Ascites, portal hypertension + sequelae

Question 1

Define ascites

Answer 1

pathological fluid collection within the peritoneal cavity

Question 2

What are the grades of clinical severity of ascites?

Answer 2

grade 1 = detectable by imaging only
grade 2 = clinically detectable
grade 3 = tense + obvious - can’t indent abdomen

Question 3

Causes of abdominal distention

Answer 3

fluid
foetus
faeces
flatus
fat

Question 4

How do you differentiate between exudative + transudative ascites?

Answer 4

SAAG (serum ascites-albumen gradient)

1 - take a blood sample
2 - take an ascites sample
3 - measure the albumen levels of both
4 - following formula: serum albumen-ascitic albumen
5 - >1.1 g/DL or 11g/L = transudate

Question 5

Common causes of ascites in UK

Answer 5

liver disease - cirrhosis - transudate

heart failure - transudate

cancer - exudate

Question 6

Causes of exudative ascites

Answer 6

biliary leak
nephrotic syndrome
pancreatitis
peritoneal carcinomatosis
tuberculosis

Question 7

Causes of transudative ascites with ascitic protein <2.5g/dL

Answer 7

cirrhosis
late budd-chiari syndrome
massive liver metastases

Question 8

Causes of transudative ascites with ascitic protein >2.5g/dL

Answer 8

congestive heart failure
constrictive pericarditis
early budd-chiari syndrome
IVC obstruction
sinusoidal obstruction syndrome

Question 9

How is an ascitic tap carried out?

Answer 9

mark the skin
pull the skin downwards ~2cm
insert the needle perpendicular to skin and aspirate ~20ml ascitic fluid
withdraw needle and release skin

Question 10

What tests do you do on ascitic fluid?

Answer 10

ascitic albumen
ascitic cytology (GI + gynae)
ascitic fluid cell count and culture
triglycerides
amylase (pancreatitis)
bilirubin (bile leak)
adenine deaminase (TB)

Question 11

How do ascites form (arterial underfilling hypothesis)?

Answer 11

increased intrahepatic resistance
increased mesenteric blood flow
portal pressure goes up
reduced intrathoracic blood volume
activation of vasoconstrictor mechanisms: norepinephrine, ADH, renin angiotensinogen axis
hold onto water and salt at kidney level
increased venous pressure at capillaries of mesenteric system
increased loss of lymph from liver surface
intraperitoneal accumulation of fluid

Question 12

Ascites treatment

Answer 12

diuretics first line if safe to give
spironolactone
furosemide
no added salt
(pathogenesis driven by salt and water excess)

Question 13

Ascites treatment if diuretic-resistant of diuretic-intractable

Answer 13

large volume paracentesis under US guidance
leave drain in for 6h
give back albumen 100mls 20% - 2.5L

Question 14

Cirrhosis aetiologies

Answer 14

HCV
Alcohol
NAFLD
HBV
Autoimmune hepatitis
PSC (primary sclerosing cholangitis)
PBC (primary biliary cholangitis)
Wilson’s
Haemochromatosis
Cryptogenic
Drig-induced

Question 15

Can fibrosis and cirrhosis be reversed?

Answer 15

fibrosis can be reversed if cause treated
cirrhosis is the point of no return and is irreversible

Question 16

Portal hypertension complications

Answer 16

variceal haemorrhage
encephalopathy
ascites

Question 17

Post-hepatic causes of portal hypertension

Answer 17

budd-chiari syndrome
IVC webs
cardiac causes

Question 18

Intrahepatic causes of portal hypertension

Answer 18

pre-sinusoidal - schistosomiasis

sinusoidal - cirrhosis, alcoholic hepatitis

post-sinusoidal - veno-occlusive syndrome

Question 19

Pre-hepatic causes of portal hypertension

Answer 19

portal vein thrombosis
splenic vein thrombosis
massive splenomegaly

Question 20

What causes encephalopathy in liver disease?

Answer 20

ammonia is converted to glutamine
this crosses BBB
causes astrocyte swelling
this is worsened by hyponatraemia

Question 21

What is asterixis?

Answer 21

liver flap

Question 22

Hepatic encephalopathy treatment

Answer 22

lactulose (alters gut pH) - encourages bacteria that don’t produce as much ammonia
rifaximin

Question 23

Treatment of oesophageal varices

Answer 23

splanchnic vasoconstrictors (eg. terlipressin)
endoscopic therapy (eg. variceal banding)

Question 24

Complications of cirrhosis

Answer 24

hepatocellular carcinoma
osteoporosis (vit D metabolism altered)
immune paresis (liver important for innate immune system –> fungal sepsis more common in liver patients)
death
ascites
varices
portal htn

Question 25

What are some liver decompensation events?

Answer 25

ascites
jaundice
variceal bleed
encephalopathy

Question 26

Definitive treatment of liver decompensation event?

Answer 26

liver transplant (consider palliative care if can’t treat underlying pathology)

Question 27

What is the minimum UKELD score to be considered for transplantation? [UK model for end-stage liver disease]

Answer 27

49

Question 28

Main indications for TIPSS?

Answer 28

refractory variceal hemorrhage and refractory ascites

Question 29

What is TIPSS?

Answer 29

Transjugular intrahepatic portosystemic shunt
involves inserting a metal tube (shunt) through the liver which joins two large veins (the portal vein and hepatic vein). This allows blood to flow through the liver and relieves the portal hypertension which causes the varices. This shunt remains in place permanently. A large vein in your neck (jugular vein) is used to reach your liver.