Presentation ascites approach,DDs, management.pptx

Ascites..DDs.. Approach

1. ABDOMINAL SWELLING AND ASCITES

2. Abdominal Swelling Numerous causes Usual complaint is sensation of bloating/fullness/increase in girth size(belt/clothes) Abdominal pain is unusual. If Pain+swelling:> associated infection, peritonitis or pancreatitis to be r/o. If Ascites is the cause,new onset of inguinal/umblical hernia. Dyspnea

3. CAUSES

4. FLATUS Normal..200 ml N2,02(consumed) CO2, Hydrogen,Methane(intraluminally produced) Causes of increased abdominal gas Aerophagia Bacterial metabolism of excess fermentable substances(lactose and other oligosaccharides) Impaired Gas transit (IBS)

5. FAT Weight gain Imbalance between calory intake and energy expenditure+poor diet &sedentary lifestyle Cushing syndrome Risk for insulin resistance and cardiovascular disease.

6. Fetus Pregnancy 12-14 weeks ,uterus abdominal organ Seen before due to fluid retention/relaxation of abdominal muscles.

7. Feces Severe constipation Intestinal obstruction/paralytic ileus. Accompanied by pain/nausea/vomiting

8. Fatal Growth Neoplasm Abscess Cyst Organomegaly(hepatomegaly, splenomegaly, abdominal aortic aneurysm,bladder distension)

9. Fluid Ascites To be discussed in detail Grade 1-USG Grade 2-Physical examination 1.5 L Grade 3-Marked abdominal distension

10. APPROACH TO A PATIENT Symptoms suggestive of malignancy Symptoms of intestinal obstruction Symptoms of paralytic ileus Symptoms of Aerophagia Symptoms of CLD Past history of TB,heart failure, valvular heart disease

11. Examination General examination Pallor Icterus Clubbing Lymphadenopathy (Virchows) Edema Stigmata of Chronic liver disease.

12. System examination Inspection Palpation(tenderness,liver,spleen) Percussion(gas or fluid) Auscultation(bowel sounds&hum)

13. Other systems CVS JVP Pericardial Knock MURMUR

14. Investigation Blood tests- CBC,PT/INR,LFT including Total Protein/Albumin,S.Amylase,Lipase Urine protein Detection of gases in expired air(Hydrogen&Methane) Abdominal Xray USG CT scan Selected cases..Hepatic venous pressure gradient Liver biopsy

15. ASCITES CAUSES Cirrhosis(84%) Others Cardiac Ascites Peritoneal carcinomatosis Hepatic metastasis Infection (Tb/Chlamydia) Pancreatitis Renal disease (Nephrotic syndrome) Hypothyroidism Familial Mediterranean fever

16. Pathogenesis in Cirrhosis 1****Portal Hypertension Pressure=Flow*Resistance Development of hepatic fibrosis Activation of hepatic stellate cells Decrease in eNOS production-decrease in NO production and increased intrahepatic vasoconstriction. Increased systemic circulating levels of NO Increased levels of vascular endothelial growth factor, Tumor necrosis factor—splanchnic artery vasodilatation. Hypvolemia to Kidney Compensatory increase in ADH-vasoconstriction-free water retention & Activation of sympathetic nervous system and RAAS-Sodium and water retention. 2**Hypoalbuminemia

17. Pathogenesis in other cases Primary peritoneal malignancy Abdominal malignancy Mets from breast, lung,melanoma Tuberculous peritonitis Pancreatic Ascites

18. Evaluation of Ascites Paracentesis Technique Complications Interpretation Appearance Albumin TC,DC Grams stain and culture

19. Apperance Turbid.. Infection White milky … Chylous ..TG--)200 Trauma Cirrhosis Tumor Tuberculosis Congenital anomalies Dark brown..biliary tract perforation Black fluid..pancreatic necrosis/metastatic melanoma

20. SAAG

21. To r/o DD’s Investigation NTPro BNP Ascites glucose and LDH Ascites Amylase Cytology (peritoneal carcinomatosis , TB) Ascitic ADA/AFB smear /culture When causes are unclear Laporotomy / Laproscopy with peritoneal biopsy

22. Treatment Restriction of salt intake to 2g/day. Diuretics (Spironolactone( amiloride *)& Furosemide)400/160 Refractory Alpha 1 adrenergic agonist/ Midodrine Alpha 2 adrenergic agonist/clonidine Large volume paracentesis (Albumin infusion) TIPS (hepatic encephalopathy) Alfapump system Malignant ascites( LVP,transcutaneous drainage catheter,peritoneovenous shunt,Alfapump ) Tb peritonitis..ATT Noncirrhotic Ascites of other causes-correction of precipitating condition.

23. COMPLICATIONS SBP Symptoms..Fever , increase in abdominal girth, vomiting,hepatic encephalopathy O/ E..Abdomen tender (40%) PMN>=250/micro litre Culture MC organism.. Ecoli , Klebsiella,Streptococci.Enterococci Treatment :IV Cefotaxime

24. Prevention Upper GI bleed…Oral ciplox / norflox /IV Ceftriaxone Diuretics..increase activity of Ascitic fluid protein opsonins …decrease risk of SBP

25. 2** HEPATIC HYDROTHORAX CF:Dyspnea,hypoxia or infection Rx:dyspnea;hypoxia;infection Rx:sodium restriction,diuretics,thoracocentesis or TIPS.