Ascites, SBP, HE medicine powerpoint.pptx

Medicine

1. MANAGEMENT OF ASCIT E S, SPONTANEOUS BACTERIAL PERITONITIS & HEPATIC ENECEPALOPATHY 1 RAJALEKSHMI P A

2. ASCITES Definition : Accumulation of free/excess fluid within the peritoneal cavity. With larger accumulations of fluid (>1L); Abdominal distension Fullness in the flanks Shifting dullness on percussion When ascites is marked A fluid thrill/ fluid wave Most common causes; Portal hypertension by cirrhosis Intra abdominal malignancies Heart failure 2

3. CAUSES Common Causes: Malignnat disease: hepatic, peritoneal Cardiac failure Hepatic cirrhosis Other causes: Hypoproteinemia : nephrotic syndrome, protein losing enteropathy , malnutrition Pancreatitis Lymphatic obstruction Infection: TB Hepatic venous occlusion : Budd- Chiari syndrome, veno -occlusive disease Rare: Meigs ’ syndrome, hyothyroidism 3

4. PATHOGENESIS 4

5. INVESTIGATIONS Ultrasonography Paracentesis under ultrasonic guidance to obtain ascitic fluid for analysis Cirrhosis : clear, straw- coloured or light green Malignancy : bloody Infection : cloudy Biliary communication : heavy bile stained Lymphatic obstruction : milky- white Chest X- Ray 5

6. OTHER USEFUL INVESTIGATIONS Total albumin, serum albumin, total protein Amylase Neutrophil count Cytology Microscopy and culture Measurement of SAAG 6

7. SAAG : Serum Ascites A lbumin G radient A physiological clinical diagnostic tool for the evaluation of ascites. Formula Serum Ascites Albumin Gradient (SAAG) = [Albumin]serum – [Albumin]ascites. Based on difference between albumin level of serum and of ascitic fluid May use to assess the extent of ascites. Thought to reflect the colloid osmotic pressure gradient and the degree of portal hypertension The SAAG is proposed to be a factor determining the degree of portal hypertension and prognosis of patients with cirrhosis. 7

8. SAAG : Serum Ascites A lbumin G radient High SAAG High gradient (SAAG >1.1 g/ dL ) indicates portal hypertension and suggests a non-peritoneal cause of ascites Transudative ascites Low SAAG Low gradient (SAAG < 1.1 g/ dL ) indicates non-portal hypertension and suggests a peritoneal cause of ascites. Exudative ascites – secondary to any infections, malignancy/ inflammation 8

9. SAAG : Serum Ascites A lbumin G radient 9

10. MANAGEMENT Treatment relieves discomfort but do not prolong life. If vigorous, produce Disorders of Fluid/ electrolyte balance Hepatic encephalopathy Treatment of transudative ascites; Restricting sodium intake Promoting urine output with diuretics Paracentesis , if necessary Treatment of exudative ascites; Paracentesis 10

11. General measures Hospitalization ; if massive ascites Check serum electrolytes, renal function test – at start of treatment and twice a week. Weight the patient daily Measure abdominal girth Strict intake and output monitoring daily 11

12. Dietary sodium restriction Essential to achieve negative sodium balance Restriction to 100 mmol /24 hrs (no added salt diet) is normally adequate. Avoid sodium-rich drugs ( eg . many antibiotics, antacids) and those promoting sodium retention ( eg . steroids, NSAIDs). Restriction of water intake to 1 – 1.5 L/24 hrs if plasma sodium falls below 125 mmol /L. Few patients managed successfully alone with this method. 12

13. Diuretics Aim: to produce a net loss of fluid of about 700 ml per day Spironolactone (100–400 mg/day) Drug of choice Powerful aldosterone antagonist May cause painful gynaecomastia and hyperkalaemia Amiloride (5-10 mg/day) When spironolactone cause painful gynaecomastia and hyperkalaemia Loop diuretics Eg . Furosemide. Often combined with above drugs. Diuresis improves, Rest in bed – renal blood flow improves in horizontal position 13

14. Refractory ascites Patient not respond to maximal doses (diuretic resistant) or Who are unable to tolerate these doses due to hyponatraemia or Renal impairment (diuretic intolerant) Treatment IV salt-poor albumin, 25g in 3 hrs Oral midodrine 7.5g 3 times daily Large volume paracentesis Shunts Transjugular intrahepatic portosystemic stent shunt (TIPSS) Le veen shunt Slow low dose continuous albumin, furosemide with/without terilpressin SIFA(T) infusion Liver transplantation 14

15. Paracentesis Large-volume paracentesis with IV albumin First-line treatment of refractory ascites or when other treatments fail. Circulation is supported with an intravenous colloid such as human albumin Removal of 3-5 L of fluid over 1-2 hours 6-8g /L of ascites removed, usually as 100mL of 20% or 25% human albumin solution (HAS) for every 2-3L of ascites drained Drains should be removed after 6-12 hours to reduce risk of infection 15

16. Paracentesis Indications Refractory ascites: Used to relieve symptomatic tense ascites eg . Cardiorespiratory distress due to gross ascites Impending rupture of a hernia Complications Hypovolemic shock and renal dysfunction 16

17. Transjugular intrahepatic portosystemic stent shunt( TIPSS) TIPSS can relieve resistant ascites, but does not prolong life Used in; Patients awaiting liver transplantation Patients with reasonable liver function May aggravate encephalopathy Le Veen shunt Peritoneovenous shunt Allow the peritoneal fluid to shunt directly into the internal jugular vein 17

18. TREATMENT ALGORITHM 18

19. SPONTANEOUS BACTERIAL PERITONITIS Definition Common and severe complication of ascites Characterized by spontaneous infection of ascitic fluid without an evident intra-abdominal surgically treatable source. Causative agents Ecoli , Klebsiella / enterococci / other gut bacteria 19

