Peritoneum Flashcards
Most important lab test for ascites?
another very important lab test for ascites?
Abdominal paracentensis
WBC w/ differential
Two broad categories of ascites?
Diseased and normal peritoneum
Most common casue of ascites?
Portal HTN secondary to liver disease
Most forms of ascites have a SAAG < 1.1 g/dL
What is the ONLY one that doesn’t?
Portal HTN
POrtal HTN is seen when the pressure gradient b/w the portal vein and IVC is greater than?
10
Most ascites is secondary to liver disease, so what are the implications for a physical exam/
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])
JVD suggests?
CHF
another possible cause of hepatic congestion/portal HTN
Large tender liver on PE?
indicative of alcoholic hepatitis or budd-chiari syndrome
risk factors for portal HTN -> ascites
PE is relatively insensitive for detecting ascitic fluid. How much fluid is needed for detection?
1500
Signs of portal HTN?
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)
Signs of liver dz?
muscle wasting
malnourishment
A fever would suggest what type of ascites?
Bacterial peritonitis
A shifting-dullness test would display what?
A dullness where the fluid is… so the dullness should shift when going form sitting/standing to lateral recumbent
Most pts w/ ascites will get what as part of their eval?
abdominal paracentesis
Visual inspection of fluid can be suggestive…
- Milky?
- Cloudy?
- Bloody?
- Milky - chylous
- Cloudy - bacterial
- Bloody - traumatic draw OR MALIGNANCY
Routine study… most important test? (aside from paracentesis)
WBC w/ differential
if PMNs > 250, and > 75 % of WBC, highly suggestive of bacterial peritonitis
Best single test for classification of ascites into portal HTN/non portal casues?
SAAG!
however SAAG doesn’t r/o concomitant malignancy
Abd US for?
Detection of fluid AND guidance of paracentesis
CT imaging, along w/ US, can help distinguish between?
portal/non-portal causes
Hx of liver dz and ascites?
fever and abd pn?
Bacterial peritonitis
Common pathogens for spontaneous bacterial peritonitis
Strep pneumo E Coli Enterococcus Klebsiella Strep viridans
Though pn if often present w/ spontaneous bacterial peritonitis, tenderness….
tenderness suggests other process
r/o SBP if pt has TTP
W/ any ascites, abd paracentensis is the most important…
asictic fluid should be send for cell count w/ diff and blood culture
Spontaneous bacterial peritonitis MUST be distinguished from?
secondary bacterial perotonitis, which would be an infection of peritonitis from elsewhere.
Ascitic fluid total protein, LD, and glucose are useful in distinguishing between spontaneous bac peritonitis and secondary infection
Many pts w/ secondary bacterial infections have decreased glucose, elevated LD, OR total protein greater than 1g/dL
If secondary bacterial peritonitis is suspected, what should we do?
Order an abd CT to leave for evidence of the source of infection…
70 percent of patients who surive spontaneous bacterial peritonitis will have another episode… So consider prophylaxs with?>
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])
Empiric tx for spontaneous bacterial peritonitis?
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
Two thirds of malignant ascites is caused by?
peritoneal carcinomatosis
most commonly a primary adenocarcinoma
Causes of malignant ascites include?
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
Patients w/ malignant ascites may present w/?
nonspecific abdominal discomfort and wt loss w/ incraesed abdominal girth
Accumulation of lipid rich lymph in the peritoneal cavity
Milky white in appearance
Wha’ts this called and what are we thinking?
chylous ascites attributable to a lymphatic obstruction
LYMPHOMA
Pancreatic ascites (seen inchronic pancreatitis)?
intraperitoneal accumulation of massive amount of pancreatic secretions due to disruption of pancreatic duct
Bile ascites?
Due to complications frmo biliary tract surgery or percutanous liver biopsy
Tuberculous peritonitis… where might we consider that?
Pt has to be actively infected w/ TB
Rare in US, maybe seen on deployment
Asbestos -> mesothelioma -> maybe ascites
aight
