Ascites

Question 1

What are the two main complications to worry about in a patient with ascites?

Answer 1

1.  Spontaneous bacterial peritonitis

2.  Respiratory compromise

Question 2

What is the minimal length of treatment for spontaneous bacterial peritonitis?

Answer 2

10 days

Question 3

How can you tell that ascites fluid has a chylous (lymphatic) source?

(4)

Answer 3

1.  Peritoneal fluid looks “creamy”
2.  High fat content
3.  High triglycerides (>400)
4.  Few WBCs (despite creamy appearance)

Question 4

Cirrhotic ascitic fluid is usually described as being what color?

Answer 4

Straw colored

Question 5

More than 75 PMNs/mL of peritoneal fluid suggests that the ascites is due to what process?

Answer 5

Inflammation

Infection has a much higher PMN count

Question 6

How is spontaneous bacterial peritonitis (SBP) treated?

3 modalities

Answer 6

1.  Antibiotics
2.  Paracentesis
3.  Correct the underlying problem

Question 7

Creamy ascitic fluid that is high in fat is most likely coming from what source? (2)

Answer 7

Lymphatic obstruction or

Trauma

(aka chylous ascites

Question 8

Why might a patient with a single mediastinal tumor develop ascites?

Answer 8

Compression of portal venous return to the heart

Or

Compression of lymphatic return (thoracic duct)

Question 9

If the amylase value is high in the peritoneal fluid, what diagnosis should be considered?

Answer 9

Pancreatitis

Question 10

What do you need to order after obtaining peritoneal fluid for diagnostic purposes?

Answer 10

1.  WBC count & cytology
2.  Gram stain & culture
3.  LDH & pH
4.  Amylase/lipase
5.  Total protein & albumin
6.  Cholesterol & triglycerides (TGs)

(look for infection, fat, & belly-related stuff)

Question 11

What diagnoses must be considered in a neonate with ascites? (3)

Answer 11

Lysosomal storage diseases

Cardiac abnormalities

Hepatitis (viral/neonatal)

(and other metabolic problems)

Question 12

What dietary modifications help patients with ascites?

Answer 12

1.  Low salt intake

2.  Water restriction (75 % of maintenance)

Question 13

Diuretics are sometimes used in the treatment of ascites. What complication do you need to be especially worried about in these patients?

Answer 13

Prerenal azotemia compromising the kidneys

(or possibly inducing hepatorenal syndrome

Question 14

What is hepatorenal syndrome?

Answer 14

Sudden loss of kidney function in a patient with liver disease

Question 15

When would surgical portosystemic shunting be useful for an ascites patient?

Answer 15

If portal hypertension is a significant cause of the ascites

Question 16

When should infected peritoneal fluid be reevaluated to determine the effectiveness of therapy?

Answer 16

48 h after antibiotics are started

Question 17

In a patient with new-onset ascites, and no obvious etiology, what diagnosis (in general terms) must be ruled out?

Answer 17

Abdominal malignancy

Question 18

If a patient with known, chronic, liver disease suddenly develops ascites, what “triggers” should you look for? (3)

Answer 18

1.  Significant GI bleeding
2.  Sepsis
3.  New liver infection (causing acute liver decompensation, then ascites)

Question 19

How is ascites diagnosed by physical examination?

Answer 19

Fluid wave: This sign can be elicited in a cooperative patient by tapping sharply on one flank while receiving the wave with the other hand. The transmission of the wave through fatty tissue should be blocked by a hand placed on the center of the abdomen.
• Shifting dullness: With the patient supine, percussion of the abdomen will demonstrate a central area of tympany at the top that is surrounded by flank percussion dullness. This dullness shifts when the patient moves laterally or stands up.
• “Puddle sign”: A cooperative and mobile patient may be examined in the knee-chest position. The pool of ascites is tapped while you listen for a sloshing sound or change in sound transmission with the stethoscope.