بسم الله الرحمن الرحيم

APPROACH TO PATIENT WITH ASCITIES.

DEF. OF ASCITIES. Ascites is defined as the accumulation of free fluid in the peritoneal cavity.

TYPES OF ASCITIES. Broadly categorizing ascities can be:. Ascities is most often caused by liver cirrhosis which accounts for over 75% of patients while the remaining 25 % is due to malignancy (10%), heart failure (3%), pancreatitis (1%), TB (2%), or other rare causes. Broadly categorizing ascities can be:. 1...Peritoneal ascities. 2...Non peritoneal ascities.

Peritoneal Causes of Ascites Examples Malignant ascites Primary peritoneal mesothelioma Secondary peritoneal carcinomatosis Granulomatous peritonitis Tuberculous peritonitis Fungal and parasitic infections Sarcoidosis Foreign bodies (cotton ,starch, barium) Vasculitis Systemic lupus erythematosus Henoch-Schönlein purpura Miscellaneous disorders Eosinophilic gastroenteritis Whipple disease Endometriosis

Nonperitoneal Causes of Ascites Examples Intrahepatic portal hypertension Cirrhosis Fulminant hepatic failure Veno-occlusive disease Extrahepatic portal hypertension Hepatic vein obstruction (ie, Budd-Chiari syndrome) Congestive heart failure Hypoalbuminemia Nephrotic syndrome Protein-losing enteropathy Malnutrition Miscellaneous disorders Myxedema Ovarian tumors Pancreatic & Biliary ascites Chylous Secondary to malignancy, trauma

PATHOPHYSIOLOGY OF ASCITIES. FACTORES ASSOCIATED WITH ASCITES IN HEPATIC CIRROSIS Renal sodium retention Renal water retention  Portal hypertension     Poor liver function         Ascites in hepatic cirrhosis develops because of a considerable increase of total body sodium,water, and portal hypertension which localises much of that sodium and water to the peritoneal cavity

The pathogenesis of ascites formation remains controversial The pathogenesis of ascites formation remains controversial. “Underfill" theory Ascites occurs as a primary event. Sequestration of fluid into the peritoneal cavity as a result of changes in Starling's forces leads to reduction of the circulatory volume and stimulation of the sympathetic nervous & RAAS that promote renal sodium & water retention.

“Overflow theory" Renal Na retention occurs as a primary event “Overflow theory" Renal Na retention occurs as a primary event. It may be due to increased production of a sodium retaining factor or reduced synthesis of a natriuretic factor by the diseased liver. The circulatory volume is expanded & the retained fluid is preferentially localized to the peritoneal cavity as ascites.

“Peripheral Arterial Vasodilation Hypothesis" The currently accepted theory of ascites formation which include features of both the underfill and overflow theories is the “Peripheral Arterial Vasodilation Hypothesis" According to this theory, Portal pressure >12 mm Hg is required for the development of PH which will lead to formation of ascites. Chronic endotoxemia associated with cirrhosis may stimulate the synthesis and release of a potent endothelin-derived relaxing factor, Nitric oxide,;leading to PH changes.

SYPTOMS OF ASCITIES.  The symptoms of ascites depend largely on the quantity of fluid. Trace ascites ______ asymptomatic, and fluid is detected only on physical or radiologic examination. Large amount_______ complain of abdominal fullness, early satiety, abdominal pain, or shortness of breath. Ascites can give rise to a number of secondary features including :- umbilical eversion hernia pale abdominal striae scrotal edema Mechanical effects on the chest. Pleural effusion .

DIAGNOSIS. HISTORY Most cases of ascites are due to liver disease. Patients with ascites should be asked about risk factors for liver disease like:- Alcohol use and duration of use-----experience ascities in cyclic fashion. Chronic viral hepatitis or jaundice Intravenous drug use Sexual promiscuity Transfusions. Tattoos Habitation or origination from an area endemic for hepatitis

HISTORY Obesity, hypercholesterolemia, and type 2 diabetes mellitus are recognized causes of nonalcoholic steatohepatitis, which can progress to cirrhosis,leading to ascities. History of cancer, especially gastrointestinal cancer, are at risk for malignant ascites. Malignancy-related ascites is frequently painful, whereas cirrhotic ascites is usually painless. Patients who develop ascites in the setting of known diabetes or nephrotic syndrome may have nephrotic ascites. Sudden development of ascities in stable cirrhosis,consider HCC.

