W4L1 Ascites

Question 1

Def

Answer 1

Accumulation free fluid in peritoneal cavity

Question 2

Types

Answer 2

• Excudate
• Transudate
• Haemorrhagic
• Chylous
• Purulent

Question 3

Causes of transudative ascites

Answer 3

1. Portal hypertension:
   Cirrhosis, Alco hepis, Fulminant hepis, Subacute hepis, CHF
2. Hypo albumaemia:
   Nephrotic syn, Protein losing enteropathy, Malnutrition

Question 4

Coz exudate(due local peritoneal condition)

Answer 4

1. Tuberculous peritonitis
2. Malignant ascites:
   •Massive, hemorrhagic & rapid accumulate
   •Malignant cells on aspiration
   •Abd mass(tumor)
3. Pseudomyxoma peritonis:
   •Rupture mucocele of appendix
   •Rupture mucocele of gall bladder
   •Pseudomucinous cystadenoma of ovary

Question 5

Features Chylous ascites

Answer 5

due thoracic duct obs coz by lymph nodes, tumor/filariasis

Features:
• Colour: milky white.
• Rich in fat
• Clears on addition of ether.
• Stains orange with Sudan III

Question 6

Coz Hemorrhagic ascites

Answer 6

1. Traumatic(rupture spleen)
2. Malignancy
3. Hemorrhagic bl dis
4. Ruptured ectopic preg
5. Acute pancis

Question 7

Patho ascites in cirrhosis

Answer 7

1. Splanchnic vasodilatation
2. ↓ Sys art pressure→ activated ras w 2ry aldosteronism, ↑sympa
3. Portal hypertension
4. Hypoalbuminemia

Question 8

Characteristics of ascitic fluid

Answer 8

1. Aspect:
   •Straw-colored: parenchymal liver dis portal htn
   •Cloudy: Bac peritonitis, pancis
   •Bloody: Trauma, tumor, invasive technique
   •Green: Biliary tract dis, ruptured bowel
   •Milky: Tumor, T.B, Lymph obs
2. Specific gravity:
   -transudate(1005-1015), exudate(>1015)
3. Protein:(transudate= 1-2g/100ml)
   ->: inf, Budd-Chiari syn, pancis, T.B
   -

Question 9

Clinical picture of ascites

Answer 9

History:

• abd distension
• dyspepsia
• respiratory distress

Question 10

Examination

Answer 10

1. Inspection:
   - diffuse abd enlarge
   - umblicus shift down
2. Palpation:
   - Fluid transmitted thrill(in tense ascites)
   - Liver & spleen(dipping method)
   - Abd swelling(malig & TB)
3. Percussion:
   - Resonance umbilicu & dull flank(>2L)
   - Shift dull side to side (>1.5L)
   - Knee elbow position (300-500cc)
4. Auscultation
   - Puddle sign: knee elbow position, change tone → +ve = fluid
   - Venous hum: portal htn (Kenawi sign)

Question 11

CP 2ry effect ascites

Answer 11

• Rt-side pleural effusion
• Elevate diaphragm causing:
  
  • Congested neck vein
  • Shift apex of heart up&outward
  • Dullness lung base(basal collapse).
• Edema following ascites (in LCF)

Question 12

Complications ascites:

Answer 12

1. Hydrothorax
2. Spontan bac peritonitis
   - MC E. Coli
3. Hernia
   - ↑intra abd pressure: inguinal, umbilical
4. Varicose vein
   - compress venous return LL & testicle
5. Urinary sym
   - ↑ uti

Question 13

Ddx ascites

Answer 13

• Obesity(fat)
• Distension(gas)
• Full urinary bladder
• Pregnant uterus: massive amniotic fluid.
• Ovarian cysts: huge
• Large pancreatic cyst.
• Huge organo megaly: huge liver & spleen

Question 14

Inv

Answer 14

1. Abd us(obese & sm fluid)
2. Diagnostic Paracentesis(confirm & obtain ascites)
3. Serum-Ascites Albumin Gradient
   - High gradient ( ≥1.1 g/dL)=portal htn w 97% accuracy
   - Low gradient (< 1.1 g/dL)= xPHT w 97% accuracy
   - Replace exudative (>2.5 g/dL total protein) & transudative ascites(poor=56%)
4. UGIE
5. CXR

Question 15

Treatment of ascites

Answer 15

1. Bed rest
2. Diet
   - NaCl 1L/d
3. Drugs(Diuretics)
4. Paracentensis
5. Surgical ttt
   - Peritoneo-venous (leveen) shunt
   - Omentopexy
   - Porto caval method

Question 16

Peritoneovenous Shunt CI & comp

Answer 16

CI:
•Protein > 4.5 g/l (occlusion)
•Loculated ascites
•Coagulopathy
•Advanced renal/cardiac disease
•GI malignancy

Comp:
•Inf
•Hematogenous spread of mets
•DIC
•Pulmonary edema
•Pulmonary emboli