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DR.MAHMOOD ALI LODHI HOUSE OFFICER MU-1

APPROACH TO THE. PATIENT. with. DR.MAHMOOD ALI LODHI HOUSE OFFICER MU-1 14-11-2007. ASCITES. AIM. The Aim Is To Approach The Patient With Ascites In Terms Of : DEFINITION ; CAUSES ; CLINICAL FEATURES ; INVESTIGATIONS ;

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DR.MAHMOOD ALI LODHI HOUSE OFFICER MU-1

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  1. APPROACH TO THE PATIENT with DR.MAHMOOD ALI LODHI HOUSE OFFICER MU-1 14-11-2007 ASCITES

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

  3. DEFINITION

  4. ASCITES IT IS THE CONDITION OF PATHOLOGICAL ACCUMULATION OF FLUID IN ABDOMINAL CAVITY

  5. CAUSES

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

  7. 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

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

  9. CAUSES NORMAL PERITONEUM • Miscellaneous conditions • Chylous ascites • Pancreatic ascites • Nephrogenic ascites • Meig’s syndrome

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

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

  12. CAUSES DISEASED PERITONEUM • Other rare conditions • Granulomatous Peritonitis • Vasculitis

  13. CLINICAL FEATURES

  14. 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)

  15. CLINICAL FEATURES • PHYSICAL EXAMINATION • Abdominal Distension • Fullness of Flanks • Umbilicus Flat and Everted • Diverticulation of Recti Muscles • Distended Abdominal Veins • Shifting dullness (esp. when >1000ml of fluid) • Fluid Thrill • Puddle Sign

  16. 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)

  17. CLINICAL FEATURES PHYSICAL EXAMINATION • SIGNSRELATEDTOTHECAUSEOFASCITES • 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

  18. 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.

  19. INVESTIGATIONS

  20. Includes: INVESTIGATIONS • Imaging studies • Lab studies • Laparoscopy

  21. INVESTIGATIONS • IMAGING STUDIES • CHEST AND ABDOMINAL PLAIN FILMS • Detects ascites if >500ml 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

  22. 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

  23. 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

  24. INVESTIGATIONS LAB STUDIES • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) CELL COUNT • WBCS <500/mm3 and NEUTROPHILS<250/mm3: NORMAL • NEUTROPHILS>250/microL: suggests SBP • LYMPHOCYTES PREDOMINANCE: ABDOMINAL TB OR MALIGNANCY

  25. INVESTIGATIONS LAB STUDIES • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) TOTAL PROTEINS • PROTEINS<2.5g/dl: TRANSUDATE • PROTEINS>2.5g/dl: EXUDATE

  26. 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 >1.1g/dl: strongly suggest portal hypertension • When saag < 1.1g/dl: non portal hypertensive causes • Accuracy more than 97%

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

  28. INVESTIGATIONS LAB STUDIES • ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) MISCELLENOUS • GLUCOSE: low in TB peritonitis • AMYLASE: HIGH IN PANCREATIC ASCITES • PH: <7 SUGGEST BACTERIAL INFECTION • RBCS: MORE THAN 50,000/microL SUGGESTS TB,MALIGNANCY OR TRAUMA

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

  30. MANAGEMENT

  31. MANAGEMENT COMPRISES OF: • General care • Medical care • Surgical care

  32. 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 <120mmol/L Hyponatremia) • BED REST: • Improves renal perfusion which leads to diuresis

  33. 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 • FUROSEMIDE:20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states • AMILORIDE:5-20 mg PO qd • COMBINATION THERAPY: SPIRONOLACTONE + FUROSEMIDE FUROSEMIDE + AMILORIDE

  34. 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.

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

  36. 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 • Doesn’t Improve Patient’s Survival So With The Advent Of Tips It’s Becoming Obsolete

  37. COMPLICATIONS

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

  39. COMPLICATIONS • SBP • Most common bacteria is E. Coli.Bacteria are believed to gain access to peritoneum by hematogenous route. • Low ascitic fluid albumin (<1g/dl) predisposes SBP • Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Rebound Tenderness. • Ascitic Fluid analysis shows wbcs >500/mm3l and Eutrophil>250/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.

  40. MCQs.

  41. MCQs • Q. No 1 • IF SAAG IS >1.1 THEN THE CAUSE WOULD BE ALL EXCEPT: • PORTAL HYPERTENSION • MYXEDEMA • NEPHROTIC SYNDROME • TUBERCULOUS PERITONITIS

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

  43. MCQs • Q. No 3 • SBP IS MORE LIKELY WHEN • WBCS >250/microL • NEUTROPHILS>250/microL • LYMPHOCYTES>500/microL • ALL OF THE ABOVE

  44. THANK YOU

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