Clinical skills ( LP, ascitic and pleural tap)

Question 1

why do we do clinical skills

Answer 1

for diagnostic and therapeutic benefits

Question 2

what should you remember to do when you about to perform a procedure

Answer 2

-be aseptic
-be atraumatic
-to be aware of the resources
-to do useful sampling

Question 3

what are the diagnostic indications for an ascitic tap

Answer 3

-bacterial peritonitis
-TB
-intra abdominal malignancy

Question 4

what are therapeutic indications for an ascitic tap

Answer 4

if theres high pressure ascites e.g. from liver disease

Question 5

an ascitic sample is sent for what tests

Answer 5

cytology
microscopy
culture
sensitivity
biochemistry

Question 6

at what site do you perform the ascitic tap

Answer 6

3cm superomedial from the anterior superior iliac spine ( so as to avoid the inferior epigastric artery)

Question 7

what are general contraindications for an ascitic tap

Answer 7

-bleeding diathesis- due to low platelets, clotting factors

-infection at skin site
- distended bowels
-severe organomegally
-distended bladder

Question 8

what are specific contraindications for an ascitic tap

Answer 8

• patient is initially hypotensive
• hyponatremia (<126mmol/L)

Question 9

what are general risks of performing an ascitic tap

Answer 9

-uncontrolled bleeding due to damage of major vessels, liver or spleen
- infections like peritonitis or of the skin

Question 10

what are specific risks that can occur when performing an ascitic tap

Answer 10

-bowel perforation, which can cause peritonitis
-hypotension secondary to peritoneal volume loss

Question 11

how much fluid are you not allowed to remove during an ascitic tap

Answer 11

> 5L

Question 12

what happens if you tap more than 5L in an ascitic tap

Answer 12

-it can precipitate post paracentesis circulatory dysfunction
-hyponatremia
-acute kidney injury
-increased plasma renin activity

Question 13

what does serum ascites albumin gradient (SAAG) correlate with

Answer 13

portal pressure

Question 14

conditions with exudative ascites have a gradient of what

Answer 14

<1.1.g/dl

Question 15

conditions which cause transudative ascites have a gradient of what

Answer 15

> 1.1.g/dl

Question 16

which conditions cause transudative ascites : SAAG>1.1g/dl

Answer 16

Liver disorders
-cirrhosis/ alcoholic liver disease
-acute liver failure
-liver metastases

Cardiac
-right heart failure
-constrictive pericarditis

Other
-budd chiari syndrome
-portal vein thrombosis
-veno occlusive disease
-myxoedema (severe hypothyroidism)

Question 17

which conditions cause SAAG<1.1.g/dl

Answer 17

Hypoalbuminemia
-nephrotic syndrome
-severe malnutrition e.g. kwashiorkor

Malignancy e.g. peritoneal carcinomatosis

Infections
- TB

Other
-pancreatitis
-bowel obstruction connective tissue disease (serositis)
-postoperative lymphatic leak
-biliary ascites

Question 18

how else can you manage ascites

Answer 18

-reduce dietary sodium
-if sodium is <125mmol/L restrict fluid intake
-give aldosterone antagonists like spironolactone to block the RAAS and loop diuretics

Question 19

what is spontaneous bacterial peritonitis

Answer 19

its an ascitic neutrophil count of 250-255/field of microscope

Question 20

how do you treat spontaneous bacterial peritonitis

Answer 20

with IV antibiotics like cephalosporins then prophylactic antibiotics with oral quinolones like ciprofloxacin in pts with protein of 1.5g/dl or less until ascites resolves
-TIPS (transjugular intrahepatic portosystemic shunt)