Approach to ascites

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Some slides for the topic for SSS ID (Kahov) today!

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  • TCP, leucopenia, anemia\nhNA, hK\nHRS, DM\nALT, AST, bilirubin\nINR\n
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  • Meig = ascite + Rt pleural effusion + benign ovarian fibroma\n
  • Meig = ascite + Rt pleural effusion + benign ovarian fibroma\n
  • Meig = ascite + Rt pleural effusion + benign ovarian fibroma\n
  • Meig = ascite + Rt pleural effusion + benign ovarian fibroma\n
  • Meig = ascite + Rt pleural effusion + benign ovarian fibroma\n
  • Meig = ascite + Rt pleural effusion + benign ovarian fibroma\n
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  • Approach to ascites

    1. 1. This gentleman hasabdominal distention, pleaseexamine him.
    2. 2. Before you start doing PE,think……
    3. 3. Before you start doing PE,think…… What is the differential diagnosis of abdominal distention?
    4. 4. Before you start doing PE,think…… What is the differential diagnosis of abdominal distention? Remember 5F’s  Fat  Flatulence  Feces  Fluid  Fetus
    5. 5. Before you start doing PE,think…… What is the differential diagnosis of abdominal distention? Remember 5F’s  Fat  Flatulence  Feces  Fluid  Fetus What are some of the causes of ascites?
    6. 6. Ascites GIT (Liver diseases) CVS (CCF) Nephro Lymph Etc…Bear these in your mind so that you know what to look for…
    7. 7. General condition+ Yellow discoloration of skin+ Cachetic appearance
    8. 8. Upper Limbs+ Finger clubbing+ Palmar erythemao Liver flapo Leukonychiao Dupuytren’s contracture+ Scratch marks+ Scars on cubital fossa+ Tattoo scar on shoulder
    9. 9. Head+ Yellow discolouration of sclerao Pallor of conjunctivao Kayser-Fleischer ringo Puffy eyeo Parotid swellingo Lymphadenopathyo Oral candidiasis
    10. 10. Neck+ Virchow nodeo JVP distention
    11. 11. Chest+ Virchow node+ Gynaecomastia+ Spider naevi+ Loss of axillary hairo Apex beat displacement Dual rhythm, no murmur (DRNM)o Gallop rhythm (S3/S4)
    12. 12. Abdomen+ Abdominal distention+ Scar on abdomen+ Dilated veins+ Inverted umbilicus
    13. 13. Abdomen+ Hepatomegaly, describe: tender, hard, nodular, 2 FB below costal margin. Liver span 12cm+ Splenomegaly, dull sound on Traube’s space Try to ballot the kidney+ Hepatic bruit + Bowel soundo Splenic rub o Renal bruit
    14. 14. AbdomenCheck shifting dullnessCheck fluid thrills
    15. 15. Lower limbs+ Bilateral pedal edema until level below the knee
    16. 16. Complete your PE with: Check the testes Check for lymphadenopathy Per rectum (PR) examination Some investigations to find underlying cause
    17. 17. How to present &conclude? Your findings Possible Dx, DDx Severity Functional status, failure? Complication? Etiology Associating syndrome
    18. 18. For example…
    19. 19. For example… Findings : Stigmata of chronic liver disease sign of risk factor
    20. 20. For example… Findings : Stigmata of chronic liver disease sign of risk factor Dx, lesion: Cirrhosis, Hepatosplenomegaly
    21. 21. For example… Findings : Stigmata of chronic liver disease sign of risk factor Dx, lesion: Cirrhosis, Hepatosplenomegaly Severity : Child-Pugh Score
    22. 22. For example… Findings : Stigmata of chronic liver disease sign of risk factor Dx, lesion: Cirrhosis, Hepatosplenomegaly Severity : Child-Pugh Score Fx status : Ascites, liver failure
    23. 23. For example… Findings : Stigmata of chronic liver disease sign of risk factor Dx, lesion: Cirrhosis, Hepatosplenomegaly Severity : Child-Pugh Score Fx status : Ascites, liver failure Complic : Hepatocellular carcinoma (HCC) no hepatic encephalopathy
    24. 24. For example… Findings : Stigmata of chronic liver disease sign of risk factor Dx, lesion: Cirrhosis, Hepatosplenomegaly Severity : Child-Pugh Score Fx status : Ascites, liver failure Complic : Hepatocellular carcinoma (HCC) no hepatic encephalopathy Etiology : Hep B / Hep C
    25. 25. For example… Findings : Stigmata of chronic liver disease sign of risk factor Dx, lesion: Cirrhosis, Hepatosplenomegaly Severity : Child-Pugh Score Fx status : Ascites, liver failure Complic : Hepatocellular carcinoma (HCC) no hepatic encephalopathy Etiology : Hep B / Hep C Assoc : Portal Hypertension
