ascites it is the condition of pathological accumulation of fluid in abdominal cavity
TRANSCRIPT
ASCITESASCITES
IT IS THE CONDITION OF PATHOLOGICAL IT IS THE CONDITION OF PATHOLOGICAL ACCUMULATION OF FLUID IN ABDOMINAL ACCUMULATION OF FLUID IN ABDOMINAL CAVITYCAVITY
CAUSESCAUSES
Can Be Broadly Classified On The Can Be Broadly Classified On The Basis Of : Basis Of :
Normal peritoneumNormal peritoneum
Diseased peritoneumDiseased peritoneum
NORMAL PERITONEUMNORMAL PERITONEUM
Portal hypertensionPortal hypertension Congestive Heart FailureCongestive Heart Failure
Constrictive Pericarditis Constrictive Pericarditis
Tricuspid Insufficiency Tricuspid Insufficiency
Budd-Chiari Syndrome Budd-Chiari Syndrome
Liver Cirrhosis Liver Cirrhosis
Alcoholic Hepatitis Alcoholic Hepatitis
Fulminant Hepatic FailureFulminant Hepatic Failure
Massive Hepatic MetastasesMassive Hepatic Metastases
CAUSESCAUSES
NORMAL PERITONEUMNORMAL PERITONEUMHypoalbuminemiaHypoalbuminemiaNephrotic Syndrome Nephrotic Syndrome
Protein-losing Enteropathy Protein-losing Enteropathy
Severe Malnutrition with AnasarcaSevere Malnutrition with Anasarca
CAUSESCAUSES
NORMAL PERITONEUMNORMAL PERITONEUMMiscellaneous conditionsMiscellaneous conditions Chylous ascites Chylous ascites
Pancreatic ascites Pancreatic ascites
Nephrogenic ascitesNephrogenic ascites
MeigMeig’’s syndromes syndrome
CAUSESCAUSES
DISEASED PERITONEUMDISEASED PERITONEUMInfections Infections Tuberculous PeritonitisTuberculous Peritonitis
Bacterial PeritonitisBacterial Peritonitis
Fungal PeritonitisFungal Peritonitis
HIV associated peritonitisHIV associated peritonitis
CAUSESCAUSES
DISEASED PERITONEUMDISEASED PERITONEUM
Malignant conditionsMalignant conditions Peritoneum CarcinomatosisPeritoneum Carcinomatosis
Hepatocellula CarcinomaHepatocellula Carcinoma
Primary MesotheliomaPrimary Mesothelioma
Pseudomyxoma PeritoneiPseudomyxoma Peritonei
CAUSESCAUSES
DISEASED PERITONEUMDISEASED PERITONEUM
Other rare conditionsOther rare conditionsGranulomatous PeritonitisGranulomatous Peritonitis
VasculitisVasculitis
CAUSESCAUSES
CLINICAL FEATURESCLINICAL FEATURES
PRESENTING COMPLAINTSAbdominal DistensionAbdominal Distension
Diffuse Abdominal PainDiffuse Abdominal Pain
Bloated Feeling of AbdomenBloated Feeling of Abdomen
Dyspnoea Dyspnoea andand Orthopnea Orthopnea (due to elevation (due to elevation of daipharagm)of daipharagm)
Indigestion and Heart burn Indigestion and Heart burn (due to inc intra (due to inc intra abdominal pressure)abdominal pressure)
PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONAbdominal DistensionAbdominal DistensionFullness of FlanksFullness of FlanksUmbilicus Flat and EvertedUmbilicus Flat and EvertedDiverticulation of Recti MusclesDiverticulation of Recti MusclesDistended Abdominal VeinsDistended Abdominal VeinsShifting dullness Shifting dullness (esp. when >1000ml of fluid)(esp. when >1000ml of fluid)Fluid ThrillFluid ThrillPuddle SignPuddle Sign
CLINICAL FEATURESCLINICAL FEATURES
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION SIGNS RELATED TO SECONDARY SIGNS RELATED TO SECONDARY EFFECTS OF ASCITESEFFECTS OF ASCITESScrotal EdemaScrotal EdemaPleural effusionPleural effusion (due to defect in the (due to defect in the diaphragm and fluid pass into the pleural diaphragm and fluid pass into the pleural space)space)EdemaEdemaCardiac apex is shifted upwardCardiac apex is shifted upward due to due to raised diaphragm)raised diaphragm)Distended neck veinsDistended neck veins due to inc rt atrial due to inc rt atrial pressure)pressure)
CLINICAL FEATURESCLINICAL FEATURES
CLINICAL FEATURESCLINICAL FEATURES
PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONSIGNSSIGNS RELATEDRELATED TOTO THETHE CAUSECAUSE OFOF ASCITESASCITES LIVER DISEASE:
Jaundice,Anemia,Palmar erythema,Spider Jaundice,Anemia,Palmar erythema,Spider angiomas,Hepatosplenomegaly,angiomas,Hepatosplenomegaly,CARDIAC DISEASE:
Elevated JVPElevated JVPMALIGNANCY:
SISTER MARY JOSEPH NODUE in umblicus(peritoneal SISTER MARY JOSEPH NODUE in umblicus(peritoneal carcinomatosis like gastric, pancreatic and hepatic carcinomatosis like gastric, pancreatic and hepatic malignancies)malignancies)
VIRCHOW NODE (rt supraclavicular lymph node due to VIRCHOW NODE (rt supraclavicular lymph node due to upper abdominal malignancy)upper abdominal malignancy)
NEPHROTIC SYNDROME:NEPHROTIC SYNDROME: Edema or AnasarcaEdema or Anasarca
STAGINGSTAGING
Can Be Semi Quantified Into:Can Be Semi Quantified Into:
Stage 1+Stage 1+ is detectable only after careful is detectable only after careful examination. examination.
