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2a Liver and GI > Asites > Flashcards

Asites Flashcards

1
Q

What does ascites refer to?

A

Detectable collection of fluid in the peritoneal cavity

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2
Q

Broadly, how do ascites form?

A

Increased pressure in the portal system means fluid leaks out of liver capillaries and other organs into the peritoneal cavity

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3
Q

What are symptoms of portal hypertension?

A

GI bleeding (if vessels rupture) + Blood in stool
Varices + Vomit blood
Ascites
Oedema
Encephalopathy
Jaundice
Caput medusa

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4
Q

What are symptoms of ascites?

A

Increased size of abdomen
Shifting dullness
Fluid thrill
Early satiety
Feeling out of breath
Jaundice
Pruritis
Severe painful distension (may be SBP)

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5
Q

What does “shifting dullness” refer to?

A

In ascites the fullness in flanks causes resonant and then dull sound when turned as fluid shifts

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6
Q

What is fluid thrill?

A

Test where patient pushes down on midline of abdomen
Examiner taps one flank and feels for the tap on the other flank.
Pressure normally should stop vibration of tap across but doesn’t if fluid is present.

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7
Q

What are broad concepts for ascites developing?

A

Low protein (decreased oncotic pressure)
Local inflammation
Flow stasis

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8
Q

What are reasons for inflammation which causes ascites?

A

Malignancy (eg ovarian)
Peritonitis (bacterial infection)
TB

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9
Q

What conditions cause there to be low levels of protein in the blood which can cause ascites?

A

Nephrotic syndrome
Hypoalbuminaemia (liver failure)

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10
Q

What are some conditions causing flow stasis leading to ascites?

A

Cirrhosis
Budd Chiari
Congestive heart failure
Constrictive pericarditis

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11
Q

Name some major causes of ascites?

A

Cirrhosis
Malignancy
Heart failure
TB
Pancreatitis

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12
Q

How does fibrosis lead to portal hypertension?

A

Fibrotic tissue replaces healthy liver tissue, disrupting the liver architecture.
Results in increased resistance to blood flow = portal hypertension

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13
Q

How does portal hypertension lead to ascites?

A

Increased pressure forces blood out of the vessels into the peritoneal cavity

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14
Q

Who are the kidneys involved in fibrosis and ascites?

A

Fibrosis causes portal hypertension which triggers splanchnic vasodilation to redistribute blood.
Causes lower blood pressure at kidneys so RAAS activated.
leads to increased water and sodium retention which contributes to fluid accumulation in peritoneal cavity.

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15
Q

How do albumin levels in cirrhosis contribute to ascites?

A

Cirrhosis leads to hypoalbuminemia resulting in lower oncotic pressure so more fluid moves out of vessels into cavity compared to in.

Also inflammation of liver and peritoneum increases the permeability of vessels so more proteins like albumin can leak out.

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16
Q

What system is unable to keep up with the accumulation of fluid in the peritoneum causing ascites to develop?

A

Lymphatic system

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17
Q

At what volume does ascites typically become clinically detectable?

A

500ml

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18
Q

What classifies as stage 1 ascites?

A

Detectable only after careful examination or ultrasound

19
Q

What classifies as stage 2 ascites?

A

Easily detectable but of relatively small volume

20
Q

What classifies as stage 3 ascites?

A

Obvious, not tense ascites

21
Q

What classifies as stage 4 ascites?

A

Tense ascites (large)

22
Q

How is ascites diagnosed?

A

Shifting dullness

Ascitic tap:
Neutrophilia
Raised ESR and CRP
Measure protein
MC&S (identify causative organism)

23
Q

What should be excluded in suspected ascites?

A

Pregnancy: take B-hCG test

Bowel obstruction: abdominal XR

Perforated colon: Erect CXR showing air under diaphragm

24
Q

How is ascites managed?

A

Low sodium diet
Aldosterone agonists eg spironolactone (increases natriuresis so more fluid flushed out whilst conserving potassium)

Fluid restriction
Paracentesis (ascitic tap)
Prophylactic Abx
TIPS (transjugular intrahepatic portosystemic shunt)
Liver transplant

25
Q

What does “refractory ascites” mean?

A

Resistant to standard management strategies
Often means ascites is recurrent and persistent with increased risk of complications

26
Q

What might cause the ascitic to appear clear or straw coloured?

A

Liver cirrhosis

27
Q

What might cause the ascitic fluid to appear cloudy?

A

SBP
Perforated bowel
Pancreatitis

28
Q

What might cause the ascitic fluid to appear bloody?

A

Malignancy
Haemorrhagic pancreatitis

29
Q

What might cause the ascitic fluid to appear milk coloured/ chylous?

A

Lymphoma
TB
Malignancy

30
Q

Is there typically more or less protein present in the ascitic fluid in SBP and TB?

A

More
>4g/dL

31
Q

Is there typically more or less glucose present in the ascitic fluid in TB/malignancy compared to the serum level?

A

Less than serum level

32
Q

In pancreatitis causing ascites, does the ascitic fluid typically contain more or less amylase compared to the serum level?

A

More

33
Q

In which conditions may there be a higher than normal RCC in the ascitic fluid?

A

Malignancy
TB
Haemorrhage
Trauma

34
Q

If there is a high WCC with predominantly neutrophils in the ascitic fluid, what condition is it likely to be?

A

SBP

35
Q

If there is a high WCC with predominantly lymphocytes in the ascitic fluid, what condition is it likely to be?

A

TB

36
Q

What does a high SAAG mean (over 1.1g/dL or 11g/L)?

A

Big difference in serum albumin to ascitic fluid albumin suggests there is portal hypertension (increased hydrostatic pressure forcing liquid but not protein out blood)

Suggests ascitic fluid is a transudate

37
Q

What does a low SAAG mean (under1/1 g/dL or 11 g/l)?

A

Means high concentration of protein in ascitic fluid
Small difference in serum albumin to ascitic fluid albumin suggests lots of protein is leaking out from inflammation

Eg malignancy
infection
pancreatitis
nephrotic syndrome

Suggests ascitic fluid is an exudate

38
Q

A transudative ascites has a protein concentration of below…

A

25 g/l
(associated with high hydrostatic pressure)

39
Q

What are some conditions which lead to high hydrostatic pressure so transudative ascites?

A

Liver cirrhosis
Heart failure
Constrictive pericarditis
(also hypoalbuminaemia but to do with low oncotic pressure rather than high hydrostatic pressure)

40
Q

An exudative ascites has a protein concentration of…

A

Over 25 g/l
(associated with inflammation)

41
Q

True or false: exudative ascites will be cloudy fluid?

A

True

42
Q

What will the colour of transudative ascites be?

A

Clear (low protein so not cloudy)

43
Q

What are some conditions which lead to increased permeability of blood vessels so exudative ascites?

A

Infection
IBD
Malignancy
Pancreatitis
Budd Chiari syndrome

44
Q

How do you work out the Serum Ascites Albumin Gradients (SAAG)?

A

Serum albumin - ascites albumin

2a Liver and GI (61 decks)

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