EXAMINATION Physical examination findings are variable. The accuracy of detecting ascites depends on the amount of fluid present and the body habitus of the patient (detecting ascites may be more technically difficult in obese patients). If ascites is present, typical findings include generalized abdominal distention, flank fullness,shifting dullness,fluid thrill and +puddle sign.

SHIFTING DULLNESS METHOD OF EXAMINATION BEGIN BY PERCUSSING AT THE UMBILICUS AND MOVING TOWARD THE FLANKS. THE TRANSITION FROM AIR TO FLUID CAN BE IDENTIFIED WHEN THE PERCUSSION NOTE CHANGES FROM TYMPANIC TO DULL. ROLL THE PATIENT ON THEIR SIDE AND PERCUSS AS BEFORE. THE AREA OF TYMPANY WILL SHIFT TOWARDS THE TOP AND THE AREA OF DULLNESS TOWARDS THE BOTTOM.

FLUID THRILL METHOD OF EXAMINATION HAVE THE PATIENT OR ASSISTANT PLACE THEIR HANDS IN THE MIDLINE TAP ONE FLANK SHARPLY AND USE THE FINGERTIPS OF THE OPPOSITE HAND TO FEEL FOR AN IMPULSE ON THE OPPOSITE FLANK

PUDDLE SIGN METHOD OF EXAMINATION PATIENT IS PRONE FOR 3-5 MINUTES AND THEN RISES TO ALL FOURS DIAPHRAGM OF THE STETHOSCOPE IS PLACED OVER MOST DEPENDENT AREA OF THE ABDOMEN BEGIN BY FLICKING A FINGER OVER A LOCALIZED FLANK AREA MOVE THE STETHOSCOPE OVER THE OPPOSITE FLANK SUDDEN INCREASE IN INTENSITY IS A POSITIVE SIGN (NO LONGER USED)

GRADING OF ASCITIES Two grading systems for ascites have been used depending upon physical findings. The older system 1+ is minimal and barely detectable. 2+ is moderate. 3+ is massive but not tense. 4+ is massive and tense. The International Ascites Club grading (2003) Grade 1: mild ascites detectable only by USG. Grade 2: moderate ascites manifested by moderate symmetrical abdominal distension. Grade 3: large or gross ascites with marked abdominal distension.

INVESTIGATIONS A.DETECTION OF ASCITIES. B.FINDING CAUSE OF ASCITIES. 1.ULTRASONOGRAPHY. 2.DIAGNOSTIC PARACENTESIS. B.FINDING CAUSE OF ASCITIES. 1.IMAGING. 2.ENDOSCOPY. 3.BIOCHEMICAL PARAMETERS.

PERACENTESIS Indications Symptomatic relief in Cirrhotic Ascites Diagnostic study Suspected Spontaneous Bacterial Peritonitis Examine ascitic fluid for other etiology General Remove up to 4-6 L ascitic fluid Salt-poor albumin Preparation: 25% 50 cc bottle IV Give 1 bottle for every 1.5L of ascitic fluid removed Labs Prior to procedure Complete Blood Count PT APPT If platelets <40,000 then Transfuse 6 pack of platelets before paracentesis.

PARACENTESIS Procedure Preparation Place Foley and empty bladder before procedure Patient at 30 degrees head up (reverse Trendelenburg) Prepare site Midline at approximately 2 cm below and lateral to Umbilicus Clean and prep site well as SBP is a risk . Local 1% Lidocaine anesthetic Paracentesis Consider Z-Tracking needle on entry into abdomen Use vacuum bottle to apply suction Labs to send in ascitic fluid Cytology (if malignancy suspected) Cultures (rule-out SBP) Serum-to-Ascites Albumin Gradient (SAAG) Adverse Effects Hypotension .Abdominal wall hematomas. Hyponatremia Hemoperitoneam. Bleeding Bowel entry.

