Weight loss and ascites Flashcards
Name3 chronic diseases cachexia can be associated with (4)
- CHF
- CKD
- wide range of neoplastic disease
- chronic inflammatory/infectious disease
What are 2 things cachexia is characterised by
- poor calorific intake
- inflammation=circulating cytokines= detrimental effect on metabolism
Define sarcopenia
Loss of lean body mass that occurs with ageing but no significant clinical disease
What are the categories for weight loss causes?
Adequate diet but
- Competition for or limited access to food
- Oral disease- any dysphagia?
- Metabolic rate
- Hyperthyroidism/ chronic pyrexia
- Caloric requirement – pregnancy
- Impaired use/loss of nutrients
- PLE/PLN, DM, maldigestion/malabsorption
- Liver disease
- Chronic inflammatory disease
- Neoplastic disease
- Apparent weight loss – fat redistribution?
- Pathologic muscle loss – inflammatory myositis
Inadequate diet
- Poor quality
- Change in type/change in formulation
- Starvation
What is the associatio of pyrexia and weight loss?
Increased BMR
- associated with infection, inflammation, immune mediated disease, neoplasia
- Increases the calorie requirement in the pet – so if they don’t keep up with this it means they loose weight
Name infectious disease causing weight loss (3)
- Chronic infections – granulomatous diseases
- Mycobacteria
- FeLV/FIV (cats)
- FIP (cats)
What questions can be asked to question causes of weight loss?
- What is the timescale?
- Acute, subacute, chronic
- Have there been any management changes?
- Competition in the house from a new pet?
- Has the diet changed?
- Quantity and/or quality
- Has there been a change in appetite?
- Recognise diseases that cause weight loss in the face of appetite
- Are there any other clinical signs?
- Is there evidence of concurrent disease?
- Osteoarthritis in an elderly cat might ¯ mobility and therefore ¯ food intake
- Is there evidence of concurrent disease?
- Can you document the weight loss
How much does 1litre of ascites way?
1kg
Name causes of weight loss and inceased appetite (4)
- Endocrine disease
- Diabetes mellitus (dogs and cats)
- Hyperadrenocorticism (dogs)
- Loss of muscle mass
- Fat redistributes
- Hyperthyroidism (cats)
- GI disease
- EPI
- Intestinal malabsorptive diseases (**appetite often is ¯ but can be )
- IBD
- Lymphangiectasia
- PLE
- Liver disease: (**unlikely…usually appetite will ¯)
- Not always pathological:
- Growing animals
Name 4 diseases of the GI system causing weight loss (5)
- Oral disease?
- Oesophageal disease – chronic regurgitation à ¯ intake
- Liver/pancreatic disease
- Chronic intestinal disease
Name 2 diseases of the respiratory and CRS system causing weight loss (3)
- Usually see other clinical signs
- Pulmonary neoplasia may “only” see weight loss/ “not doing well”
- Occult AF/CHF
Name 2 diseases of the endocrine system causing weight loss (3)
- Hyperthyroidism
- Hypoadrenocorticism/hyperadrenocorticism
- Diabetes mellitus
Name a disease of the urinary system causing weight loss (2)
- CKD often associated with weight loss
- Chronic UTI
Name a disease of the haemolymphatic system causing weight loss
- Inflammatory and neoplastic disease
- Often occult disease causes chronic weight loss
- Sometimes difficult to localize
Name 4 disease of the neuromuscular/MSK system causing weight loss (5)
- Neurogenic atrophy of muscles
- Inflammatory or degenerative myopathies
- Chronic neurodegenerative disease
- Inflammatory neurological disease
- Chronic orthopaedic disease and pain can lead to weight loss
What is the standard aproach to investigation of weigh loss?
- Start with a thorough history
- Perform a complete physical examination
- Generate a clear and defined problem list
- Think about primary and secondary problems
- Primary problems will be more useful for differentials (e.g. vomit/diarrhea)
- Secondary problems might need treatment (e.g. dehydration or weight loss)
- Come up with a systems based differential list and then prioritise this list
- Undertake appropriate investigations to rule likely differentials in or out
- Review the case if things are not going according to plan
- Seek advice and help at any stage if you need to!
Do primary or secondary problems guide the differentials?
Primary
Define ascites
An abnormal collection of fluid in the abdominal cavity
How would you investigate ascites?
- Take a thorough history and perform a good physical exam
- Is there a clue to the primary disease?
- Collapse
- Could there be haemoabdomen due to a splenic bleed?
- Diarrhoea
- Could the ascites be due to hypoalbuminaemia from GI loss (eg PLE)
- PU/PD
- Could the cause be pln progressing to ckd?
- Jaundice
- Is there a leak in the biliary system?
- Exercise intolerance
- Is there any suggestion of cardiac or pericardial disease
- Anuria
- Has the urethra or bladder ruptured?
- Is there evidence of effusion elsewhere?
- Dull chest sounds might indicate pleural fluid. Could therefore be a reduced COP.
- Generalised or localised?
What would you investigate to understand if there was cardiac or pericardial disease?
Are there any abnormal heart sounds?
What do the jugular veins look like?
What diagnostic imaging can you do for ascites?
- Abdominal ultrasound
- Confirm presence of fluid if necessary
- Look for underlying cause
- Is there a mass?
- Is the intestinal wall thickened and/or any change in echogenicity?
- Can you identify the gall bladder and/or urinary bladder?
- Ultrasound guided sampling if necessary?
- Radiography?
