Ascites (Clinical Approach) - aman maurya

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clinical approach to patient of ascites

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Ascites (Clinical Approach):

Ascites (Clinical Approach) Aman Maurya (10) Aman Jain(09)

Definition :

Definition Collection of the free fluid in the peritoneal cavity.

Causes:

Causes Ascites with anasarca CCF Nephrotic syndrome Hypoproteinemia with severe anemia Pericardial effusion Constrictive pericarditis Myxoedema Filariasis Protein losing enteropathy

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Ascites without anasarca Cirrhosis of liver Peritonitis Portal vein thrombosis Meig’s syndrome Pancreatic ascites Budd chiari syndrome Lymphoma or leukemia Chylous ascites

Causes of transudative and exudative ascites:

Causes of transudative and exudative ascites Transudative Cirrhosis of liver CCF Nephrotic syndrome Hypoproteinemia with severe anemia Protein losing enteropathy Constrictive pericarditis Pericardial effusion Meig’s syndrome Myxoedema IVC obstruction

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Exudative Peritonitis Pancreatic ascites Budd chiari syndrome Lymphoma or leukemias Rupture of hollow viscus Injury or obstruction to the thoracic duct Myxoedema , Meig’s syndrome and chylous ascites may be exudative .

Clinical features:

Clinical features Symptoms- Abdominal Distension Diffuse Abdominal Pain Bloated Feeling of Abdomen Dyspnoea and Orthopnea (due to elevation of diaphragm ) Indigestion and Heart burn (due to increased intra abdominal pressure

Physical examination:

Physical examination General appearance – Patient will be in propped up position due to dyspnoea . General examination- PICLE, vitals

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Abdominal examination Inspection- Abdominal Distension Fullness of Flanks Umbilicus Everted nd transverse slit Divarication of Recti Muscles Distended Abdominal Veins Skin is stretched and shiny Abdominal hernia or abdominal striae

Palpation:

Palpation Fluid thrill Flow of blood in veins around the umbilicus Hepatosplenomegaly For any other abdominal mass Measurements – Maximum girth at umblicus Spino-umblical distance Distance b/w xiphisternum and umblicus > distance b/w umblicus and symphisis pubis

Percussion :

Percussion Shifting dullness Puddle sign Note – shifting dullness is the most important sign of ascites .

Auscultation :

Auscultation Venous hum over the distended veins around umblicus in cirrhosis with portal hypertension

Other signs:

Other signs Respiratory – Hydrothorax (commonly rt. Sided) Basal collapse CVS – Apex beat Diffuse pulsation over the precordium

Imp. Physical findings for aetiological diagnosis:

Imp. Physical findings for aetiological diagnosis Virchow’s gland- GI malignancy Skin changes of hepatocellular failure- usually cirrhosis of liver Engorged nd pulsatile neck vein- CCF, Pericardial effusion, constrictive pericarditis Prominent abd . Vein- Portal Hypertension Non pitting edema in feet- Myxoedema , filariasis

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Spleenomegaly - mainly portal hypertension(cirrhosis of liver), also in lymphoma, leukaemias , Budd- Chiari synd. Hepatomegaly - firm liver indicates cirrhosis,, hard nd tender liver for malignancy Tenderness- Peritonitis

D/D:

D/D Ascites Ovarian cyst Hydramnios Obesity Liver cirrhosis Tuberculous peritonitis Portal vein thrombosis Costrictive pericarditis CCF Nephrotic syndrome hypoproteinemia

Important Points:

Important Points Fluid Should remain under tension for + ve fluid thrill, At least 2 ltr . Fluid is neccesary to elicit fluid thrill. Patient is asked to evacuate his/her bladder before test for shifting dullness and fluid thrill. Shifting dullness is never found in encysted fluid in abdomen. ½-1 ltr fluid is reqd. to demo. Sh. Dullness 120 ml of fluid can be detected by puddle sign Remember 7 F’s of distention of Abdomen.

