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Gc2 ascitis


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Gc2 ascitis

  1. 1. General Clinics - 2 Parvathy Premchandran Aditi Singh Devi Dileep Vimala Colaco Chaitra AC
  2. 2. Personal Data• Patient name - Naveen Kumar• Age- 8 years• Address -Sakleshpura, Hassan District• Informant- Mother(Reliable)• Date of admission - 20/7/12• Mothers name and education- Shobha (Illiterate)• Fathers name and education- Chandra (3rd)
  3. 3. Presenting Complaints• Abdominal Distension since 1 Month• Loss of appetite since 1 month
  4. 4. History of presenting illness• Abdominal Distension since 1 month• Onset insidious, gradual progression• Uniform distension• Not associated with facial puffiness or pedal edema• No H/o pain abdomen, fever• Associated with loss of appetite• No H/o yellowish discoloration of sclera or urine
  5. 5. • No H/o Reduced urine output• No H/o orthopnoea, PND• No H/o cough with expectoration, evening rise of temperature• No H/o Vomiting, hemetemesis or malaena• No H/o bleeding tendencies• No H/o blood transfusions• No H/o Constipation or diarrhoea• NoH/o Lethargy, drowsiness• No H/o altered sensorium, altered sleep wake cycle
  6. 6. Past History• No similar complaints in the past• No H/o contact with TB• No H/o Jaundice• 5 months back, patient was admitted for swelling of right foot associated with fever and some procedure was done
  7. 7. Antenatal History• Birth Order- 2nd• Age at pregnancy - 27 years• 1st trimester-Regular ANCs, No H/o fever with rash, irradiation, drug intake, alcohol intake• 2nd trimester- No history suggestive of PIH/GDM/APH. T.T injection taken• 3rd trimester- No history suggestive of PIH/GDM/APH
  8. 8. Natal and postnatal history• Spontaneous onset of labour, FTNVD at home unattended by a trained dai• Baby cried immediately• Birth weight not known• Breastfeeding initiated within 1 hour• Meconium and urine passed within 24hrs
  9. 9. Immunization History• 9th month- Measles and Vit A not given• 5th year- DT Booster not given• Rest all given as per NIP Development History• Appropriate for age• Studies in 2nd std
  10. 10. Dietary History• Complimentary feeding started at 1 month• Breastfeeding continued till 18 months Calories(kcal) Protiens(g) Breakfast 370 9.8 Lunch 300 9 Snacks 160 3.8 Dinner 275 5 Total 1105 27.6 Expected 1580 28.8 Deficit 475 1.2
  11. 11. Family history• Non consanguineous marriage• No of members-5• No h/o similar complaints• No h/o jaundice in family• No h/o TB/congenital defects in the family• Upper lower socioeconomic status
  12. 12. Summary• 8 yr old male child came to RAPCC with progressive abdominal distension and loss of appetite since 1 month. His development is appropriate for age. He has not received measles and DT booster. His calorie is deficient in 475 kcal and protein by 1.2g
  13. 13. Ascitescardiac renal hepatic nutritional No pedal no facial No generalized Abdominal edema puffines edema distension
  14. 14. Abdominal distention Ascites gaseous distention faecal retention acute acute chronic peritoneal hemorrhagepancreatitisinfarcted/perforated bowel
  15. 15. Examination
  16. 16. General physical examination• No pallor, icterus, clubbing, cyanosis, lymphadenopat hy, pedal oedema Head to toe• Oral cavity hygiene is good• Upper central incisors absent• Numerous pigmented elevated papule like lesions on the finger pulps of Rt hand• 2 by 2 cm scar healed by sec intention present on the dorsum of Rt foot.• No signs of liver cell failure
  17. 17. VitalsAfebrile during examinationPulse-88 beats/min regularRespiratory rate-38 cycles/minBP-100/80 mm hg Rt arm supineJVP not raised
  18. 18. AnthropometryWeight for ageObserved-20.8kgExpected-24kg (3-10th percentile)Height for ageObserved-116cmExpected-125cm(<3rd percentile)Weight for heightNormal
  20. 20. PER ABDOMENOn Inspection•Shape – grossly distended•Umbilicus - pushed down, everted & transversely stretched•Flanks – full•Corresponding quadrants move equally with respiration•No visible pulsations or visible peristalsis•Skin – tense & shiny•Scar – a circular scar healed by secondary intention around theumbilicus (branding)•Dilated veins – thin veins over the costal margin•Hernial orifices appear to be normal•Genitalia - normal
  21. 21. On Palpation•Local rise of temperature & tenderness – absent•Guarding & rigidity – absent•Liver - palpable 8cm below the right costal margin non tender firm in consistency sharp lower border smooth surface•No other organomegaly•Abdominal girth - 62cmOn Percussion•Liver dullness – right 5th intercostal space•Liver span – 12cm•Fluid thrill – presentOn Auscultation•Bowel sounds – not appreciated
  22. 22. Respiratory system examinationExamination of upper respiratory tract•Nose•Para nasal sinuses normal•PharynxExamination of lower respiratory tractOn inspection•Trachea - deviated to left•Shape of chest – B/L symmetrical, elliptical in cross section•Movement of chest – decreased on right side•No venous pulses in the neck•No scars, skin lesions, swellings
