Ascites, portal hypertension + sequelae Flashcards
Define ascites
pathological fluid collection within the peritoneal cavity
What are the grades of clinical severity of ascites?
grade 1 = detectable by imaging only
grade 2 = clinically detectable
grade 3 = tense + obvious - can’t indent abdomen
Causes of abdominal distention
fluid
foetus
faeces
flatus
fat
How do you differentiate between exudative + transudative ascites?
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
Common causes of ascites in UK
liver disease - cirrhosis - transudate
heart failure - transudate
cancer - exudate
Causes of exudative ascites
biliary leak
nephrotic syndrome
pancreatitis
peritoneal carcinomatosis
tuberculosis
Causes of transudative ascites with ascitic protein <2.5g/dL
cirrhosis
late budd-chiari syndrome
massive liver metastases
Causes of transudative ascites with ascitic protein >2.5g/dL
congestive heart failure
constrictive pericarditis
early budd-chiari syndrome
IVC obstruction
sinusoidal obstruction syndrome
How is an ascitic tap carried out?
mark the skin
pull the skin downwards ~2cm
insert the needle perpendicular to skin and aspirate ~20ml ascitic fluid
withdraw needle and release skin
What tests do you do on ascitic fluid?
ascitic albumen
ascitic cytology (GI + gynae)
ascitic fluid cell count and culture
triglycerides
amylase (pancreatitis)
bilirubin (bile leak)
adenine deaminase (TB)
How do ascites form (arterial underfilling hypothesis)?
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
Ascites treatment
diuretics first line if safe to give
spironolactone
furosemide
no added salt
(pathogenesis driven by salt and water excess)
Ascites treatment if diuretic-resistant of diuretic-intractable
large volume paracentesis under US guidance
leave drain in for 6h
give back albumen 100mls 20% - 2.5L
Cirrhosis aetiologies
HCV
Alcohol
NAFLD
HBV
Autoimmune hepatitis
PSC (primary sclerosing cholangitis)
PBC (primary biliary cholangitis)
Wilson’s
Haemochromatosis
Cryptogenic
Drig-induced
Can fibrosis and cirrhosis be reversed?
fibrosis can be reversed if cause treated
cirrhosis is the point of no return and is irreversible
Portal hypertension complications
variceal haemorrhage
encephalopathy
ascites
Post-hepatic causes of portal hypertension
budd-chiari syndrome
IVC webs
cardiac causes
Intrahepatic causes of portal hypertension
pre-sinusoidal - schistosomiasis
sinusoidal - cirrhosis, alcoholic hepatitis
post-sinusoidal - veno-occlusive syndrome
Pre-hepatic causes of portal hypertension
portal vein thrombosis
splenic vein thrombosis
massive splenomegaly
What causes encephalopathy in liver disease?
ammonia is converted to glutamine
this crosses BBB
causes astrocyte swelling
this is worsened by hyponatraemia
What is asterixis?
liver flap
Hepatic encephalopathy treatment
lactulose (alters gut pH) - encourages bacteria that don’t produce as much ammonia
rifaximin
Treatment of oesophageal varices
splanchnic vasoconstrictors (eg. terlipressin)
endoscopic therapy (eg. variceal banding)
Complications of cirrhosis
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
What are some liver decompensation events?
ascites
jaundice
variceal bleed
encephalopathy
Definitive treatment of liver decompensation event?
liver transplant (consider palliative care if can’t treat underlying pathology)
What is the minimum UKELD score to be considered for transplantation? [UK model for end-stage liver disease]
49
Main indications for TIPSS?
refractory variceal hemorrhage and refractory ascites
What is TIPSS?
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.