ASCITIC FLUID ANALYSIS Appearance Cause Translucent or yellow or straw coloured. Normal/sterile ,cirrhosis. Brown Hyperbilirubinemia GB or biliary perforation Cloudy or turbid Infection Pink or blood tinged Mild Trauma Grossly bloody Malignancy Abdominal trauma Milky ("chylous") Lymphatic obstruction.

BIOCHEMICAL EVALUATION. ROUTINE SOME TIMES USEFUL RARELY HELPFUL CELL COUNT TOTAL PROTEINS PH DIFFERENTIAL COUNT GLUCOSE LACTATE ALBUMIN LDH GRAM STAIN CULTURES AMYLASE TRIGLYCERIDES CYTOLOGY BILLIRUBIN TB SMEAR AND CULTURE

ASCITIC FLUID ANALYSIS If the PMN count is >250 cells/mm3,spontaneous bacterial peritonitis. Serum-ascites albumin gradient = serum albumin - ascitic fluid albumin if > 1.1 g/dL portal hypertension is present; if < 1.1 g/dL portal hypertension is not present (about 97% accurate). Cytology - only positive in peritoneal carcinomatosis. Lactate dehydrogenase >225mU/L, glucose <50mg/dL, total protein >1g/dL and multiple organisms on gram stain suggest secondary bacterial peritonitis (ruptured viscus or loculated abscess). A high level of triglycerides confirms chylous ascites. An elevated amylase level suggest pancreatitis or gut perforation. An elevated bilirubin level suggest biliary or gut perforation.

TREATMENT Mild to moderate ascites can be treated as an outpatient, but more severe ascites is treated best in hospital. Important factors in treating ascites include : 1.Bed rest. 2.Removing precipitating factors, 3.Controlling sodium intake 4.Controlling water intake, and potassium depletion. 5.Promoting sodium excretion with diuretic drugs, 6.Removing ascites by paracentesis, 7. Diverting ascitic fluid into the systemic circulation via a transjugular intrahepatic portal systemic stent (TIPSS) shunt or a Leveen shunt . None this treatment prolongs life, and prognosis for patients with hepatic cirrhosis and ascites is generally poor, liver transplantation should be considered.

MCQs.

Q. No 1 MCQs IF SAAG IS >1.1 THEN THE CAUSE WOULD BE ALL EXCEPT: PORTAL HYPERTENSION MYXEDEMA NEPHROTIC SYNDROME TUBERCULOUS PERITONITIS

Q. No 2 MCQs THE MOST EFFICACIOUS TREATMENT FOR REFRACTORY ASCITES IS MAXIMUM DOSE OF DIEURETICS THERAPEUTIC PARACENTESIS TIPS LEE VEEN SHUNT

Q. No 3 MCQs SBP IS MORE LIKELY WHEN WBCS >250/microL NEUTROPHILS>250/microL LYMPHOCYTES>500/microL ALL OF THE ABOVE

SCENARIO 54 year old female presented in emergency department with history of abdomional pain and abdominal distension for last 6 days.In past history she was HCV positive for last 3 years. What physical signs you can suspect in this case ?

SCENARIO BP 100/70 mmHg Pulse 90/min Abdomen examination revealed Distended abdomen with everted umbilicus Splenomegaly Shifting dullness is positive Bowel sounds present HOW WILL YOU INVESTIGATE THIS CASE ?

SCENARIO CP shows pancytopenia PT is 4 seconds prolong LFTS are normal Serum albumin is 3.2 Ascitic fluid analysis Albumin 2.0 TLC 350 POLYMORPHS 20% LYPHOCYTES 80% WHAT ARE THE DIFFENTIAL DIAGNOSIS? WHAT IS YOUR LIKELY DIAGNOSIS ?

SCENARIO HOW WILL YOU MANAGE THIS CASE?

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