  23. 23. On Palpation•Local rise of temperature/tenderness – absent•Trachea – deviated to left•Cardiac impulse – left 5th intercostal space, lateral to mid clavicular line•Chest expansion – decreased on right sideOn Percussion•Resonant – B/L in all areas except for -•Dull note – right axillary and infra axillary area•On Auscultation•Breath sounds – vesicular B/L•Intensity – decreased on the right axillary & infra axillary area
  24. 24. Examination of cardiovascular system•Apex beat – left 5th intercostal space lateral to mid clavicular line•On auscultation – S1 & S2 heardExamination of central nervous system•No abnormality detected
  25. 25. Differential diagnosis Vimala Colaco
  26. 26. Ascites• Hepatic Cirrhosis Lysosomal storage disease Wilson’s disease• Infectious Tuberculosis• Neoplastic Lymphoma Neuroblastoma
  27. 27. Cirrhosis• Inherited metabolic liver disease Wilson’s disease Hemochromatosis alpha 1 antytrypsin deficiency• Chronic viral hepatitis• Billiary cirrhosis primary billiary cirrhosis primary sclerosing cholangitis
  28. 28. • Miscellaneous Eosinophilic ascites Chylous ascites Hypothyroidism
  29. 29. On examination- Ascites with hepatomegaly• Hepatic Cirrhosis Lysosomal storage disease Wilson’s disease• Infectious Tuberculosis• Neoplastic Lymphoma Neuroblastoma
  30. 30. Investigations Chaithra A C 080201350
  31. 31. HEMATOLOGICAL INVESTIGATIONS• Haemoglobin• Total count and Differential count• ESR• Platelet• Blood grouping
  32. 32. • Hemoglobin 20TH July-15.5g/dL 29th July-14.9g/dl• Counts Total count- 15,800/cc• Platelets 1,89,000/cc• Blood group B positive
  33. 33. Biochemical investigation• Liver function test• Serum ceruloplasmin• Urine copper excretion• Electrolyte• Serum urea and creatinine• Blood sugar
  34. 34. LIVER FUNCTION TESTTotal Bilirubin - 0.4mg/dL (0.2-1.2mg/dL)Direct Bilirubin - 0.04mg/dL (upto 0.3mg/dL)SGPT - 18U/L ( 5-40 U/L)SGOT - 36 U/L (15-55U/L)ALP - 137U/LTotal protien - 6.9 g/dl (6-8g/dl)Albumin - 4.4g/dl (3.5-5.5/dl)PT - 21.5 (18-22s)INR - 1.6
  35. 35. • ELECTROLYTES Na+ --139meq/L (136-149meq/L) K --4.2meq/L (3.5-5.3meq/L) Cl- --103.3meq/L (98-111meq/L) HCO3- --18.6 meq/L (23-27meq/L)• Urea -13mg/dl (5-18mg/dl)• Creatinine -0.4mg/dl (0.3-0.7mg/dl)• Serum ceruloplasmin-32.8mg/dl (15-30mg/dl)• Blood sugar -76mg/dl
  36. 36. Investigations for tuberculosis• Sputum AFB (negative )• Mantoux test (negative )
  37. 37. Radiological Investigation• Ultrasound abdomen• Chest X RAY• Doppler
  38. 38. Ultrasound• Hepatomegaly 13cm• Gross ascitis• Pleural effusion on right side• Portal vein is normal
  39. 39. • Liver biopsy – to confirm the diagnosis• Ascitic fluid tap ( evaluated for cell count with differential, albumin level and serum ascites albumin gradient , total protein, and culture)• Depenicillamine challenge test
  40. 40. • Serum serum-ascites albumin gradient (SAAG) :• is calculated by subtracting the ascitic fluid albumin value from the serum albumin value• The SAAG is the best single test for classifying ascites into portal hypertensive (SAAG >1.1 g/ dL) and non–portal hypertensive (SAAG <1.1 g/dL) causes.• The accuracy of the SAAG results is approximately 97%• Preferably the serum and ascitic fluid specimens should be obtained simultaneously.
  41. 41. • A high gradient is associated• diffuse parenchymal liver disease• occlusive portal and hepatic venous disease,• liver metastasis and• hypothyroidism.
  42. 42. Limitations of using SAAG• (a) the gradient may be falsely low if the patient with cirrhosis has a serum albumin level <1.1 g/dL, and also in disease state of hypergammaglobulinemia (>5 g/dL)• b) errors may occur if the albumin assay is inaccurate the samples are not withdrawn at relatively same time, and if the patient is in shock• (c) a falsely high value in chylous ascites , as lipid fractions tend to interfere with laboratory determination of albumin.
  43. 43. Management
  44. 44. Principles• Mobilization of ascitic fluid is accomplished by creating a negative sodium balance until ascites has diminished or resolved• Restriction of dietary sodium [2meq/kg/day]and administration of diuretics. resistant large-volume paracentesis
  45. 45. • Transjugular intrahepatic portosystemic shunting (TIPS)• Orthotopic liver transplantation
  46. 46. Diuretics• Spironolactone- cirrhotic ascites• Furosemide Aim reduce body weight by 0.5-1% /day
  47. 47. Albumin supplementation• 25% albumin 1 g/kg IV up to 3 times per day until serum levels are >2.5 g/dL.
  48. 48. Therapeutic paracentesis• Tense ascites, non-responsive to diuretics• 118 ± 56 mL/kg at a time• iv albumin 1g/kg
  49. 49. Spontaneous bacterial peritonitis• Infection of ascitic fluid without evidence of an abdominal source• Escherichia coli , methicillin-resistant Staphylococcus aureus• Diagnosis – paracentesis/ ascitic fluid culture• Treatment – 3rd gen cephalosporins- cefotaxime 5 days
  50. 50. Wilson’s disease• Penicillamine[ 10mg/kg/day max 1g/day]• Pyridoxine [50mg/week]• Zinc [25-50mg daily before meals]• avoidance of Cu rich food• Liver transplantation