    26. 26. Empahsize… Stigmata of chronic liver disease Risk factors: IVDU, tattoo  Hep B/C HCC (hepatic bruit), is there encephalopathy Child-Pugh score if have investigation result Portal hypertension (splenomegaly) Probable cause: Hep B/C  confirm with Ix Provide suitable negative sign to exclude other DDx
    27. 27. InvestigationBasic: FBC, RP, U&E, LFT Coag profile Urine protein US, CT
    28. 28. InvestigationSpecific: Hep B, C αFP ANA, AMA, ASMA, ALKMA Iron profile Urine Cu, serum ceruloplasmin Diagnostic peritoneal tap Liver biopsy OGDS
    29. 29. Main causes of ascites?
    30. 30. Main causes of ascites? Portal hypertension in cirrhosis Abdominal malignancy CCF
    31. 31. Less common causes?
    32. 32. Less common causes? Nephrotic syndrome Constrictive pericarditis TB peritonitis Chylous ascites Budd-Chiari syndrome (BCS) Meig’s syndrome
    33. 33. Transudate / Exudate?
    34. 34. Transudate / Exudate? Protein < 25 g/l  Transudate Protein > 25 g/l  Exudate
    35. 35. What is ‘serum-ascitesalbumin gradient’ (SAAG)?
    36. 36. What is ‘serum-ascitesalbumin gradient’ (SAAG)? SAAG = serum alb – ascitic alb
    37. 37. What is ‘serum-ascitesalbumin gradient’ (SAAG)? SAAG = serum alb – ascitic alb > 11g/l  + Portal HPT (transudative) < 11g/l  o Portal HPT (exudative)
    38. 38. SAAG > 11 SAAG < 11 Cirrhosis  Peritoneal Alcoholic hep carcinomatosis CCF  Peritoneal TB BCS  Nephrotic syndrome Fulminant liver  Serositis failure  Pancreatic / biliary ascites
    39. 39. +Pedal o Pedal edemaedema Portal HPT  TB ascites CCF  BCS Nephrotic syndrome  Malignancy: Hypoalbuminenia Hepatoma Stomach Pancreas Ovarian
    40. 40. Possible complications in this
    41. 41. Possible complications in this Ascites:  Breathing problem  Spontaneous bacterial peritonitis (SBP) Chronic liver disease:  Hepatocellular carcinoma (HCC)  Hepatic encephalopathy Portal HPT:  Upper GI bleeding (UGIB)  Hemorrhoid
    42. 42. When can you dx SBP?
    43. 43. When can you dx SBP? Symptoms: fever, abd pain, no bowel sound, altered mental status In ascitic fluid there is either: >500 WBC / µl, or >250 PMN / µl No local infectious source
    44. 44. 1o & 2o prophylaxis in UGIB dueto oesophgeal varices rupture?
    45. 45. 1o & 2o prophylaxis in UGIB dueto oesophgeal varices rupture? 1o prophylaxis: no UGIB yet need to prevent it from happening
    46. 46. 1o & 2o prophylaxis in UGIB dueto oesophgeal varices rupture? 1o prophylaxis: no UGIB yet need to prevent it from happening 2o prophylaxis: got UGIB already need to prevent recurrence
    47. 47. 1o & 2o prophylaxis in UGIB dueto oesophgeal varices rupture? 1o prophylaxis: no UGIB yet need to prevent it from happening 2o prophylaxis: got UGIB already need to prevent recurrence Propanolol
    48. 48. 1o & 2o prophylaxis in UGIB dueto oesophgeal varices rupture? 1o prophylaxis: no UGIB yet need to prevent it from happening 2o prophylaxis: got UGIB already need to prevent recurrence Propanolol Endoscopic banding
    49. 49. How will you manage thispt?
    50. 50. How will you manage thispt? Sodium restriction Fluid restriction Diuretic: Lasix + Spironolactone Peritoneal tap + albumin infusion TIPSS LeVeen’s Peritoneojugular shunt Liver transplant
    51. 51. Treating chronic liverdiseases Viral hep : Antiviral Autoimm. hep : Steroids Alcoholism : Stop alcohol
    52. 52. When need livertransplant?
    53. 53. When need livertransplant?Milan criteria for cirrhosis / HCC: 1 lesion <5 cm, or 2-3 lesions <3 cm No extra-hepatic manifestation No vascular invasion
    54. 54. When need livertransplant?Milan criteria for cirrhosis / HCC: 1 lesion <5 cm, or 2-3 lesions <3 cm No extra-hepatic manifestation No vascular invasionOther criteria: King’s College Hospital Criteria
    55. 55. When need livertransplant?Milan criteria for cirrhosis / HCC: 1 lesion <5 cm, or 2-3 lesions <3 cm No extra-hepatic manifestation No vascular invasionOther criteria: King’s College Hospital Criteria Model of End-stage Liver Disease (MELD)
    56. 56. Thank You Not only youcan have ascites

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