Peritoneum

Question 1

Most important lab test for ascites?

another very important lab test for ascites?

Answer 1

Abdominal paracentensis

WBC w/ differential

Question 2

Two broad categories of ascites?

Answer 2

Diseased and normal peritoneum

Question 3

Most common casue of ascites?

Answer 3

Portal HTN secondary to liver disease

Question 4

Most forms of ascites have a SAAG < 1.1 g/dL

What is the ONLY one that doesn’t?

Answer 4

Portal HTN

Question 5

POrtal HTN is seen when the pressure gradient b/w the portal vein and IVC is greater than?

Answer 5

10

Question 6

Most ascites is secondary to liver disease, so what are the implications for a physical exam/

Answer 6

pts should be asked about risk factors for liver disease (alcohol consumption, drug use, hx of hepatitis, hx of malignancy, etc.)

Also note that pts w/ chronic liver disease are most likely to develop spontanous bacterial peritonits

(elevated JVP, hepatomegaly, caput medusa, palmar erythema, spider angiomas, gynecomastia, muscle wasting, asterixis [secondary to hepatic encephalopathy])

Question 7

JVD suggests?

Answer 7

CHF

another possible cause of hepatic congestion/portal HTN

Question 8

Large tender liver on PE?

Answer 8

indicative of alcoholic hepatitis or budd-chiari syndrome

risk factors for portal HTN -> ascites

Question 9

PE is relatively insensitive for detecting ascitic fluid. How much fluid is needed for detection?

Answer 9

1500

Question 10

Signs of portal HTN?

Answer 10

Hepatic enlargement

Elevated JVP (or JVD)

Large abdominal wall veins

(Though not exactly portal HTN, chronic liver dz is stronlgy associated. CLD ssx include: palmar erythema, cutaneous spider angiomas, gynecomastia, muscle wasting, asterixis, anasarca perhaps)

Question 11

Signs of liver dz?

Answer 11

muscle wasting

malnourishment

Question 12

A fever would suggest what type of ascites?

Answer 12

Bacterial peritonitis

Question 13

A shifting-dullness test would display what?

Answer 13

A dullness where the fluid is… so the dullness should shift when going form sitting/standing to lateral recumbent

Question 14

Most pts w/ ascites will get what as part of their eval?

Answer 14

abdominal paracentesis

Question 15

Visual inspection of fluid can be suggestive…

1. Milky?
2. Cloudy?
3. Bloody?

Answer 15

1. Milky - chylous
2. Cloudy - bacterial
3. Bloody - traumatic draw OR MALIGNANCY

Question 16

Routine study… most important test? (aside from paracentesis)

Answer 16

WBC w/ differential

if PMNs > 250, and > 75 % of WBC, highly suggestive of bacterial peritonitis

Question 17

Best single test for classification of ascites into portal HTN/non portal casues?

Answer 17

SAAG!

however SAAG doesn’t r/o concomitant malignancy

Question 18

Abd US for?

Answer 18

Detection of fluid AND guidance of paracentesis

Question 19

CT imaging, along w/ US, can help distinguish between?

Answer 19

portal/non-portal causes

Question 20

Hx of liver dz and ascites?

fever and abd pn?

Answer 20

Bacterial peritonitis

Question 21

Common pathogens for spontaneous bacterial peritonitis

Answer 21

Strep pneumo
E Coli
Enterococcus 
Klebsiella
Strep viridans

Question 22

Though pn if often present w/ spontaneous bacterial peritonitis, tenderness….

Answer 22

tenderness suggests other process

r/o SBP if pt has TTP

Question 23

W/ any ascites, abd paracentensis is the most important…

Answer 23

asictic fluid should be send for cell count w/ diff and blood culture

Question 24

Spontaneous bacterial peritonitis MUST be distinguished from?

Answer 24

secondary bacterial perotonitis, which would be an infection of peritonitis from elsewhere.

Question 25

Ascitic fluid total protein, LD, and glucose are useful in distinguishing between spontaneous bac peritonitis and secondary infection

Answer 25

Many pts w/ secondary bacterial infections have decreased glucose, elevated LD, OR total protein greater than 1g/dL

Question 26

If secondary bacterial peritonitis is suspected, what should we do?

Answer 26

Order an abd CT to leave for evidence of the source of infection…

Question 27

70 percent of patients who surive spontaneous bacterial peritonitis will have another episode… So consider prophylaxs with?>

Answer 27

Cipro 250-500

TMP-SMX DS

(also consider prophylaxis in pts who haven’t had a SBP but are at risk [low asctic protein, < 1])

Question 28

Empiric tx for spontaneous bacterial peritonitis?

Answer 28

ADMIT

Then, IV 3rd gen cephalosporin (ceftriaxone, cefotaxime) or beta lactam/beta lactamase (ampicillin/sulbactam), usually for 5 days but maybe 10 if it’s a virulent pathogen

Question 29

Two thirds of malignant ascites is caused by?

Answer 29

peritoneal carcinomatosis

most commonly a primary adenocarcinoma

Question 30

Causes of malignant ascites include?

Answer 30

blocked lymphatic channels as a result of malignancy

direct production of fluid into the peritoneal cavity by highly active cancers

“functional” cirrhosis develops in patients with extensive hepatic metastases

Question 31

Patients w/ malignant ascites may present w/?

Answer 31

nonspecific abdominal discomfort and wt loss w/ incraesed abdominal girth

Question 32

Accumulation of lipid rich lymph in the peritoneal cavity

Milky white in appearance

Wha’ts this called and what are we thinking?

Answer 32

chylous ascites attributable to a lymphatic obstruction

LYMPHOMA

Question 33

Pancreatic ascites (seen inchronic pancreatitis)?

Answer 33

intraperitoneal accumulation of massive amount of pancreatic secretions due to disruption of pancreatic duct

Question 34

Bile ascites?

Answer 34

Due to complications frmo biliary tract surgery or percutanous liver biopsy

Question 35

Tuberculous peritonitis… where might we consider that?

Answer 35

Pt has to be actively infected w/ TB

Rare in US, maybe seen on deployment

Question 36

Asbestos -> mesothelioma -> maybe ascites

Answer 36

aight