- Contrast radiographs to identify leak in urinary tract?
- Thoracic ultrasound
- Is there any pleural fluid or is this just an abdominal problem?
- Is there any evidence of pericardial fluid as a cause?
- Pericardial or right sided heart failure is not an uncommon cause of ascites
- Abdominocentesis
- We need a sample
- Sterile technique is important
- Surgical prep
- Cannot interpret the sample well if it has not been collected in the appropriate fashion
- Minimise the risk of haemocontamination
- Where is the spleen?
- If you jab the spleen then you will think there is a haemoabdomen!!! And go in for surgery!!
- What colour is the sample as you collect it? As you collect it!
What do we do with a fluid sample?
Collect samples in appropriate blood tubes
- plain tube for protein and biochemical analysis
- bilirubin?
- creatinine?
- EDTA tube for cell counts
- smears for cytology made ASAP to minimise deterioration
- direct if sample appears turbid and is likely to be quite cellular
- if clear may need to centrifuge the sample and then prepare a smear
- don’t spin too fast or too long or à damaged cells
- bench centrifuge for 5 mins at 500-1000 rpm or Cytospin
- important to minimise artefacts
- air dry rapidly
- careful staining if in-house, keep an unstained sample for external cytology
- sterile pot for bacterial culture
What else can we do with the fluid sample?(4)
- Compare fluid glucose with blood glucose
- if blood glucose is 1.1mmols/l higher than effusion, suggests septic peritonitis or malignant effusion
- Compare fluid lactate with blood lactate
- if fluid lactate is > 2.5 mmol/l & higher than blood lactate, suggests septic peritonitis
- Compare fluid creatinine and potassium with blood values
- if effusion : serum creatinine ratio >2:1 then indicates uroabdomen in 85% dogs
- if effusion : serum potassium ratio > 1.4:1 then indicates uroabdomen in 100% dogs
- Compare fluid bilirubin and blood bilirubin
- bile peritonitis?
What is the normal pathophysiology for transudates?
- Fluid forms in small amounts for
- lubrication
- diffusion of substances eg electrolytes
- Rate of formation depends on balance between plasma COP and hydrostatic forces
- Any excess fluid in the abdominal cavity will usually be absorbed by the lymphatic system
What fluid type is this, and what are the properties?
- Appearance: clear, colourless
- Protein: <20 g/l
- Nucleated cells: <1.5 x109/l
- Specific gravity <1.017
- Cell type/s:
- few RBCs
- small mixed nucleated cell population
- neutrophils up to 60%
- lymphocytes, monocytes, macrophages, mesothelial cells
What are these, what should we do if we see them?
Mesothelial cells
Seen singly and in clumps in all body cavity fluids.
Don’t confuse reactive mesothelial cells for malignant cells
Mesothelial cells, if dysplastic, may appear neoplastic, with deeply basophilic cytoplasm, variable nuclear to cytoplasmic ratio.They maybe multi- nucleated, with clumped chromatin & prominent nucleoli.
However, an apparent fringe of pink villi on some cells can help to identify them as mesothelial cells.
Do not make a call of malignancy just from dodgy abdo fluid!!!
In what numbers do mesothelial cells occur?
Occur in increased numbers, and may become dysplastic
when there is irritation or inflammation present.
What is this and what are the properties?
Modified transudate
- Appearance: variable
- clear/turbid/watery/yellow/orange/red
- Protein: >20 g/l - <50g/l
- Nucleated cells: <5 x109/l
- Specific gravity >1.017 - < 1.025
Cell type/s:
Moderate mixed nucleated cell population (mostly neutrophils and macrophages, mesothelial cells are often seen, occasional lymphocytes and monocytes)
What is this and what are the properties?
- Appearance: turbid/bloody/purulent
- Protein: > 30 g/l (
- Nucleated cells: >5x109/l
- Specific gravity >1.025
- Cell type/s:
- many RBCs
- nucleated cells are mostly neutrophils (degenerate)
- **bacteria may be present**
What is this and what are the properties?
Neoplastic effusion
- Appearance: may be bloody and/or turbid
- Protein: often > 35 g/l
- Nucleated cells: often 5-25 x109/l
- Specific gravity often >1.025
- Cell type/s:
- RBCs, mixed nucleated cell population
- Neoplastic cells may be seen
- particularly with exfoliative disease such as lymphoma
- RBCs, mixed nucleated cell population
What is the issue here?
Neoplastic effusion
What is this and what are the properties?
- Appearance: milky, white or pink
- Protein: 10-30 g/l
- Nucleated cells: 5-20 x109/l
- Cell type/s:
- cells vary with chronicity
- mostly mature lymphocytes early in the disease process
- mixed with chronicity, macrophages contain Sudan staining inclusions
What is the differece between chyle and pseudochyle?
What can be seen here?
Diagnosing septic peritonitis especially associated with leaking of GI tract - extreme example is a pneumoperitoneum Air highlighting diaphragmatic margins – gas opacity at the top, also seeing quite off gas shadows highlight intestinal tract – makes us think there is air in abdo cavity, and unless there is recent surgery, then need to assume there is something ruptured
Do you need bacterial culture?
Bacteria in a cell – cannot be contaminate!!
PATHOLOGICAL AS ENGULFED BY NEUTROPHIL
- Not really but may do. Send one off anyway, but don’t sit and wait or it to come back to say yes or no whether it has septic peritonitis- patient may be dead by this point.
- too slow to rely on for decision making about surgery!
- may help guide treatment at a later stage
