Ascites Flashcards
What are the two main complications to worry about in a patient with ascites?
- Spontaneous bacterial peritonitis
2. Respiratory compromise
What is the minimal length of treatment for spontaneous bacterial peritonitis?
10 days
How can you tell that ascites fluid has a chylous (lymphatic) source?
(4)
- Peritoneal fluid looks “creamy”
- High fat content
- High triglycerides (>400)
- Few WBCs (despite creamy appearance)
Cirrhotic ascitic fluid is usually described as being what color?
Straw colored
More than 75 PMNs/mL of peritoneal fluid suggests that the ascites is due to what process?
Inflammation
Infection has a much higher PMN count
How is spontaneous bacterial peritonitis (SBP) treated?
3 modalities
- Antibiotics
- Paracentesis
- Correct the underlying problem
Creamy ascitic fluid that is high in fat is most likely coming from what source? (2)
Lymphatic obstruction or
Trauma
(aka chylous ascites
Why might a patient with a single mediastinal tumor develop ascites?
Compression of portal venous return to the heart
Or
Compression of lymphatic return (thoracic duct)
If the amylase value is high in the peritoneal fluid, what diagnosis should be considered?
Pancreatitis
What do you need to order after obtaining peritoneal fluid for diagnostic purposes?
- WBC count & cytology
- Gram stain & culture
- LDH & pH
- Amylase/lipase
- Total protein & albumin
- Cholesterol & triglycerides (TGs)
(look for infection, fat, & belly-related stuff)
What diagnoses must be considered in a neonate with ascites? (3)
Lysosomal storage diseases
Cardiac abnormalities
Hepatitis (viral/neonatal)
(and other metabolic problems)
What dietary modifications help patients with ascites?
- Low salt intake
2. Water restriction (75 % of maintenance)
Diuretics are sometimes used in the treatment of ascites. What complication do you need to be especially worried about in these patients?
Prerenal azotemia compromising the kidneys
(or possibly inducing hepatorenal syndrome
What is hepatorenal syndrome?
Sudden loss of kidney function in a patient with liver disease
When would surgical portosystemic shunting be useful for an ascites patient?
If portal hypertension is a significant cause of the ascites
When should infected peritoneal fluid be reevaluated to determine the effectiveness of therapy?
48 h after antibiotics are started
In a patient with new-onset ascites, and no obvious etiology, what diagnosis (in general terms) must be ruled out?
Abdominal malignancy
If a patient with known, chronic, liver disease suddenly develops ascites, what “triggers” should you look for? (3)
- Significant GI bleeding
- Sepsis
- New liver infection (causing acute liver decompensation, then ascites)
How is ascites diagnosed by physical examination?
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.
