Liver Ascites

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  • Bowel loops floating in ascitic fluid
  • Liver Ascites

    1. 1. ASCITES 1 MOST PATIENTS HAVE CIRRHOSIS www.medicinemcq.com
    2. 2. Hepatocellular carcinoma 2  When to suspect? Sudden development of ascites in a stable cirrhotic patient www.medicinemcq.com
    3. 3. Constrictive pericarditis 3 Tuberculosis One of the few curable causes of ascites www.medicinemcq.com
    4. 4. Tuberculous peritonitis 4 Very important cause Curable www.medicinemcq.com
    5. 5. Peritoneal carcinomatosis 5  Protein rich fluid by tumor cells lining the peritoneum  ECF enters the peritoneal cavity to maintain oncotic balance  Tuberculosis  Also causes production of protein rich fluid www.medicinemcq.com
    6. 6. Sister Mary Joseph's nodule 6 Hard periumbilical nodule Metastatic Pelvic disease or gastrointestinal primary tumor www.medicinemcq.com
    7. 7. www.medicinemcq.com 7
    8. 8. www.medicinemcq.com 8
    9. 9. www.medicinemcq.com 9
    10. 10. Virchow's node 10 Supraclavicular adenopathy GI malignancy www.medicinemcq.com
    11. 11. www.medicinemcq.com 11
    12. 12. www.medicinemcq.com 12
    13. 13. www.medicinemcq.com 13
    14. 14. IVC blockage 14 Large veins Back www.medicinemcq.com
    15. 15. Portal hypertension 15  First pathogenetic abnormality in ascites formation in cirrhosis www.medicinemcq.com
    16. 16. Obstruction of hepatic lymphatics 16 Cause exudation of hepatic lymph from the surface www.medicinemcq.com
    17. 17. Increased hepatic lymph 17  Normal physiology  Lymph  To produced in the hepatic sinusoids systemic circulation by the thoracic duct  When sinusoidal pressures rise  Lymph spills over from the surface of the liver to the peritoneal cavity www.medicinemcq.com
    18. 18. PATHOGENESIS OF ASCITES 18  Splanchnic vasodilatation  Chief factor contributing to ascites  Increased hydrostatic pressure within the splanchnic capillary bed  Exudation of lymph from the surface of the cirrhotic liver www.medicinemcq.com
    19. 19. Kidneys 19  Increased sodium and water reabsorption www.medicinemcq.com
    20. 20. Hypoalbuminemia 20  Reduced plasma oncotic pressure www.medicinemcq.com
    21. 21. www.medicinemcq.com 21
    22. 22. PRECIPITATING FACTORS 22 1. Excessive salt intake 2. Failure to take drugs 3. Peritoneal infection 4. Worsening of liver disease 5. Hepatocellular carcinoma 6. Portal vein thrombosis www.medicinemcq.com
    23. 23. USS 23  Best test to detect even small amount of ascites  Can detect as little as 100 mL of fluid www.medicinemcq.com
    24. 24. www.medicinemcq.com 24
    25. 25. www.medicinemcq.com 25
    26. 26. Morrison’s pouch 26  Earliest fluid collection  Hepato-renal pouch  POD www.medicinemcq.com
    27. 27. www.medicinemcq.com 27
    28. 28. More than 500 to 1000 mL 28 Shifting dullness  Fluid thrill Not very useful www.medicinemcq.com
    29. 29. No flank dullness 29 Ascites www.medicinemcq.com unlikely
    30. 30. www.medicinemcq.com 30
    31. 31. www.medicinemcq.com 31
    32. 32. www.medicinemcq.com 32
    33. 33. Paracentesis 33  Final confirmation of ascites  Best method for diagnosing the cause www.medicinemcq.com
    34. 34. Routine tests on ascitic fluid 34 1. Cell count 2. Albumin 3. Total protein www.medicinemcq.com
    35. 35. Optional 35 4. Culture 5. Glucose 6. Gram’s stain 7. Amylase 8. Cytology www.medicinemcq.com
    36. 36. Cell count 36 Single most helpful ascitic fluid test www.medicinemcq.com
    37. 37. WBC count 37  Uncomplicated cirrhotic ascites  < 500 WBCs/mm3 in  Absolute neutrophil count  < 250/mm3 in uncomplicated cirrhotic ascitic fluid  Empiric antibiotic treatment  Based on absolute neutrophil count rather than the culture www.medicinemcq.com
    38. 38. Spontaneous bacterial peritonitis 38  Most common cause of an elevated ascitic WBC count  PMN > 70% of the total WBC count www.medicinemcq.com
    39. 39. Elevated ascitic WBC count – other causes 39 Tuberculous peritonitis 2. Peritoneal carcinomatosis Predominance of lymphocytes 1. www.medicinemcq.com
    40. 40. SAAG 40  Serum ascites albumin gradient  Serum albumin in g/dL minus ascites albumin in g/dL  To differentiate cirrhotic ascites from other causes of ascites  Better than total protein content in the ascitic fluid www.medicinemcq.com
