space and crosses the diaphragm

Budd chiari syndrome = occlusion of the hepatic vein that creates back flow of fluid that presents as ascites

36
Q

Occasionally in patients with ascites, a firm nodules can be located in the umbilicus (known as Sister Mary Joseph’s nodule). What is this suggestive of?

1 - lymphadenopathy
2 - malignancy
3 - hernia
4 - infection

A

2 - malignancy

  • suggests peritoneal carcinomatosis originating from gastric, pancreatic, or hepatic primaries.
  • virchows nodule (supraclavicular) is upper gastric cancer
37
Q

Which of the following is NOT a typical differential for ascites?

1 - abdominal mass (giant ovarian or mesenteric cyst)
2 - obesity
3 - bowel obstruction
4 - appendicitis

A

4 - appendicitis

38
Q

When assessing a patient with ascites, we would perform routine blood tests. Which of the following is NOT true typically if the cause of the ascites is due to cirrhosis or liver pathology?

1 - raised LFTs
2 - increased international normalised ratio (INR)
3 - hypoalbuminaemia
4 - atrial natriuretic factor
5 - thrombocytopenia
6 - anemia
7 - leukopenia
8 - raised ammonia

A

4 - atrial natriuretic factor (ANF)

  • released by cardiac cells when too much fluid
  • signals body to reduce Na+ and H20 reabsorption
39
Q

Paracentesis is often performed in patients with ascites to help identify the cause of the ascites. What is paracentesis?

1 - multiple girth measurements of abdomen
2 - biopsy of liver
3 - sample of ascites taken and analysed
4 - parental feeding is commenced

A

3 - sample of ascites taken and analysed

  • rule in or out spontaneous bacterial peritonitis (SBP).
40
Q

The serum-to-ascites albumin gradient (SAAG) can indicate pathology and help identify the cause. What is a high SAAG?

1 - >0.1g/dL
2 - >1.1g/dL
3 - >2.2g/dL
4 - >3.3g/dL

A

2 - >1.1g/dL

  • low is <1.1g/dL
41
Q

Is a high serum-to-ascites albumin gradient (SAAG) more likely to be due to malignancy (cancer) or non-malignancy (portal hypertension, liver cirrhosis, nephrotic syndrome)?

A
  • non-malignant
42
Q

A 58 year old man who drinks 70 units per week presents to ED with confusion, jaundice and abdominal swelling. On examination he has a liver flap, is clinically jaundiced, has a distended abdomen with evidence of shifting dullness and leg oedema. Bloods showed an Hb 105, wcc 12.5, platelets 80, Albumin 25, bilirubin 125, ALT 100, CRP 75, sodium 128.

What is the cause of this man’s symptoms?
1 - Cholecystitis
2 - Decompensated liver disease
3 - Diverticulitis
4 - Ischaemic colitis
5 - Pancreatitis

A

2 - Decompensated liver disease
- symptoms are all associated with liver issues

43
Q

A sample of the fluid can be taken via paracentesis. We can look at the colour of this fluid and also measure the serum-to-ascites albumin gradient (SAAG). What is the SAAG if the cause of the ascites is liver related?

1 - >3g/L
2 - >7g/L
3 - >11g/L
4 - >15g/L

A

3 - >11g/L
- same as ≥1.1 g/dL

  • high hydrostatic pressure in the venous circulatory system forces more fluid to leave the circulation into the peritoneal space (ascites)
44
Q

A sample of the fluid can be taken via paracentesis. We can look at the colour of this fluid. The most common colours are:

  • clear, cloudy, milky, bloody or opalescent, brown

Match up the cause for each of these colours using the causes below:

1 - traumatic tap
2 - uncomplicated ascites
3 - slightly raised triglycerides
4 - infected fluid
5 - high triglycerides
6 - jaundice

A

1 - traumatic tap = bloody
2 - uncomplicated ascites = clear
3 - slightly raised triglycerides = opalescent
4 - infected ascites = cloudy
5 - high triglycerides = milky
6 - jaundice = brown

45
Q

If a patient has a sample taken from their ascites the white cell count is typically low. However, if the white cell count is high, what does this suggest?

1 - malignancy
2 - obstruction
3 - perforation
4 - spontaneous bacterial infection

A

4 - spontaneous bacterial infection
- needs to be treated

46
Q

A 67 year old lady presented to the emergency department with symptoms of bloating, weight loss and abdominal distension. On examination she had a distended abdomen with evidence of shifting dullness but had audible bowel sounds. Bloods: haemoglobin 110, wcc 9.4, platelets 540, bilirubin 10, albumin 34, creatinine 54, CRP 45. She underwent an USS which showed she had ascites and a left adnexal mass. ​

What is the most likely cause of her ascites?​

1 - Heart failure​
2 - Decompensated liver disease​
3 - Nephrotic syndrome​
4 - Ovarian cancer​
5 - Pancreatitis​

A

4 - Ovarian cancer​
- signs associated with cancer

47
Q

Patient with malignancy can have ascites. Which of the following can cause the ascites in a patient with malignancy?

1 - decrease vascular permeability (VEGF, IL2)​
2 - obstruction of lymphatic system by tumour​
3 - hypotension
4 - all of the above

A

4 - all of the above

48
Q

A 64 year old woman presented to the emergency department with a history of progressive leg and abdominal swelling, foamy urine, fatigue and loss of appetite. On examination she had bilateral pitting oedema extending up to her thighs and a distended abdomen with shifting dullness. Her blood pressure was 170/85, HR 80, sats 94% RA. Blood tests showed: Hb 110, Wcc 6.5, sodium 132, potassium 4.3, creatinine 90, albumin 17, ALT 45, bilirubin 6. Urine dipstick showed protein +++.

What is the most likely cause of her symptoms?

