Liver Ascites

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2. Hepatocellular carcinoma 2 When to suspect? Suddendevelopment of ascites in a stable cirrhotic 3. Constrictive pericarditis 3Tuberculosis Oneof the few curable causes of 4. Tuberculous peritonitis 4Very important cause 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 6. Sister Mary Joseph's nodule 6Hard periumbilical nodule MetastaticPelvicdiseaseor gastrointestinal primary 7. www.medicinemcq.com7 8. www.medicinemcq.com8 9. www.medicinemcq.com9 10. Virchow's node 10Supraclavicularadenopathy GI 11. www.medicinemcq.com11 12. www.medicinemcq.com12 13. www.medicinemcq.com13 14. IVC blockage 14Large veins 15. Portal hypertension 15 First pathogenetic abnormality inascites formation in 16. Obstruction of hepatic lymphatics 16Cause exudation ofhepatic lymph from the 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 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 19. Kidneys 19 Increased sodium and water 20. Hypoalbuminemia 20 Reduced plasma oncotic 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 23. USS 23 Best test to detect even small amountof ascites Can detect as little as 100 mL of 24. www.medicinemcq.com24 25. www.medicinemcq.com25 26. Morrisons pouch 26Earliest fluid collection Hepato-renal pouch 27. www.medicinemcq.com27 28. More than 500 to 1000 mL 28Shiftingdullness Fluid thrill Not very 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 34. Routine tests on ascitic fluid 341. Cell count2. Albumin 3. Total 35. Optional 354. Culture5. Glucose 6. Grams stain 7. Amylase 8. Cytology 36. Cell count 36Single most helpfulascitic fluid 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 38. Spontaneous bacterial peritonitis 38 Most common cause of an elevatedascitic WBC count PMN > 70% of the total WBC 39. Elevated ascitic WBC count other causes 39Tuberculous peritonitis 2. Peritoneal carcinomatosis Predominance of lymphocytes 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 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 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 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. 46. High gradient (transudative) ascites 46 Right heart failure Anothercommon cause Nephrotic 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' 48. LOW GRADIENT