Liver Ascites

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  • 1. ASCITES 1MOST PATIENTS HAVE CIRRHOSISwww.medicinemcq.com

2. Hepatocellular carcinoma 2 When to suspect? Suddendevelopment of ascites in a stable cirrhotic patientwww.medicinemcq.com 3. Constrictive pericarditis 3Tuberculosis Oneof the few curable causes of asciteswww.medicinemcq.com 4. Tuberculous peritonitis 4Very important cause Curablewww.medicinemcq.com 5. Peritoneal carcinomatosis 5 Protein rich fluid by tumor cells liningthe peritoneum ECF enters the peritoneal cavity to maintain oncotic balance Tuberculosis Also causes production of protein rich fluidwww.medicinemcq.com 6. Sister Mary Joseph's nodule 6Hard periumbilical nodule MetastaticPelvicdiseaseor gastrointestinal primary tumorwww.medicinemcq.com 7. www.medicinemcq.com7 8. www.medicinemcq.com8 9. www.medicinemcq.com9 10. Virchow's node 10Supraclavicularadenopathy GI malignancywww.medicinemcq.com 11. www.medicinemcq.com11 12. www.medicinemcq.com12 13. www.medicinemcq.com13 14. IVC blockage 14Large veins Backwww.medicinemcq.com 15. Portal hypertension 15 First pathogenetic abnormality inascites formation in cirrhosiswww.medicinemcq.com 16. Obstruction of hepatic lymphatics 16Cause exudation ofhepatic lymph from the surfacewww.medicinemcq.com 17. Increased hepatic lymph 17 Normal physiology Lymph Toproduced in the hepatic sinusoidssystemic circulation by the thoracic duct When sinusoidal pressures rise Lymphspills over from the surface of the liver to the peritoneal cavitywww.medicinemcq.com 18. PATHOGENESIS OF ASCITES 18 Splanchnic vasodilatation Chief factor contributing to ascites Increased hydrostatic pressure within thesplanchnic capillary bed Exudation of lymph from the surface of the cirrhotic liverwww.medicinemcq.com 19. Kidneys 19 Increased sodium and water reabsorptionwww.medicinemcq.com 20. Hypoalbuminemia 20 Reduced plasma oncotic pressurewww.medicinemcq.com 21. www.medicinemcq.com21 22. PRECIPITATING FACTORS 221. Excessive salt intake2. Failure to take drugs 3. Peritoneal infection 4. Worsening of liver disease5. Hepatocellular carcinoma 6. Portal vein thrombosiswww.medicinemcq.com 23. USS 23 Best test to detect even small amountof ascites Can detect as little as 100 mL of fluidwww.medicinemcq.com 24. www.medicinemcq.com24 25. www.medicinemcq.com25 26. Morrisons pouch 26Earliest fluid collection Hepato-renal pouch PODwww.medicinemcq.com 27. www.medicinemcq.com27 28. More than 500 to 1000 mL 28Shiftingdullness Fluid thrill Not very usefulwww.medicinemcq.com 29. No flank dullness 29Asciteswww.medicinemcq.comunlikely 30. www.medicinemcq.com30 31. www.medicinemcq.com31 32. www.medicinemcq.com32 33. Paracentesis 33 Final confirmation of ascites Best method for diagnosing thecausewww.medicinemcq.com 34. Routine tests on ascitic fluid 341. Cell count2. Albumin 3. Total proteinwww.medicinemcq.com 35. Optional 354. Culture5. Glucose 6. Grams stain 7. Amylase 8. Cytology www.medicinemcq.com 36. Cell count 36Single most helpfulascitic fluid testwww.medicinemcq.com 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 culturewww.medicinemcq.com 38. Spontaneous bacterial peritonitis 38 Most common cause of an elevatedascitic WBC count PMN > 70% of the total WBC countwww.medicinemcq.com 39. Elevated ascitic WBC count other causes 39Tuberculous peritonitis 2. Peritoneal carcinomatosis Predominance of lymphocytes 1.www.medicinemcq.com 40. SAAG 40 Serum ascites albumin gradient Serum albumin in g/dL minus ascites albumin in g/dL To differentiate cirrhotic ascites fromother causes of ascites Better than total protein content in the ascitic fluidwww.medicinemcq.com 41. High SAAG (> 1.1 g/dL) 41 Uncomplicated cirrhotic ascites Serum albumin concentration Atleast 1 g/dL higher than that of the ascitic fluid albumin concentration.www.medicinemcq.com 42. SAAG - indirect but accurate index of portal pressure 42 1.1 g/dL or more Portal hypertension Accuracy97% < 1.1 g/dL No portal hypertension Accuracywww.medicinemcq.com97% 43. Accuracy > 97% 43 Even with Asciticfluid infection Diuresis Paracentesis IV albumin Varying causes of liver diseasewww.medicinemcq.com 44. High SAAG 44 Does not confirm cirrhosis Indicateswww.medicinemcq.comportal hypertension 45. Typical of cirrhosis 454.SAAG >1.1 g/dL WBC count < 500 cells/mm3 Predominant lymphocytes Specific gravity less than 10165.Urine Na low1.2. 3.www.medicinemcq.com 46. High gradient (transudative) ascites 46 Right heart failure Anothercommon cause Nephrotic syndromewww.medicinemcq.com 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' syndromewww.medicinemcq.com 48. LOW GRADIENT