Ascites
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Transcript of Ascites
Ascites
By R.Gnanaraj
DefinitionDefinition• From greek derivation askhos which
refers to a ‘bag’ or ‘sack’.• Pathologic fluid accumulation in the
peritoneal cavity.
Causes of ascitesCauses of ascites• Hepatic• Renal• Cardiac• Infectious• GI • Neoplasm• Gynecological• Pancreatic• miscellaneous
Causes of ascitesCauses of ascites• Ascites in newborn is classified as 1.associated with hydrops 2.isolated ascites 3.ascites due to peritonitis
Associated with hydropsAssociated with hydrops1.CVS(20%)- heart block auricular tachycardia hypoplastic left heart ebstein disease2.Hematological (10%)-isoimmune hemolytic disease homozygous alpha thalassemia3.Chromosomal(10%)-turner syndrome trisomy 13,18,214.Infection(10%)-TORCH group syphilis5.Pulmonary(5%)-diaphramatic hernia
Contd…Contd…6.Gastrointestinal(5%)-atresia7.Renal(5%)-nephrosis8.Maternal conditions(5%)-Toxemia, Diabetes9.Miscellaneous(5%)- Wilm’s tumors Neuroblastoma10.Liver-Cirrhosis Alpha-1 antitrypsin deficency Neonatal hemochromatosis11.Placenta or cord-Cord compression Chorangioma12.Unknown(20%)
• Isolated ascites-Chylous ascites Obstructive uropathy Biliary ascites• Ascites due to peritonitis Bacterial Chemical
Causes of ascites in childrenCauses of ascites in children• Extrahepatic-Venous obstruction CHF AV fistula• Intrahepatic-Biliary tract disease Hepatocellular disease Toxins Schistosomiasis• Other causes-TB Nephrotic syndrome Pancreatitis Chlamydial infection Rheumatoid arthritis
Causes of acute ascitesCauses of acute ascites• Venous obstruction• Peritonitis• Fulminant hepatic failure
PathophysiologyPathophysiology
•Underfill theory•Overflow theory•Peripheral vasodilation theory
Clinical featuresClinical features• Distension of abdomen• Abdominal pain• Respiratory distress
Signs of ascites Signs of ascites • 5 classic physical signs Bulging flanks Flank dullness Shifting dullness Fluid wave Puddle sign
Look for…Look for…• Triad of PHT• Umbilical herniation• Pedal edema & anasarca • Hepatojugular reflux & dilated veins
with flow upwards• Fever & abdominal pain with
guarding & rigidity• Evidence of malignancy
Investigations Investigations • Blood – cell counts,viral markers• Urine analysis• LFT• Mantoux test• Renal & cardiac evaluation• Ascitic fluid analysis• USG, CT scan , MRI
Grading of ascites Grading of ascites • Mild - only seen in USG or puddle
sign• Moderate – shifting dullness present• Severe – fluid thrill present
Abdominal paracentesisAbdominal paracentesis• Position• Site• Technique – ‘Z’ tract
Ascitic fluid analysisAscitic fluid analysis• Colour • Cell count• Protein• Culture• SAAG• LDH• Amylase• TG, bilirubin
Serum ascites albumin Serum ascites albumin gradient(SAAG)gradient(SAAG)
• Ratio >1.1 portal hypertension• Ratio <1.1 peritoneal pathology -TB -SBP -Malignancy
Exudative & transudative Exudative & transudative causescauses
• Exudative(<1.1) 1.Peritonitis 2.IVC obstruction 3.Malignancy 4.Pancreatitis 5. Chylous
ascites 6.Hemorrhagic
• Transudative(>1.1) 1.Nephritic
syndrome 2.Hypoproteinemia 3.CCF 4.End stage liver
cell failure 5.Protein losing
enteropathy
Complications Complications • Spontaneous bacterial peritonitis• Hernias• Respiratory distress
Management Management • Depends on the SAAG Low albumin gradient ascites High albumin gradient ascites
Low albumin gradient Low albumin gradient ascitesascites
• Does not respond to salt restriction & diuretics• Treatment depends on the cause TB peritonitis- ATT Pancreatic ascites- endoscopic stenting somatostatin therapy surgery Chlamydial-tetracycline Nephrotic & lupus ascites-steroids Malignancy-chemotherapy surgery
High albumin gradient High albumin gradient ascitesascites
• Bed rest• Diet restriction• Diuretics• Beta blockers
Diet restrictionDiet restriction• Sodium restriction upto 5 mEq/day (1-4 yrs)
upto 20mEq/day (4-11 yrs) upto 30mEq/day (>12 yrs)
• No fluid restriction
Diuretics Diuretics • Potassium sparing diuretics• Loop diuretics• Thiazides
SpironolactoneSpironolactone
• Starting Dose - 1-2mg/kg/day• Gradually increased upto
6mg/kg/day• Onset – 2-4days• Side effects – hyperkalemia metabolic acidosis gynecomastia• Others – triamterene,amiloride
Loop diureticsLoop diuretics• Furosemide,bumetanide,ethacrynic acid• Starting Dose - 1-2mg/kg/day• Gradually increased upto 6mg/kg/day• Onset – 2-4days• Side effects – hypokalemia hyperchloremic acidosis ototoxicity
Thiazide diureticsThiazide diuretics• Hydrochlorthiazide indicated when
diuresis on high doses are inadequate.
• Dose – 2-3mg/kg/day• Side effects-hypokalemia hyperglycemia hyperuricemia
Duration of diureticsDuration of diuretics• Treatment – till ascites is cured• Maintenance – in case of cirrhosis for
months to years.
Beta blockers Beta blockers • Causes increased natriuresis by 1.lowering of portal pressure 2.inhibition of renin secretion
Refractory ascitesRefractory ascites• Fluid overload unresponsiveness to
salt restriction & high dose diuretic• Causes-infection malignancy TB liver cell failure renal causes
Treatment for refractory Treatment for refractory ascites ascites
• Paracentesis• LeVcen shunt (peritoneal venous
shunt)• Orthotropic liver transplantation
Paracentesis Paracentesis • LVP - 200-400ml/kg/day slowly over
4-6hrs • Simultaneous infusion of 6g of 20%
albumin for every liter of fluid removed.
• Mechanism-paracentesis decreases systemic venous congestion, increases GFR & renal plasma flow
Chylous ascitesChylous ascites• Causes• Anomaly of lymphatics• cirrhosis• trauma• Tumor• Rheumatoid arthritis• Infections
Clinical featuresClinical features• Abdominal distension• Poor weight gain• Loose stools• Anasarca
Management Management • Fluid analysis-white in colour Increased protein Increased TG Decreased gamma globulin Lymphocytosis• Treatment 1.diet- low fat diet with MC TG High protein diet 2.paracentesis 3.surgery
Reference OP Ghai Nelson IAP Pediatricks
Thank you