Exam 3 - Ascites Flashcards
T/F: ascites is a sign of disease & not a diagnosis
true
what is ascites?
accumulation of fluid in the peritoneal cavity causing abdominal swelling
what are some other causes of abdominal distension that should be ruled out when considering ascites?
obesity, pregnancy, GDV, distended bladder, constipation, mass
what is the first step in working up a patient known to have ascites?
need to determine what type of abdominal effusion is present - diagnostic abdominocentesis is an essential part of the work up
what tests should be run on abdominal effusion in a patient with ascites?
specific gravity, total protein, +/- BUN, creatinine, bilirubin, & cytology
after doing a physical exam & getting a history on a patient presenting with abdominal enlargement, what diagnostics should you pursue? why?
rads & ultrasound - need to differentiate between organomegaly, abdominal effusion, or the absence of a mass/fluid
what supplies do you need for an abdominocentesis?
red top - for biochemistry panel
EDTA - for cytology
culturette tubes for bacterial culture
slides for cytology
can do blind or ultrasound guided
what is the 4 quadrant approach for abdominocentesis?
patient in left lateral or dorsal recumbency
in left lateral - insert needle just caudal to the umbilicus 1 to 2 cm to the right of midline & avoid the epigastric blood vessels
in dorsal recumbency - insert needle just caudal to the umbilicus 1 to 2 cm to the left/right of midline & avoid the epigastric blood vessels
what are the 7 general types of effusions seen in patients with ascites?
- septic exudate
- transudate
- modified transudate
- bile peritonitis
- hemo-abdomen
- uro-abdomen
- chylo-abdomen
how are effusions classified?
based on specific gravity, protein content, & number of cells present
what is the main sign that you have an exudative effusion?
high number of cells, >5,000, mostly neutrophils, & protein >3
what are some examples of diseases that can cause a pure transudate?
hypoalbuminemia, portal hypertension (pre-sinusoidal)
what are some examples of diseases that can cause a modified transudate?
right-sided heart failure, portal hypertension, & neoplasia
what are some examples of diseases that can cause a septic exudate?
bowel perforation, foreign body, & septic bile peritonitis
what are some examples of diseases that can cause a non-septic exudate?
pancreatitis, FIP, urine, bile, & neoplasia
if you have a result of a transudate or modified transudate on your patient with ascites, what should you investigate?
check their albumin
check for right-sided heart failure
check for portal vein thrombosis/portal hypertension
check for pancreatitis (usually exudate though)
if you have a result of an exudative effusion on your patient with ascites, what should you investigate?
check for the presence of bacteria
check for pancreatitis
check for bile/urine
if you have a result of a hemorrhagic effusion on your patient with ascites, what should you investigate?
check for bleeding disorders
check for bleeding masses
if you have a result of a chylous effusion on your patient with ascites, what should you investigate?
look for neoplasia or a lymphatic blockage
what is the most common cause of a pure transudate effusion?
low oncotic pressure due to a serum albumin concentration < 1.6 g/dL
if you have a patient with a pure transudate effusion off of abdominocentesis, & you suspect protein losing nephropathy, what do you expect their serum globulin concentration to be? what diagnostic test would you use to confirm?
normal to high
urine protein to creatinine ratio > 2
if you have a patient with a pure transudate effusion off of abdominocentesis, & you suspect hepatic insufficiency, what do you expect their serum globulin concentration to be? what diagnostic test would you use to confirm?
normal to high
serum bile acid testing
if you have a patient with a pure transudate effusion off of abdominocentesis & suspect protein losing enteropathy, what do you expect their serum globulin concentration to be? what diagnostic test would you use to confirm?
decreased, normal, or high
rule out other causes - fecal alpha-1 proteinase inhibitor
T/F: radiographs are very sensitive for detecting ascites
false
T/F: pure transudates are rarely caused by pre-sinusoidal portal hypertension such as portal vein thrombosis or hepatic artery/vein malformation
true
what is the general cause of modified transudates?
