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APPROACH TO THE PATIENT WITH ASCITES

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Title: APPROACH TO THE PATIENT WITH ASCITES Author: DR.MAHMOOD ALI LODHI Last modified by: Family Created Date: 11/7/2007 9:27:07 AM Document presentation format – PowerPoint PPT presentation

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Title: APPROACH TO THE PATIENT WITH ASCITES


1
(No Transcript)
2
APPROACH TO THE
PATIENT
with
ASCITES
  • DR.MAHMOOD ALI LODHI
  • HOUSE OFFICER MU-1

  • 14-11-2007

3
AIM
  • The Aim Is To Approach The Patient With Ascites
    In Terms Of
  • DEFINITION
  • CAUSES
  • CLINICAL FEATURES
  • INVESTIGATIONS
  • MANAGEMENT
  • COMPLICATIONS
  • MCQs.

4
DEFINITION
5
ASCITES
  • IT IS THE CONDITION OF PATHOLOGICAL ACCUMULATION
    OF FLUID IN ABDOMINAL CAVITY

6
CAUSES
7
CAUSES
  • Can Be Broadly Classified On The Basis Of
  • Normal peritoneum
  • Diseased peritoneum

8
CAUSES
  • NORMAL PERITONEUM
  • Portal hypertension
  • Congestive Heart Failure
  • Constrictive Pericarditis
  • Tricuspid Insufficiency
  • Budd-Chiari Syndrome
  • Liver Cirrhosis
  • Alcoholic Hepatitis
  • Fulminant Hepatic Failure
  • Massive Hepatic Metastases

9
CAUSES
  • NORMAL PERITONEUM
  • Hypoalbuminemia
  • Nephrotic Syndrome
  • Protein-losing Enteropathy
  • Severe Malnutrition with Anasarca

10
CAUSES
  • NORMAL PERITONEUM
  • Miscellaneous conditions
  • Chylous ascites
  • Pancreatic ascites
  • Nephrogenic ascites
  • Meigs syndrome

11
CAUSES
  • DISEASED PERITONEUM
  • Infections
  • Tuberculous Peritonitis
  • Bacterial Peritonitis
  • Fungal Peritonitis
  • HIV associated peritonitis

12
CAUSES
  • DISEASED PERITONEUM
  • Malignant conditions
  • Peritoneum Carcinomatosis
  • Hepatocellula Carcinoma
  • Primary Mesothelioma
  • Pseudomyxoma Peritonei

13
CAUSES
  • DISEASED PERITONEUM
  • Other rare conditions
  • Granulomatous Peritonitis
  • Vasculitis

14
CLINICAL FEATURES
15
CLINICAL FEATURES
  • PRESENTING COMPLAINTS
  • Abdominal Distension
  • Diffuse Abdominal Pain
  • Bloated Feeling of Abdomen
  • Dyspnoea and Orthopnea (due to elevation of
    daipharagm)
  • Indigestion and Heart burn (due to inc intra
    abdominal pressure)

16
CLINICAL FEATURES
  • PHYSICAL EXAMINATION
  • Abdominal Distension
  • Fullness of Flanks
  • Umbilicus Flat and Everted
  • Diverticulation of Recti Muscles
  • Distended Abdominal Veins
  • Shifting dullness (esp. when gt1000ml of fluid)
  • Fluid Thrill
  • Puddle Sign

17
CLINICAL FEATURES
  • PHYSICAL EXAMINATION
  • SIGNS RELATED TO SECONDARY EFFECTS OF ASCITES
  • Scrotal Edema
  • Pleural effusion (due to defect in the diaphragm
    and fluid pass into the pleural space)
  • Edema
  • Cardiac apex is shifted upward due to raised
    diaphragm)
  • Distended neck veins due to inc rt atrial
    pressure)

18
CLINICAL FEATURES
  • PHYSICAL EXAMINATION
  • SIGNS RELATED TO THE CAUSE OF ASCITES
  • LIVER DISEASE
  • Jaundice,Anemia,Palmar erythema,Spider
    angiomas,Hepatosplenomegaly,
  • CARDIAC DISEASE
  • Elevated JVP
  • MALIGNANCY
  • SISTER MARY JOSEPH NODUE in
    umblicus(peritoneal carcinomatosis like gastric,
    pancreatic and hepatic malignancies)
  • VIRCHOW NODE (rt supraclavicular lymph node
    due to upper abdominal malignancy)
  • NEPHROTIC SYNDROME
  • Edema or Anasarca