    41. 41. High SAAG (> 1.1 g/dL) 41  Uncomplicated cirrhotic ascites  Serum albumin concentration At least 1 g/dL higher than that of the ascitic fluid albumin concentration. www.medicinemcq.com
    42. 42. SAAG - indirect but accurate index of portal pressure 42  1.1 g/dL or more  Portal hypertension Accuracy 97%  < 1.1 g/dL  No portal hypertension Accuracy www.medicinemcq.com 97%
    43. 43. Accuracy > 97% 43  Even with  Ascitic fluid infection  Diuresis  Paracentesis  IV albumin  Varying causes of liver disease www.medicinemcq.com
    44. 44. High SAAG 44  Does not confirm cirrhosis Indicates www.medicinemcq.com portal hypertension
    45. 45. Typical of cirrhosis 45 4. SAAG >1.1 g/dL WBC count < 500 cells/mm3 Predominant lymphocytes Specific gravity less than 1016 5. Urine Na low 1. 2. 3. www.medicinemcq.com
    46. 46. High gradient (transudative) ascites 46  Right heart failure Another common cause  Nephrotic syndrome www.medicinemcq.com
    47. 47. HIGH GRADIENT ≥1.1 g/DL 47  Cardiac   TR Constrictive pericarditis  Alcoholic hepatitis  Massive liver metastases  Fulminant hepatic failure  Budd-Chiari syndrome  Portal vein thrombosis  Myxedema  Meigs' syndrome www.medicinemcq.com
    48. 48. LOW GRADIENT <1.1 g/DL 48  Peritonitis  TB, Bacterial  Peritoneal carcinomatosis  Pancreatic ascites  Bowel obstruction or infarction  Biliary ascites  Postoperative lymphatic leak  Serositis in connective tissue diseases www.medicinemcq.com
    49. 49. Blood-stained ascitic fluid 49  Traumatic tap  Frequently clots  Tuberculous peritonitis  Hepatoma  Peritoneal secondaries www.medicinemcq.com
    50. 50. Peritonitis 50  Bacterial  Polymorphonuclear cells predominate  Gram's stain may be positive  TB  Predominant lymphocytes  Diagnosis  Granulomas on peritoneal biopsy  AFB  Difficult to recover from ascitic fluid  May take 4 to 6 weeks www.medicinemcq.com
    51. 51. CHYLOUS ASCITES 51  Lymphatic obstruction  Trauma  Tumor  TB  Filariasis  Cirrhosis  Nephrotic syndrome  Congenital abnormalities www.medicinemcq.com
    52. 52. Salt restriction 52  Most important treatment of cirrhotic ascites  Normal diet contains  5 to 15 grams of sodium chloride www.medicinemcq.com
    53. 53. Spironolactone plus furosemide produce a diuresis in most patients 53  If sodium restriction alone does not cause diuresis and weight loss  Spironolactone  Drug of choice  Furosemide  Risk of excessive diuresis  Hypokalemia Precipitate www.medicinemcq.com encephalopathy
    54. 54. Fluid intake 54  Restricted only if there is dilutional hyponatremia  High levels of antidiuretic hormone Diagnosis Serum sodium < 130 mEq/L in the presence of ascites www.medicinemcq.com
    55. 55. Large-volume paracentesis 55 Treatment of choice for large-volume ascites www.medicinemcq.com
    56. 56. LARGE VOLUME PARACENTESIS 56  Tense ascites  Respiratory distress  Poor response to medical therapy www.medicinemcq.com
    57. 57. www.medicinemcq.com 57
    58. 58. www.medicinemcq.com 58
    59. 59. Hepatorenal syndrome 59  Renal failure  Profound vasoconstriction in the renal circulation Due to excessive activity of endogenous vasoactive substances www.medicinemcq.com
    60. 60. Hemodynamic hallmark 60  Systemic vasodilation  Renal vasoconstriction www.medicinemcq.com
    61. 61. Clinical hallmarks 61 Worsening azotemia Hyponatremia Progressive oliguria Hypotension www.medicinemcq.com
    62. 62. Treatment 62  Vasoconstrictor drugs  Norepinephrine, midodrine, terlipressin or alpha-adrenergic agents  In combination with albumin www.medicinemcq.com
    63. 63. Liver transplantation 63 Most effective treatment for hepatorenal syndrome www.medicinemcq.com
    64. 64. SBP 64  No obvious primary source of infection  Contrast-enhanced CT To exclude an intra-abdominal source for infection www.medicinemcq.com
    65. 65. Cefotaxime and an aminoglycoside 65 90 % Monomicrobial Enteric GNB www.medicinemcq.com
    66. 66. What is the diagnosis 66  A 30-year-old male is admitted with mild abdominal swelling, fever, and loss of weight. Ascitic fluid shows the following changes. Macroscopic appearance - hemorrhagic. Proteins = 3 grams/dl. SAAG = < 1.1 g/dl. Cells = WBCs in plenty. 70% of cells are lymphocytes. Few mesothelial cells are also present. He occasionally takes alcohol. What is the most probable diagnosis? www.medicinemcq.com
    67. 67. Answer 67  TB  Predominant www.medicinemcq.com lymphocytes

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