Stage 2+ Stage 2+ is easily detectable but of relatively is easily detectable but of relatively small volume. small volume.
Stage 3+ Stage 3+ is obvious ascites but not tense is obvious ascites but not tense ascites.ascites.
Stage 4+Stage 4+ is tense ascites.is tense ascites.
Includes:Includes:
Imaging studiesImaging studiesLab studiesLab studiesLaparoscopyLaparoscopy
INVESTIGATIONSINVESTIGATIONS
INVESTIGATIONSINVESTIGATIONS
IMAGING STUDIESIMAGING STUDIESCHEST AND ABDOMINAL PLAIN FILMSCHEST AND ABDOMINAL PLAIN FILMSDetects ascites if >500ml fluidDetects ascites if >500ml fluidElevated diaphragmElevated diaphragmPleural effusion (hepatic hydrothorax)Pleural effusion (hepatic hydrothorax)Diffuse abdominal hazinessDiffuse abdominal haziness
USG ABDOMENUSG ABDOMENcan detect as small as 5ml fluidcan detect as small as 5ml fluidcan identify the cause like liver cirrhosiscan identify the cause like liver cirrhosis
CT SCAN:CT SCAN:can identify the cause like malignanciescan identify the cause like malignancies
LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)
Ascitic Fluid Ascitic Fluid should be analyzed forshould be analyzed forAPPEARANCEAPPEARANCECELL COUNTCELL COUNTTOTAL PROTEINSTOTAL PROTEINSSAAG(SERUM ASCITIC ALBUMIN GRADIENT)SAAG(SERUM ASCITIC ALBUMIN GRADIENT)CYTOLOGYCYTOLOGYCULTURECULTUREMISCELLENOUSMISCELLENOUSBASELINE INVESTIGATIONS LIKE BLOOD BASELINE INVESTIGATIONS LIKE BLOOD CP,LFTS,PT APTTCP,LFTS,PT APTT
INVESTIGATIONSINVESTIGATIONS
LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)
APPEARANCEAPPEARANCE TRANSPARENT AND TINGEDTRANSPARENT AND TINGED:: NORMAL NORMAL
STRAW COLORED: STRAW COLORED: CIRRHOSISCIRRHOSIS
HEAMORRHGIC: HEAMORRHGIC: MALIGNANCYMALIGNANCY
CLOUDY: CLOUDY: INFECTIONINFECTION
BILE STAINED: BILE STAINED: BILIARY CONTAMINATIONBILIARY CONTAMINATION
CHYLOUS: CHYLOUS: LYMPHATIC OBSTRUCTIONLYMPHATIC OBSTRUCTION
INVESTIGATIONSINVESTIGATIONS
INVESTIGATIONSINVESTIGATIONS
LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)
CELL COUNTCELL COUNTWBCS <500/mm3 and NEUTROPHILS<250/mm3: WBCS <500/mm3 and NEUTROPHILS<250/mm3: NORMALNORMAL
NEUTROPHILS>250/microL: NEUTROPHILS>250/microL: suggests SBPsuggests SBP
LYMPHOCYTES PREDOMINANCE:LYMPHOCYTES PREDOMINANCE: ABDOMINAL TB ABDOMINAL TB OR MALIGNANCYOR MALIGNANCY
INVESTIGATIONSINVESTIGATIONS
LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)
TOTAL PROTEINSTOTAL PROTEINSPROTEINS<2.5g/dl:PROTEINS<2.5g/dl: TRANSUDATE TRANSUDATE
PROTEINS>2.5g/dl:PROTEINS>2.5g/dl: EXUDATE EXUDATE
INVESTIGATIONSINVESTIGATIONS
LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)
SAAG (Serum Ascitic Albumin SAAG (Serum Ascitic Albumin Gradient)Gradient)The Difference bw Serum Albumin and Ascitic fluid The Difference bw Serum Albumin and Ascitic fluid AlbuminAlbuminBest single test to differentiate between ascites due to Best single test to differentiate between ascites due to portal hypertension and non-portal hypertensionportal hypertension and non-portal hypertensionWhen saag >1.1g/dl: When saag >1.1g/dl: strongly suggest portal strongly suggest portal hypertensionhypertensionWhen saag < 1.1g/dl: When saag < 1.1g/dl: non portal hypertensive non portal hypertensive causescausesAccuracy more than 97%Accuracy more than 97%