Investigations:

Investigations Routine blood examinations Urine examination Stool examination Serum cholesterol Plasma proteins X-ray of the abdomen USG Examination of ascitic fluid Liver function tests Peritoneoscopy Liver biopsy

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IMAGING STUDIES CHEST AND ABDOMINAL PLAIN FILMS Detects ascites if >500ml fluid Elevated diaphragm Pleural effusion (hepatic hydrothorax) Diffuse abdominal haziness USG ABDOMEN can detect as small as 5ml fluid can identify the cause like liver cirrhosis CT SCAN : can identify the cause like malignancies

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LAB STUDIES ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) Ascitic Fluid should be analyzed for APPEARANCE CELL COUNT TOTAL PROTEINS SAAG(SERUM ASCITIC ALBUMIN GRADIENT) CYTOLOGY CULTURE

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ASCITIC FLUID ANYALYSIS ( DIAGNOSTIC PARACENTESIS) APPEARANCE TRANSPARENT AND TINGED: NORMAL STRAW COLORED: CIRRHOSIS HEAMORRHGIC: MALIGNANCY CLOUDY: INFECTION BILE STAINED: BILIARY CONTAMINATION CHYLOUS: LYMPHATIC OBSTRUCTION

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ASCITIC FLUID ANYALYSIS ( DIAGNOSTIC PARACENTESIS) CELL COUNT WBCS <500/mm3 and NEUTROPHILS<250/mm3: NORMAL NEUTROPHILS>250/ microL : suggests SBP LYMPHOCYTES PREDOMINANCE: ABDOMINAL TB OR MALIGNANCY ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) TOTAL PROTEINS PROTEINS<2.5g/dl: TRANSUDATE PROTEINS>2.5g/dl: EXUDATE

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ASCITIC FLUID ANYALYSIS ( DIAGNOSTIC PARACENTESIS) SAAG (Serum Ascitic Albumin Gradient) The Difference bw Serum Albumin and Ascitic fluid Albumin Best single test to differentiate between ascites due to portal hypertension and non-portal hypertension When saag >1.1g/dl: strongly suggest portal hypertension When saag < 1.1g/dl: non portal hypertensive causes Accuracy more than 97%

Management :

Management COMPRISES OF: General care Medical care Surgical care

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GENERAL CARE MONITORING OF INPUT OUT PUT ABDOMINAL GIRTH WEIGHT DIETRY MODIFICATIONS SODIUM RESTRICTION UPTO 1g/day WATER RESTRICTION (If Serum Sodium Level Is <120mmol/L Hyponatremia ) BED REST: Improves renal perfusion which leads to diuresis

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MEDICAL CARE THE AIM OF THE THERAPY IS WT LOSS OF BODY WIGHT DAILY 300g-500g IF ONLY ASCITES 800g-1000g IF ASCITES AND EDEMA DIURETICS MAINSTAY THERAPY FOR ASCITES SPIRONOLACTONE 25-200 mg/d PO qd or divided bid FUROSEMIDE: 20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states AMILORIDE: 5-20 mg PO qd COMBINATION THERAPY: SPIRONOLACTONE + FUROSEMIDE FUROSEMIDE + AMILORIDE

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MEDICAL CARE THERAPEUTIC PARACENTESIS In patients with massive ascites (grade 3 or 4) In ascites refractory to dieuretics If cardio respiratory distress due to ascites 3-5litres can be removed with the replacement of salt free albumin . TIPS(TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT) Becoming standard of care in dieuretic resistant ascites

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SURGICAL CARE LEE VEEN SHUNT: It is a peritoneovenous shunt Alternative for medically intractable ascites Improves Cardiac Out Put, renal Blood Flow, Glomerular Filtration Rate, Urinary Volume, And Sodium Excretion And Decreased Plasma Renin Activity And Plasma Aldosterone Concentration Doesn ’ t Improve Patient ’ s Survival So With The Advent Of Tips It ’ s Becoming Obsolete

Complications :

Complications Collection of the fluid in the rt. Pleural sac Spontaneous bacterial peritonitis Hernia Mesenteric venous thrombosis Functional renal failure

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THANK YOU

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