19
STAGING
  • Can Be Semi Quantified Into
  • Stage 1 is detectable only after careful
    examination.
  • Stage 2 is easily detectable but of relatively
    small volume.
  • Stage 3 is obvious ascites but not tense
    ascites.
  • Stage 4 is tense ascites.

20
INVESTIGATIONS
21
Includes
INVESTIGATIONS
  • Imaging studies
  • Lab studies
  • Laparoscopy

22
INVESTIGATIONS
  • IMAGING STUDIES
  • CHEST AND ABDOMINAL PLAIN FILMS
  • Detects ascites if gt500ml fluid
  • Elevated diaphragm
  • Pleural effusion (hepatic hydrothorax)
  • Diffuse abdominal haziness
  • USG ABDOMEN
  • can detect as small as 5ml fluid
  • can identify the cause like liver cirrhosis
  • CT SCAN
  • can identify the cause like malignancies

23
INVESTIGATIONS
  • LAB STUDIES
  • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
  • Ascitic Fluid should be analyzed for
  • APPEARANCE
  • CELL COUNT
  • TOTAL PROTEINS
  • SAAG(SERUM ASCITIC ALBUMIN GRADIENT)
  • CYTOLOGY
  • CULTURE
  • MISCELLENOUS
  • BASELINE INVESTIGATIONS LIKE BLOOD CP,LFTS,PT APTT

24
INVESTIGATIONS
  • LAB STUDIES
  • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
  • APPEARANCE
  • TRANSPARENT AND TINGED NORMAL
  • STRAW COLORED CIRRHOSIS
  • HEAMORRHGIC MALIGNANCY
  • CLOUDY INFECTION
  • BILE STAINED BILIARY CONTAMINATION
  • CHYLOUS LYMPHATIC OBSTRUCTION

25
INVESTIGATIONS
  • LAB STUDIES
  • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
  • CELL COUNT
  • WBCS lt500/mm3 and NEUTROPHILSlt250/mm3 NORMAL
  • NEUTROPHILSgt250/microL suggests SBP
  • LYMPHOCYTES PREDOMINANCE ABDOMINAL TB OR
    MALIGNANCY

26
INVESTIGATIONS
  • LAB STUDIES
  • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
  • TOTAL PROTEINS
  • PROTEINSlt2.5g/dl TRANSUDATE
  • PROTEINSgt2.5g/dl EXUDATE

27
INVESTIGATIONS
  • LAB STUDIES
  • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
  • SAAG (Serum Ascitic Albumin Gradient)
  • The Difference bw Serum Albumin and Ascitic fluid
    Albumin
  • Best single test to differentiate between ascites
    due to portal hypertension and non-portal
    hypertension
  • When saag gt1.1g/dl strongly suggest portal
    hypertension
  • When saag lt 1.1g/dl non portal hypertensive
    causes
  • Accuracy more than 97

28
INVESTIGATIONS
  • LAB STUDIES
  • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
  • CYTOLOGY
  • 58-75 HELPING FOR DETECTING MALIGNANT ASCITES
  • CULTURE AND GRAM STAIN
  • MORE IMPORTANT IN SBP

29
INVESTIGATIONS
  • LAB STUDIES
  • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
  • MISCELLENOUS
  • GLUCOSE low in TB peritonitis
  • AMYLASE HIGH IN PANCREATIC ASCITES
  • PH lt7 SUGGEST BACTERIAL INFECTION
  • RBCS MORE THAN 50,000/microL SUGGESTS
    TB,MALIGNANCY OR TRAUMA

30
INVESTIGATIONS
  • LAPROSCOPY
  • IN SOME PATIENTS FOR DIRCET VISUALIZATION
  • TO TAKE BIOPSIES OF
  • LIVER
  • PERITONEUM
  • INTRA ABDOMINAL LYMPHNODES