1 - Heart failure
2 - Decompensated liver disease
3 - Nephrotic syndrome
4 - Ovarian cancer
5 - Pancreatitis

A

3 - Nephrotic syndrome

49
Q

Osmotic pressure = solutes (Na+, K+) and proteins (albumin) that are able to retain H2O. So if the osmotic pressure is high in the blood vessels, will H2O remain in blood vessels or diffuse into tissues?

A
  • blood vessels
  • H2O follows where the higher higher concentration of solutes is
50
Q

Oncotic pressure = proteins in the blood (albumin etc.) that are able to retain H2O. So if the oncotic pressure is high in the blood vessels, will H2O remain in blood vessels or diffuse into tissues?

A
  • blood vessels
  • H2O follows where the higher higher concentration of proteins is
51
Q

Which protein accounts for 70% of oncotic pressure, and is therefore crucial for retaining fluid in the blood vessels?

1 - globulins
2 - albumin
3 - prothrombin
4 - fibrinogen

A

2 - albumin

52
Q

Which of the following are causes of hypoalbuminemia?

1 - nephrotic syndrome
2 - GIT disease/syndrome
3 - malnutrition
4 - liver failure
5 - all of the above

A

5 - all of the above

  • nephrotic syndrome = loss in urine
  • GIT disease/syndrome = reduced absorption
  • malnutrition = low intake
  • liver failure = less albumin production
53
Q

Which of the following is NOT a common clinical feature of nephrotic syndrome that can lead to hypoalbuminemia?

1 - oedema
2 - proteinuria >3.5g/24hrs
3 - hypoalbuminemia
4 - hyperlipidaemia
5 - hypocoagulability state
6 - frothy urine
7 - fatigue

A

5 - hypocoagulability state
- antithrombin 3 is lost in urine

54
Q

The lights criteria can be used to identify if an effusion in exudative or transudative. The sample us exudative if it meets 1 or more of the following:

  • pleural fluid protein >0.5 (serum protein/pleural protein)
  • pleural LDH >0.6 (serum LDH/pleural LDH)
  • pleural fluid LDH level is more than 2/3 of the normal upper value of serum LDH

Using the example below, is the sample transudative or exudative?

Pleural fluid sample =
- Total protein: 12
- LDH: 50

Serum blood sample =
Total protein: 56
LDH: 210

A
  • transudative

pleural protein / serum protein
= 12 / 56 = 0.2

pleural LDH / serum LDH
= 12 / 56 = 0.2

55
Q

Although there may be no cells in fluids taken from effusions such as ascites, however, which of the following can be found?

1 - Mesothelial cells
2 - Macrophages
3 - Lymphocytes
4 - Neutrophils
5 - Eosinophils
6 - Cancer cells
7 - all of the above

A

7 - all of the above
- can provide evidence of the cause

56
Q

Which imaging modality it the gold standard for confirming the presence of ascites and liver cirrhosis?

1 - ultrasound
2 - CT
3 - MRI
4 - X-ray

A

1 - ultrasound

  • CT can be used if ultrasound fails to detect anything and can provide much more information, generally 2nd line though
57
Q

When treating patients with ascites, that may be associated with liver cirrhosis, what should patients be advised to reduce from their diet?

1 - K+
2 - Cl-
3 - fluid intake
4 - Na+

A

4 - Na+

  • Na+ should be reduced in the form of salt
58
Q

When treating patients with ascites, that may be associated with liver cirrhosis, what group of medication should patients be advised to avoid?

1 - NSAIDs
2 - paracetamols
3 - loop diuretics
4 - potassium-sparing

A

1 - NSAIDs

  • patients are already at risk of kidney failure, so NSAIDs could make them worse
59
Q

What is often the 1st line medication prescribed to patients with ascites?

1 - Bumetanide
2 - Indapamide
3 - Bendroflumethiazide
4 - Spironolactone

A

4 - Spironolactone

60
Q

What is the mechanism of action of spironolactone?

1 - inhibit Na+/K+ exchanger in distal convoluted tubules
2 - inhibits K+ channels in loop of Henley
3 - inhibits Na+/K+/Cl- channels in loop of henley
4 - inhibit aldosterone release from adrenal glands

A

1 - inhibit Na+/K+ exchanger in distal convoluted tubules

-inhibits Na+ pump and ⬇️ Na+ reabsorption from lumen

  • inhibits Na+ / K+ ATPase at basolateral membrane (blood)
  • Na+ and H2O is not re-absorbed
  • MUST MONITOR K+ LEVELS
61
Q

Spironolactone is often the 1st line medication prescribed to patients with ascites as this reduces Na+ and H2o levels. If this is insufficient, which 2 other medication from our core drug list could be prescribed?

1 - Bumetanide
2 - Furosemide
3 - Indapamide
4 - Bendroflumethiazide

A

1 - Bumetanide
2 - Furosemide

  • both loop diuretics can be given as an adjunct
62
Q

If a patient has large fluid volumes, generally >5L they should receive what treatment for the ascites?

1 - medication
2 - paracentesis
3 - liver transplant

A

2 - paracentesis

63
Q

If a patient has severe ascites and requires >3 paracentesis a month what should treatment be, if suitable for the patient?

1 - medication
2 - continued paracentesis
3 - liver transplant
4 - transjugular intrahepatic portosystemic shunt

A

4 - transjugular intrahepatic portosystemic shunt

  • connection between portal vein (INFLOW) and hepatic vein (OUTFLOW)
64
Q

In a patients with cirrhosis who develop ascites what is the 1 and 5 year mortality?

1 - 1.5 and 30%
2 - 15 and 30%
3 - 15 and 44%
4 - 1.5 and 44%

A

4 - 1.5 and 44%

A. MLA Map Gastroenterology Including Liver (19 decks)

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