Exam 3 - Ascites Flashcards by Madeleine Swindell

T/F: ascites is a sign of disease & not a diagnosis

true

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what is ascites?

accumulation of fluid in the peritoneal cavity causing abdominal swelling

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what are some other causes of abdominal distension that should be ruled out when considering ascites?

obesity, pregnancy, GDV, distended bladder, constipation, mass

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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

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what tests should be run on abdominal effusion in a patient with ascites?

specific gravity, total protein, +/- BUN, creatinine, bilirubin, & cytology

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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

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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

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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

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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

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how are effusions classified?

based on specific gravity, protein content, & number of cells present

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what is the main sign that you have an exudative effusion?

high number of cells, >5,000, mostly neutrophils, & protein >3

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what are some examples of diseases that can cause a pure transudate?

hypoalbuminemia, portal hypertension (pre-sinusoidal)

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what are some examples of diseases that can cause a modified transudate?

right-sided heart failure, portal hypertension, & neoplasia

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what are some examples of diseases that can cause a septic exudate?

bowel perforation, foreign body, & septic bile peritonitis

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what are some examples of diseases that can cause a non-septic exudate?

pancreatitis, FIP, urine, bile, & neoplasia

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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)

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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

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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

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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

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what is the most common cause of a pure transudate effusion?

low oncotic pressure due to a serum albumin concentration < 1.6 g/dL

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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