31
MANAGEMENT
32
MANAGEMENT
  • COMPRISES OF
  • General care
  • Medical care
  • Surgical care

33
MANAGEMENT
  • GENERAL CARE
  • MONITORING OF
  • INPUT OUT PUT
  • ABDOMINAL GIRTH
  • WEIGHT
  • DIETRY MODIFICATIONS
  • SODIUM RESTRICTION UPTO 1g/day
  • WATER RESTRICTION (If Serum Sodium Level Is
    lt120mmol/L Hyponatremia)
  • BED REST
  • Improves renal perfusion which leads to diuresis

34
MANAGEMENT
  • MEDICAL CARE
  • THE AIM OF THE THERAPY IS WT LOSS OF BODY
    WIGHT DAILY
  • 300g-500g IF ONLY ASCITES
  • 800g-1000g IF ASCITES AND EDEMA
  • DIEURETICS
  • MAINSTAY THERAPY FOR ASCITES
  • SPIRONOLACTONE 25-200 mg/d PO qd or divided bid
  • FUROSEMIDE20-80 mg/d PO/IV/IM titrate up to 600
    mg/d for severe edematous states
  • AMILORIDE5-20 mg PO qd
  • COMBINATION THERAPY
  • SPIRONOLACTONE FUROSEMIDE
  • FUROSEMIDE AMILORIDE

35
MANAGEMENT
  • MEDICAL CARE
  • THERAPEUTIC PARACENTESIS
  • In patients with massive ascites (grade 3 or 4)
  • In ascites refractory to dieuretics
  • If cardio respiratory distress due to ascites
  • 3-5litres can be removed with the replacement of
    salt free albumin.

36
MANAGEMENT
  • MEDICAL CARE
  • TIPS(TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC
    SHUNT)
  • Becoming standard of care in dieuretic resistant
    ascites

37
MANAGEMENT
  • SURGICAL CARE
  • LEE VEEN SHUNT
  • It is a peritoneovenous shunt
  • Alternative for medically intractable ascites
  • Improves Cardiac Out Put, renal Blood Flow,
    Glomerular Filtration Rate, Urinary Volume, And
    Sodium Excretion And Decreased Plasma Renin
    Activity And Plasma Aldosterone Concentration
  • Doesnt Improve Patients Survival So With The
    Advent Of Tips Its Becoming Obsolete

38
COMPLICATIONS
39
COMPLICATIONS
  • THE MOST COMMON COMPLICATION IS
  • SBP (Spontaneous Bacterial Peritonitis)

40
COMPLICATIONS
  • SBP
  • Most common bacteria is E. Coli.Bacteria are
    believed to gain access to peritoneum by
    hematogenous route.
  • Low ascitic fluid albumin (lt1g/dl) predisposes
    SBP
  • Abrupt onset of Fever, Chills, Generalizd
    Abdominal Pain, Rebound Tenderness.
  • Ascitic Fluid analysis shows wbcs gt500/mm3l and
    Eutrophilgt250/mm3
  • Third generation Cephalosporins 2g tid started
    empirically for 5 days till c/s report is
    available.
  • Recurrence is common. Ciprofloxacin 750 mg once
    weekly can be given prophylacticaly.

41
MCQs.
42
MCQs
  • Q. No 1
  • IF SAAG IS gt1.1 THEN THE CAUSE WOULD BE ALL
    EXCEPT
  • PORTAL HYPERTENSION
  • MYXEDEMA
  • NEPHROTIC SYNDROME
  • TUBERCULOUS PERITONITIS

43
MCQs
  • Q. No 2
  • THE MOST EFFICACIOUS TREATMENT FOR REFRACTORY
    ASCITES IS
  • MAXIMUM DOSE OF DIEURETICS
  • THERAPEUTIC PARACENTESIS
  • TIPS
  • LEE VEEN SHUNT

44
MCQs
  • Q. No 3
  • SBP IS MORE LIKELY WHEN
  • WBCS gt250/microL
  • NEUTROPHILSgt250/microL
  • LYMPHOCYTESgt500/microL
  • ALL OF THE ABOVE

45
THANK YOU
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