ASCITES MEdical Presentation in Surgery.pptx

Ascites PPT

1. ASCITES Dr. Sangeetha K – Assistant Professor Department of General Surgery – KIMS, Hubli

2. ⦿ Aulus Cornel i us Celsus ⦿ Roman ⦿ 25 B.C to 50 A.D ⦿ Coined “ASCITES” ; askites – baglike (Greek)

3. ⦿ Defi n iti o n ⦿ Pat h o g e n esis & t h e o ries of as c ites formation ⦿ Ap p ro a ch ⦿ Di f fer e nt i al Dia g n o sis ⦿ Management

4. ⦿ Ac c u m ul a ti o n of fl u id in the p e rit o n eal cavity ⦿ Hydrop e rit o n e um ⦿ Hydras k os or a b d o m in a l d ro p sy

5. ⦿ Sim i lar to E d e m a F orm a ti o n Increased hydrostatic pressure Reduction in colloid osmotic pressure Disturbance of capillary permeability Insufficiency of lymphatic drainage

6. ⦿ Port a l h ypert e nsion ⦿ IVC o b struction ⦿ An a to m ic disru p ti o n o f He pat i c ve i ns

7. ⦿ Minimum albumin concentration – 2.5 to 3g/100ml ⦿ Hypoalbuminenia + Portal HTN- a pre-requisite for ascites due to d ecreased albumin production ⦿ Increased excretion of albumin

8. ⦿ T ra u ma ⦿ In f la m m a ti o n ⦿ Im m u n e m e di a ted

9. ⦿ M e sentr i c lymph adenopathy ⦿ Par asitic lymp h at i c o bstructi o n

10. ⦿ Und erfill theory ⦿ Overflow th e ory ⦿ L ymph im b al a nce t h e ory ⦿ V aso dil a ti o n th e ory

11. Primary Imbalance of Starling’s forces Reduced effective plasma volume Stimulation of Volume receptors,RAAS & sympathetic system Increased circulating ADH levels Increased Sodium reabsorbtion and reduced GFR Ascites formation Lymphatic insufficiency secondary to portal HTN Opening of Portosystemic shunts Decreasing PVR Formation or breakdown of vasodilatory substances

12. P rima r y Liver damage Portal hypertension sends salt retaining signal Retention of Sodium Volume expansion Overflow from Intravascular volume Ascites formation

13. ⦿ Do n ot expl a in in e a ch case ⦿ Both t h e o ries n o t m u tu ally exclusive ⦿ Doesn ’ t e f fective l y e xpla i n the i n iti a l event

14. ⦿ Con t ra dict s “clas s ical ” th e ori e s Extravasation from intravascular space (Lymph Production) Reflux into vascular system (Lymphatic Drainage)

15. ⦿ Obli t er a ti o n of di a p h ra g m a tic lymp h at i cs ⦿ Dila t ed lym p h a tic ves s els – reduced flow ⦿ Li m it e d l ymph kin e tics at the com m u n ion of lymphatics and venous systems

16. Portal Hypertension Peripheral vasodilation Plasma volume reduction Volume retention Salt retention Plasma volume expansion Ascites formation

17. ⦿ Clin i cal f e at u res ⦿ L a b o rat o ry fi n di n gs

18. ⦿ Is the d i stensi o n d u e t o As c it e s ?? ⦿ Acute or C h ro n ic?? ⦿ Possible et i ol o gical factors?? ⦿ Grade of A s cites ??

19. ⦿ M ani f est as c ites – 1.5 to 2 liters ⦿ Pu d dle sign 1 -1 5 ml ⦿ Sh i fti n g dul l n e ss 1 -1.5 lit e rs ⦿ Fl u id thr i ll >2 l i ters

20. ⦿ Colour ⦿ Cell count & Di f fere ntial ⦿ Prote i n ⦿ Sugar(Glucose < 50g / d L – Bacter i al in f ecti o n) ⦿ LDH ⦿ Bacteriol o g y - Cult u re & G ram Sta i n, TB ⦿ ADA

21. ⦿ Cle a r a n d straw colo u red ⦿ T ur bid ⦿ Hem o rrha g ic ⦿ Chylo u s

22. ⦿ Exudate ->1000/cu.mm; Transudate < 250cu.mm ⦿ PMN > 2 5 /cu. m m – Bacter i al ⦿ Lymphocytes >20% of Total Counts – TB (also Ascitic:Blood Glucose <0.7)

23. ⦿ SAAG – Serum alb u min: As c itic Al b u min ⦿ >1.1 – As c it e s secon d ary to Port a l Hypertension ⦿ <1.1 – Malignancy or Inflammation Transudate Exudate Protein <2.5g/L Protein >2.5g/L Specific Gravity <1,015 Specific gravity >1,016

24. ⦿ Gram stain ⦿ Cult u re – Aer o bic a nd a n a e ro bic ⦿ AFB sta i ni n g ⦿ PCR for T u b ercul o sis

25. ⦿ Ascites:serum <1.4 – portal hypertension ⦿ Absol u te value >4 I U/L

26. ⦿ Ferri t in ⦿ Fi b ro n ectin ⦿ Cho l ester o l ⦿ α 1 - a n titrypsin

27. Parameters Portal hypertension Infectious etiology M alignancy Clinical features Splenomegaly, spider naevi, jaundice, Dupytren’s contracture Fever, tenderness, guarding.. Sister Mary Joseph nodules, Troisier’s sign Loss of weight SAAG Protein >1.1 <2.5g/dL <1.1 >3g/dL <1.1 >3g/dL Cell count <250cells/cu.mm >1000cells/cu.mm >>1000cells/ cu.mm Ascites: Serum LDH <1.4 >1.4 >>1.4 Color Clear Clear to turbid Clear, turbid, hemorrhagic or chylous

28. ⦿ Port a l h ypert e nsion ⦿ In f ective et i ol o gy ⦿ M ali g n a ncy

29. ⦿ Sa l t r e striction ⦿ Diur e tics ⦿ Beta b l ockers ⦿ Al d oster o ne a n to g o n ist ⦿ Par a cent e sis

30. ⦿ Based on cult u re & sensit i vity ⦿ Empirically, cefotaxime 2g IV q12h for min. 5 days ⦿ Alt e rn ativel y , Oral ofl o xa c in 400m g q12h ⦿ ESBL a n ti b io t ics and a m in o glycosid e s - avoided

31. ⦿ Norfl o xacin d aily . ⦿ At risk - ascitic fl u id pr ote i n < 1 g/ dL , UGI bleed, previous SBP .