INVESTIGATIONSINVESTIGATIONS
LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)
CYTOLOGYCYTOLOGY58-75% HELPING FOR DETECTING MALIGNANT 58-75% HELPING FOR DETECTING MALIGNANT ASCITESASCITES
CULTURE AND GRAM STAINCULTURE AND GRAM STAINMORE IMPORTANT IN SBPMORE IMPORTANT IN SBP
INVESTIGATIONSINVESTIGATIONS
LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)
MISCELLENOUSMISCELLENOUSGLUCOSE:GLUCOSE: low in TB peritonitis low in TB peritonitis
AMYLASE:AMYLASE: HIGH IN PANCREATIC ASCITES HIGH IN PANCREATIC ASCITES
PH:PH: <7 SUGGEST BACTERIAL INFECTION <7 SUGGEST BACTERIAL INFECTION
RBCS: RBCS: MORE THAN 50,000/microL SUGGESTS MORE THAN 50,000/microL SUGGESTS TB,MALIGNANCY OR TRAUMATB,MALIGNANCY OR TRAUMA
INVESTIGATIONSINVESTIGATIONS
LAPROSCOPYLAPROSCOPY IN SOME PATIENTS FOR DIRCET VISUALIZATIONIN SOME PATIENTS FOR DIRCET VISUALIZATION
TO TAKE BIOPSIES OFTO TAKE BIOPSIES OF LIVERLIVER
PERITONEUMPERITONEUM
INTRA ABDOMINAL LYMPHNODESINTRA ABDOMINAL LYMPHNODES
MANAGEMENTMANAGEMENT
COMPRISES OF:COMPRISES OF:
General careGeneral care
Medical careMedical care
Surgical careSurgical care
MANAGEMENTMANAGEMENT
GENERAL CAREGENERAL CAREMONITORING OF MONITORING OF INPUT OUT PUTINPUT OUT PUT
ABDOMINAL GIRTHABDOMINAL GIRTH
WEIGHTWEIGHT
DIETRY MODIFICATIONSDIETRY MODIFICATIONSSODIUM RESTRICTION UPTO 1g/daySODIUM RESTRICTION UPTO 1g/day
WATER RESTRICTION (If Serum Sodium Level Is WATER RESTRICTION (If Serum Sodium Level Is <120mmol/L Hyponatremia)<120mmol/L Hyponatremia)
BED REST:BED REST:Improves renal perfusion which leads to diuresisImproves renal perfusion which leads to diuresis
MANAGEMENTMANAGEMENT
MEDICAL CAREMEDICAL CARE THE AIM OF THE THERAPY IS WT LOSS OF BODY WIGHT THE AIM OF THE THERAPY IS WT LOSS OF BODY WIGHT
DAILYDAILY300g-500g IF ONLY ASCITES300g-500g IF ONLY ASCITES800g-1000g IF ASCITES AND EDEMA 800g-1000g IF ASCITES AND EDEMA
DIEURETICSDIEURETICS MAINSTAY THERAPY FOR ASCITESMAINSTAY THERAPY FOR ASCITES
SPIRONOLACTONESPIRONOLACTONE 25-200 mg/d PO qd or divided bid 25-200 mg/d PO qd or divided bid FUROSEMIDE:FUROSEMIDE:20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for 20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states severe edematous states AMILORIDE:AMILORIDE:5-20 mg PO qd 5-20 mg PO qd COMBINATION THERAPY:COMBINATION THERAPY:
SPIRONOLACTONE + FUROSEMIDESPIRONOLACTONE + FUROSEMIDE FUROSEMIDE + AMILORIDEFUROSEMIDE + AMILORIDE
MANAGEMENTMANAGEMENT
MEDICAL CAREMEDICAL CARETHERAPEUTIC PARACENTESISTHERAPEUTIC PARACENTESIS
In patients with massive ascites (grade 3 or In patients with massive ascites (grade 3 or 4)4)
In ascites refractory to dieureticsIn ascites refractory to dieuretics
If cardio respiratory distress due to ascitesIf cardio respiratory distress due to ascites
3-5litres can be removed with the 3-5litres can be removed with the replacement of salt free albumin.replacement of salt free albumin.