increased hydrostatic pressure
what are some examples of right-sided heart diseases causing modified transudates? what diagnostics are indicated?
tricuspid valve disease, HWD, pericardial tamponade, restrictive pericarditis, myocardial disease, & arrhythmias
physical exam & cardiac ultrasound
what diagnostic test should you always do on exudates?
culture!!!!
what is almost always indicated in a patient with a septic exudate? what imaging should be done prior?
emergency exploratory surgery
abdominal rads - look for free gas
abdominal ultrasound
CT if available - especially in big dogs
how is portal hypertension as a cause of a modified transudate diagnosed?
abdominal ultrasound
bile acids
+/- liver biopsy
how is abdominal neoplasia as a cause of a modified transudate diagnosed?
abdominal ultrasound & surgical exploratory
T/F: fluid cytology is rarely diagnostic for neoplasia causing a modified transudate
true
what are some common causes of non-septic exudate?
pancreatitis
FIP in cats
uroabdomen
bile peritonitis
neoplasia
what diagnostics are indicated for investigating a non-septic exudate?
abdominal imaging - ultrasound & consider CT
test effusion for bilirubin or urea/creatinine as indicated
test for pancreatitis with cPLI/fPLI as indicated
consider testing for FIP in cats
how do you differentiate between a spontaneous & iatrogenic hemoabdomen based off of hemorrhagic effusion?
take a sample from abdominocentesis
leave the sample in a plain tube - if it clots, it is iatrogenic
if it doesn’t clot - spontaneous
if you have an effusion that appears to be red but you’re unsure if it is hemorrhagic, how do you investigate it?
check hematocrit - transudates & exudates usually have a PCV <5%
what are 4 examples of causes of hemoabdomen?
trauma
neoplasia
coagulopathy
hepatic amyloidosis in cats
what should be included in the work up of a patient with a hemorrhagic abdominal effusion?
ask about a history of trauma
rule out systemic bleeding disorders - platelet count, coagulation panel, +/- BMBT
thoracic/abdominal imaging to look for masses
what effusion is shown here?
chylous
what are some common causes of chylous abdominal effusions?
trauma, neoplasia, infection, & right-sided heart failure
what are the characteristics of a chylous effusions?
turbid, poaque, milky
SG > 1.025 & protein > 2.0 g/dL
effusion triglycerides are higher than serum levels
effusion cholesterol: triglyceride ratio <1
mostly lymphocytes
when would you remove abdominal effusion on a patient with ascites? why?
reserved for patients with difficulty breathing
depletes the protein reserves & fluid often quickly reforms
what does the efficacy of diuretics used for treating ascites depend on?
depends on the underlying cause of the ascites
what is the main difference between furosemide & spironolactone?
furosemide - potassium wasting
spironolactone - potassium sparing
what is included in the symptomatic treatment of ascites?
treat the underlying cause!!!!
removal of fluid - reserved for patients with difficulty breathing
diuretics
moderate sodium diet - useful adjunctive treatment
T/F: septic peritonitis is an indication for emergency surgery
true
what is the pathogenesis of portal hypertension?
hepatic fibrosis & nodular regeneration leads to hepatic (sinusoidal) portal hypertension
what are 4 examples of patients with ascites that need emergency surgery?
septic peritonitis - cytology & culture
uroabdomen - measure BUN/creatinine in fluid & blood to confirm
bile peritonitis - measure bilirubin in fluid & blood
hemoabdomen with uncontrollable bleeding - reassess patient’s vital signs & PCV
how do you evaluate a patient for a fluid wave?
place one hand on one side of the ventral abdomen & then ballot with your hand on the opposite side of the abdomen
should you just bolus fluids into a shocky patient with severe abdominal bleeding?
nope - give whole blood or autotransfuse
to determine the type of effusion, what 3 things do you need to determine?
fluid’s specific gravity/total protein
nucleated cell count
differential cell count
if you have a patient that you suspect to have ascites, and you see a jugular pulse on your physical exam, what do you think is the underlying cause of the effusion?
right-sided heart disease
