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MOST PATIENTS HAVE CIRRHOSIS

ASCITES

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Hepatocellular carcinoma

When to suspect?Sudden development of ascites in a stable cirrhotic patient

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Constrictive pericarditis

TuberculosisOne of the few curable causes of ascites

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Tuberculous peritonitis

Very important causeCurable

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Peritoneal carcinomatosis

Protein rich fluid by tumor cells lining the peritoneum ECF enters the peritoneal cavity to maintain

oncotic balance

Tuberculosis Also causes production of protein rich fluid

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Sister Mary Joseph's nodule

Hard periumbilical noduleMetastatic disease

Pelvic or gastrointestinal primary tumor

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Virchow's node

Supraclavicular adenopathy

GI malignancy

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IVC blockage

Large veins Back

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Portal hypertension

First pathogenetic abnormality in ascites formation in cirrhosis

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Obstruction of hepatic lymphatics

Cause exudation of hepatic lymph from the surface

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Increased hepatic lymph

Normal physiologyLymph produced in the hepatic

sinusoids To systemic circulation by the thoracic duct

When sinusoidal pressures riseLymph spills over from the surface of

the liver to the peritoneal cavity

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PATHOGENESIS OF ASCITES

Splanchnic vasodilatation Chief factor contributing to ascites

Increased hydrostatic pressure within the splanchnic capillary bed

Exudation of lymph from the surface of the cirrhotic liver

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Kidneys

Increased sodium and water reabsorption

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Hypoalbuminemia

Reduced plasma oncotic pressure

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PRECIPITATING FACTORS

1. Excessive salt intake2. Failure to take drugs3. Peritoneal infection4. Worsening of liver disease5. Hepatocellular carcinoma6. Portal vein thrombosis

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USS

Best test to detect even small amount of ascites

Can detect as little as 100 mL of fluid

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Morrison’s pouch

Earliest fluid collection Hepato-renal pouch POD

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More than 500 to 1000 mL

Shifting dullness Fluid thrill

Not very useful

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No flank dullness

Ascites unlikely

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Paracentesis

Final confirmation of ascitesBest method for diagnosing the cause

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Routine tests on ascitic fluid

1. Cell count2. Albumin3. Total protein

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Optional

4. Culture5. Glucose6. Gram’s stain7. Amylase8. Cytology

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Cell count

Single most helpful ascitic fluid test

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WBC count

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 culture

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Spontaneous bacterial peritonitis

Most common cause of an elevated ascitic WBC count PMN > 70% of the total WBC count

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Elevated ascitic WBC count – other causes

1. Tuberculous peritonitis2. Peritoneal carcinomatosisPredominance of lymphocytes

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SAAG

Serum ascites albumin gradient Serum albumin in g/dL minus ascites albumin in

g/dL

To differentiate cirrhotic ascites from other causes of ascites Better than total protein content in the ascitic

fluid

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High SAAG (> 1.1 g/dL)

Uncomplicated cirrhotic ascitesSerum albumin concentration

At least 1 g/dL higher than that of the ascitic fluid albumin concentration.

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SAAG - indirect but accurate index of portal pressure

1.1 g/dL or morePortal hypertension

Accuracy 97%< 1.1 g/dL

No portal hypertension Accuracy 97%

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Accuracy > 97%

Even withAscitic fluid infectionDiuresisParacentesis IV albuminVarying causes of liver disease

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High SAAG

Does not confirm cirrhosisIndicates portal hypertension

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Typical of cirrhosis

1. SAAG >1.1 g/dL2. WBC count < 500 cells/mm3

3. Predominant lymphocytes4. Specific gravity less than 1016

5. Urine Na low

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High gradient (transudative) ascites

Right heart failureAnother common cause

Nephrotic syndrome

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HIGH GRADIENT ≥1.1 g/DL

Cardiac TR Constrictive pericarditis

Alcoholic hepatitisMassive liver metastasesFulminant hepatic failureBudd-Chiari syndromePortal vein thrombosisMyxedemaMeigs' syndrome

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LOW GRADIENT <1.1 g/DL

Peritonitis TB, Bacterial

Peritoneal carcinomatosisPancreatic ascitesBowel obstruction or infarctionBiliary ascitesPostoperative lymphatic leakSerositis in connective tissue diseases

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Blood-stained ascitic fluid

Traumatic tapFrequently clots

Tuberculous peritonitisHepatoma Peritoneal secondaries

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Peritonitis

Bacterial Polymorphonuclear cells predominate Gram's stain may be positive

TB Predominant lymphocytes Diagnosis

Granulomas on peritoneal biopsy AFB

Difficult to recover from ascitic fluid May take 4 to 6 weeks

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CHYLOUS ASCITES

Lymphatic obstruction Trauma Tumor TB Filariasis

 Cirrhosis Nephrotic syndrome Congenital abnormalities

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Salt restriction

Most important treatment of cirrhotic ascites

Normal diet contains 5 to 15 grams of sodium chloride

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Spironolactone plus furosemide produce a diuresis in most patients

If sodium restriction alone does not cause diuresis and weight loss

Spironolactone Drug of choice

Furosemide Risk of excessive diuresisHypokalemia

Precipitate encephalopathy

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Fluid intake

Restricted only if there is dilutional hyponatremiaHigh levels of antidiuretic

hormone Diagnosis

Serum sodium < 130 mEq/L in the presence of ascites

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Large-volume paracentesis

Treatment of choice for large-volume ascites

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LARGE VOLUME PARACENTESIS

Tense ascitesRespiratory distressPoor response to medical therapy

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Hepatorenal syndrome

Renal failureProfound vasoconstriction in the

renal circulation Due to excessive activity of endogenous vasoactive substances

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Hemodynamic hallmark

Systemic vasodilationRenal vasoconstriction

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Clinical hallmarks

Worsening azotemiaHyponatremiaProgressive oliguriaHypotension

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Treatment

Vasoconstrictor drugsNorepinephrine, midodrine,

terlipressin or alpha-adrenergic agents

In combination with albumin

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Liver transplantation

Most effective treatment for hepatorenal syndrome

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SBP

No obvious primary source of infection

Contrast-enhanced CTTo exclude an intra-abdominal source for infection

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Cefotaxime and an aminoglycoside

90 %Monomicrobial

Enteric GNB

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What is the diagnosis

A 30-year-old male is admitted with mild abdominal swelling, fever, and loss of weight. Ascitic fluid shows the following changes. Macroscopic appearance - hemorrhagic. Proteins = 3 grams/dl. SAAG = < 1.1 g/dl. Cells = WBCs in plenty. 70% of cells are lymphocytes. Few mesothelial cells are also present. He occasionally takes alcohol. What is the most probable diagnosis?

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Answer

TB Predominant lymphocytes