MANAGEMENTMANAGEMENT
MEDICAL CAREMEDICAL CARETIPS(TRANSJUGULAR INTRAHEPATIC TIPS(TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT)PORTOSYSTEMIC SHUNT)
Becoming standard of care in dieuretic Becoming standard of care in dieuretic resistant ascitesresistant ascites
MANAGEMENTMANAGEMENT
SURGICAL CARESURGICAL CARELEE VEEN SHUNT:LEE VEEN SHUNT:It is a peritoneovenous shuntIt is a peritoneovenous shuntAlternative for medically intractable ascitesAlternative for medically intractable ascitesImproves Cardiac Out Put, renal Blood Flow, Improves Cardiac Out Put, renal Blood Flow, Glomerular Filtration Rate, Urinary Volume, Glomerular Filtration Rate, Urinary Volume, And Sodium Excretion And Decreased Plasma And Sodium Excretion And Decreased Plasma Renin Activity And Plasma Aldosterone Renin Activity And Plasma Aldosterone Concentration Concentration DoesnDoesn’’t Improve Patientt Improve Patient’’s Survival So With s Survival So With The Advent Of Tips ItThe Advent Of Tips It’’s Becoming Obsoletes Becoming Obsolete
THE MOST COMMON THE MOST COMMON COMPLICATION IS:COMPLICATION IS:
SBP (Spontaneous Bacterial Peritonitis)SBP (Spontaneous Bacterial Peritonitis)
COMPLICATIONSCOMPLICATIONS
COMPLICATIONSCOMPLICATIONS
SBPSBPMost common bacteria is E. Coli.Bacteria are believed to gain Most common bacteria is E. Coli.Bacteria are believed to gain access to peritoneum by hematogenous route. access to peritoneum by hematogenous route.
Low ascitic fluid albumin (<1g/dl) predisposes SBP Low ascitic fluid albumin (<1g/dl) predisposes SBP
Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Rebound Tenderness.Rebound Tenderness.
Ascitic Fluid analysis shows wbcs >500/mm3l and Ascitic Fluid analysis shows wbcs >500/mm3l and Eutrophil>250/mm3Eutrophil>250/mm3
Third generation Cephalosporins 2g tid started empirically for 5 Third generation Cephalosporins 2g tid started empirically for 5 days till c/s report is available. days till c/s report is available.
Recurrence is common. Ciprofloxacin 750 mg once weekly can Recurrence is common. Ciprofloxacin 750 mg once weekly can be given prophylacticaly. be given prophylacticaly.
MCQsMCQs
Q. No 1Q. No 1IF SAAG IS >1.1 THEN THE CAUSE IF SAAG IS >1.1 THEN THE CAUSE WOULD BE ALL EXCEPT:WOULD BE ALL EXCEPT:PORTAL HYPERTENSIONPORTAL HYPERTENSION
MYXEDEMAMYXEDEMA
NEPHROTIC SYNDROMENEPHROTIC SYNDROME
TUBERCULOUS PERITONITISTUBERCULOUS PERITONITIS
MCQsMCQs
Q. No 2Q. No 2THE MOST EFFICACIOUS THE MOST EFFICACIOUS TREATMENT FOR REFRACTORY TREATMENT FOR REFRACTORY ASCITES ISASCITES ISMAXIMUM DOSE OF DIEURETICSMAXIMUM DOSE OF DIEURETICS
THERAPEUTIC PARACENTESISTHERAPEUTIC PARACENTESIS
TIPSTIPS
LEE VEEN SHUNTLEE VEEN SHUNT
Q. No 3Q. No 3SBP IS MORE LIKELY WHENSBP IS MORE LIKELY WHENWBCS >250/microLWBCS >250/microL
NEUTROPHILS>250/microLNEUTROPHILS>250/microL
LYMPHOCYTES>500/microLLYMPHOCYTES>500/microL
ALL OF THE ABOVEALL OF THE ABOVE
MCQsMCQs