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MED Ascites
This document summarizes common causes of hepatomegaly and splenomegaly including malignancy, infection, and congestive heart failure. It also describes the classification of ascites based on serum-ascites albumin gradient and common causes of each type. Key aspects of cirrhosis such as causes, pathogenesis, symptoms, signs, and investigations are outlined. Budd-Chiari syndrome is defined as obstruction of hepatic venous outflow and its causes, clinical features, and investigations are summarized.
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MED Ascites
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- 3. Hepatomegaly • Liver – Malignancy– hepatoma/ metastases – Infection – Hepatitis, abscess, typhoid – Alcohol – fatty liver • Non liver causes – Congestive heart failure – Hemolytic anaemia, myeloproliferative disorder (leukemia) – Autoimmune • Others – Wilson disease (rare)
- 4. Splenomegaly • C ongestion-congestive heart failure, portal hpt • H emolytic anemia – Thal, heriditary spherocytosis • I nfection – Bacteria : IE, typhoid – Viral : IM, CMV – Parasite : malaria – Fungal • N eoplasm – myeloproliferative/ lymphoproliferative • A utoimmune - CTD
- 6. ascites Classified by serumascites to albumin concentration gradient High gradient (>11g/L) 1.Cirrhosis 2.Budd chiari syndrome 3. Alholic hepatitis 4. Fulminant hepatic failure 5. Congestive heart failure, contrictive pericarditis (cardiac ascites) 6. Myxedema Low gradient (<11gL) 1. Peritoneal ascites 2. Tb 3. Pancreatic ascites 4. Nephrotic syndrome
- 7. *serum-ascitic albumin gradient(SAAG) = serum albumin value- ascitic fluid albumin value High gradient (TRANSUDATIVE)= incr hydrostatic pressure within blood vessels of hepatic portal system, pushes the fluid into peritoneal cavity, leaving protein such as albumin in the serum Low gradient (EXUDATIVE)= not associated with portal pressure
- 8. • Transudate –dt incr hydrostatic pressure, red oncotic pressure, Na+ retention. Low protein • Exudate – incr permeability of vessels, lymphatic obstruction. Rich in protein
- 9. cirrhosis Definition -Necrosis of livercell>nodule formation& fibrosis -Abnormal liver architecture & liver blood flow and function -Produce clinical features of portal hpt and impaired liver cell fx Causes #Common- hep(c or b+/-d), alcohol or non alcoholic fatty liver ds #others: biliary cirrhosis, autoimmune hep, budd chiari, {heriditary haemochromatosis, wilson) Pathogenesis Activation of stellate cells>proliferation of fibroblast>deposition of collagen Pathology -Characteristic features: regenerating nodules sep by fibrous septa. Loss of N architecture within nodules. -2 types: micro & macronodular cirrhosis Micro Macro Ongoing alcohol damage chr viral hep Biliary tract ds
- 10. Symptoms -R hypochondriac pain -abddistension -ankle swelling -hematemesis and malena (varices dt portal hpt causing GI bleed) -pruritus (skin-cholestasis dt primary biliary cirrhosis) -gynaecomastia, loss of libido, amenorrhea (endocrine dysfunction) -confusion and drowsiness (neuropsychiatric manifestation dt portosystemic encephalopathy)
- 11. Signs Periphery -dupuytren contracture (alcoholiccirrhosis) -clubbing -palmar erythema (hyperdynamic circ also seen in pregnancy, thyrotoxicosis, RA) -xanthoma(cholesterol deposits in palmar crease or above eyes dt primary biliary cirrhosis) Face, Neck, chest -xanthelasma -parotid gland enlarge -spider naevi (>5 diagnostic, svc distribution, telengiectasia consist of central arteriole and radiating small vessels) -gynaecomastia Abdomen -Hepatomegaly>shrink in established cirrhosis -Splenomeglay(portal hpt) Endocrine Gynaecomastia Testicular atrophy
- 13. Ix 1. Severity-LFT(low serumalbumin, prolong PT, incr ALP and ALT, if decompesated CLF all will deranged), BUSE (low sodium, high cr >130 worse prognosis) 2. Types: viral serology, autoAb, ig, iron& ferritin, copper&ceruloplasmin, alpha1 antitrypsin 3. Imaging – Abd USS, CT(arterial-hcc, portal- metastases, av- haemangioma), endoscopy (varices/portal hypertensive gastropathy), MRI 4. Liver biopsy
- 14. Budd-chiari syndrome Definition Obestruction ofvenous outflow of liver Dt occlusion of haptic veins Causes -1/3 unknown -hypercoagulability state (polycythaemia vera, paroxysmal nocturnal haemoglobinuria) -thrombophilia -ocp -leukemia -others: HCC, hepatic cysts, radio/trauma/congenital venous web, renal or adrenal tumours, posterior abd wall sarcoma
- 15. Clinical features Acute: abdpain, tender hepatomegaly, ascites, nausea, vomiting Chronic: hepatomegaly, splenomegaly dt portal hpt, mild jaundice, ascites, -ve hepatojugular reflux Ix 1. LFT –high protein 2. Liver histology-centrizonal congestion, haemorrhage, fibrosis, cirrhosis 3. Imging- uss, ct, mri – hapatic venous occlusion, abN parenchyma 4. Doppler sonography 5. Thrombophilia screening (mandatory) DD 1. Inf vena cava occlusion 2. R cardiac failure 3. Non constrictive pericarditis