20. SPONTANEOUS BACTERIAL PERITONITIS Clinical Features Suspected in any patient with ascites who clinically deteriorates May present as sudden deterioration or hepatic encephalopathy in a cirrhosis patient with ascites Fever, abdominal pain / discomfort and rebound abdominal tenderness Investigations Peripheral blood: Leukocytosis Ascitic fluid: Cloudy fluid Leucocyte count: More than 500/mm³ pH: Less than 7.3 Culture: Positive. Monomicrobial E. coli is most common 20

21. TREATMENT Antibiotics Third-generation cephalosporin: cefotaxime or ceftazidime Dose of Cefotaxime : 2 g lV 8 hourly for 5 days Alternative therapy in patients without shock or hepatic encephaloputhy . Amoxicillin/ clavulanate (1.2 g IV 8 hourly followed by 625 mg orally) Ciprofloxacin (200 mg IV 12 hourly followed by 500 mg BID orally) Ofloxacin (400 mg twice daily) Note: Quinolones should not be given if patient is on norfloxacin for prophylaxis. 21

22. PROPHYLAXIS FOR SPB Indications Patients with acute gastrointestinal bleeding(antibiotic prophylaxis also reduces the rate of re-bleeding) Patients with a previous episode(s) of SBP and recovered Patients with low total ascites protein content <1.5g/dl or severe liver disease and no prior history of SBP 22

23. PROPHYLAXIS FOR SBP Drugs In patients with upper Gl hemorrhage : cefotaxime or norfloxacin (400 mg BID for 7 days) In patients with low ascitic protein content or previous episode of spontaneous bacterial peritonitis: long term quinolones such asnorfloxacin (400 mg/day) Alternative but less effective drugs: include cotrimoxazole (800 mg sulfamethoxazole + 160 mg trimethoprim once a day) or ciprofloxacin (750 mg once a week) 23

24. HEPATIC ENCEPALOPATHY Definition A neuropsychiatric syndrome caused by liver disease that progresses from confusion to coma. Most common causes Liver failure and portosystemic shunting of blood Mechanisms Not known exactly Gut derived neurotoxins mechanism is most accepted Due to disturbance of brain function resulting from various toxin substances reaching the brain 24

25. FACTORS PRECIPITATING HEPATIC ENCEPHALOPATHY 25 Drugs: sedatives and antidepressants Dehydration ( including diuretics and pracentesis ) Portosystemic shunting Infection Hypokalemia Hyponatremia Constipation

26. DIFFERENTIAL DIAGNOSIS OFHEPATIC ENCEPALOPATHY 26 Intracranial bleed Drug or alcohol intoxication Delerium tremens/alcohol withdrawal Wernicke’s encephalopathy Primary psychiatric disorders Hypoglycemia Neurological Wilson’s disease Post- ictal state

27. GRADING OF HEPATIC ENCEPHALOPATHY 27

28. E XAMINATION FINDINGS Flapping tremor( asterixis ) Inability to perform mental arithemetic problems Hyperreflexia Bilateral extensor plantar responses Fetor hepaticus - sweet musty odour to breath, sihn of liver failure and porto systemic shunting 28

29. T REATMENT General measures : Management / removal of precipitating factors Maintain nutrition with adequate calories 35-40 kcal/kg/day. Maintain hydration and correct the electrolyte imbalance. Protein restriction in diet. Administer 1-1.2 g/kg of proteins daily, preferably vegetable protein. Zinc supplementation - helpful & relatively harmless Stop / reduce diuretic therapy. Treat any infection with suitable antibiotics (e.g. ampicilin , rifaximin , metronidazole or neomycin). Stop alcohol. Avoids sedatives. For restlessness and excitement small dose of diazepam / midazolam - IV 29

30. T REATMENT Lactulose therapy To reduce plasma ammonia level 15-30 mL 3 times daily orally Non-absorbable disaccharide Produces an osmotic laxative effect It reduces the colonic pH, thereby limiting colonic ammonia absorption, and promotes the incorporation of nitrogen into bacteria Lactitol therapy Beta- galactoside sorbitol 30g daily 30

31. T REATMENT Poorly absorbed antibiotics Often used as adjunctive to sterilize the gut in patients who have difficulty with lactulose. They reduce the intestinal ammonia production by bacteria. Alternating administration of neomycin and metronidazole - reduce the individual side effects of each(neomycin for nephrotoxicity & metronidazole for peripheral neuropathy) Rifaximin Semisynthetic, gut-selective, and non-absorbable oral antibiotic Derived from rifamycin & structural analog of rifampin in dose of 550 mg twice daily / 400 mg thrice daily is very effective , without any side effects of neomycin or metronidazole. It has only 0.4% systemic absorption. 31

32. T REATMENT When there is gastrointestinal bleeding Ryles tube aspiration and bowel washes - to remove the blood and blood products. Reduces the production of nitrogen in the gut. Other drugs Bromocriptine L-ornithine L-aspartate (LOLA) Probiotics and prebiotics Sodium benzoate Zinc,polyethylene glycol, acarbose Melatonin Flumazenil 32

33. TREATMENT In acute liver failure Mannitol & judicious use of IV fluids to reduce the spontaneous cerebral edema (controversial) Liver transplantation. MARS-Molecular Adsorption reversibility System Purifies the blood by removal of albumin bound as well as water soluble substrates 33

34. MANAGEMENT OF HEPATIC ENCEPHALOPATHY 34

35. References Davidson’s Principals and Practice of Medicine Exam Preparatory Manuel for Undergraduates Medicine, Archith Boloor , Ramdas Nayak 35

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