ascites it is the condition of pathological accumulation of fluid in abdominal cavity

ASCITESASCITES

IT IS THE CONDITION OF PATHOLOGICAL IT IS THE CONDITION OF PATHOLOGICAL ACCUMULATION OF FLUID IN ABDOMINAL ACCUMULATION OF FLUID IN ABDOMINAL CAVITYCAVITY

CAUSESCAUSES

Can Be Broadly Classified On The Can Be Broadly Classified On The Basis Of : Basis Of :

Normal peritoneumNormal peritoneum

Diseased peritoneumDiseased peritoneum

NORMAL PERITONEUMNORMAL PERITONEUM

Portal hypertensionPortal hypertension Congestive Heart FailureCongestive Heart Failure

Constrictive Pericarditis Constrictive Pericarditis

Tricuspid Insufficiency Tricuspid Insufficiency

Budd-Chiari Syndrome Budd-Chiari Syndrome

Liver Cirrhosis Liver Cirrhosis

Alcoholic Hepatitis Alcoholic Hepatitis

Fulminant Hepatic FailureFulminant Hepatic Failure

Massive Hepatic MetastasesMassive Hepatic Metastases

CAUSESCAUSES

NORMAL PERITONEUMNORMAL PERITONEUMHypoalbuminemiaHypoalbuminemiaNephrotic Syndrome Nephrotic Syndrome

Protein-losing Enteropathy Protein-losing Enteropathy

Severe Malnutrition with AnasarcaSevere Malnutrition with Anasarca

CAUSESCAUSES

NORMAL PERITONEUMNORMAL PERITONEUMMiscellaneous conditionsMiscellaneous conditions Chylous ascites Chylous ascites

Pancreatic ascites Pancreatic ascites

Nephrogenic ascitesNephrogenic ascites

MeigMeig’’s syndromes syndrome

CAUSESCAUSES

DISEASED PERITONEUMDISEASED PERITONEUMInfections Infections Tuberculous PeritonitisTuberculous Peritonitis

Bacterial PeritonitisBacterial Peritonitis

Fungal PeritonitisFungal Peritonitis

HIV associated peritonitisHIV associated peritonitis

CAUSESCAUSES

DISEASED PERITONEUMDISEASED PERITONEUM

Malignant conditionsMalignant conditions Peritoneum CarcinomatosisPeritoneum Carcinomatosis

Hepatocellula CarcinomaHepatocellula Carcinoma

Primary MesotheliomaPrimary Mesothelioma

Pseudomyxoma PeritoneiPseudomyxoma Peritonei

CAUSESCAUSES

DISEASED PERITONEUMDISEASED PERITONEUM

Other rare conditionsOther rare conditionsGranulomatous PeritonitisGranulomatous Peritonitis

VasculitisVasculitis

CAUSESCAUSES

CLINICAL FEATURESCLINICAL FEATURES

PRESENTING COMPLAINTSAbdominal DistensionAbdominal Distension

Diffuse Abdominal PainDiffuse Abdominal Pain

Bloated Feeling of AbdomenBloated Feeling of Abdomen

Dyspnoea Dyspnoea andand Orthopnea Orthopnea (due to elevation (due to elevation of daipharagm)of daipharagm)

Indigestion and Heart burn Indigestion and Heart burn (due to inc intra (due to inc intra abdominal pressure)abdominal pressure)

PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONAbdominal DistensionAbdominal DistensionFullness of FlanksFullness of FlanksUmbilicus Flat and EvertedUmbilicus Flat and EvertedDiverticulation of Recti MusclesDiverticulation of Recti MusclesDistended Abdominal VeinsDistended Abdominal VeinsShifting dullness Shifting dullness (esp. when >1000ml of fluid)(esp. when >1000ml of fluid)Fluid ThrillFluid ThrillPuddle SignPuddle Sign


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION SIGNS RELATED TO SECONDARY SIGNS RELATED TO SECONDARY EFFECTS OF ASCITESEFFECTS OF ASCITESScrotal EdemaScrotal EdemaPleural effusionPleural effusion (due to defect in the (due to defect in the diaphragm and fluid pass into the pleural diaphragm and fluid pass into the pleural space)space)EdemaEdemaCardiac apex is shifted upwardCardiac apex is shifted upward due to due to raised diaphragm)raised diaphragm)Distended neck veinsDistended neck veins due to inc rt atrial due to inc rt atrial pressure)pressure)



PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONSIGNSSIGNS RELATEDRELATED TOTO THETHE CAUSECAUSE OFOF ASCITESASCITES LIVER DISEASE:

Jaundice,Anemia,Palmar erythema,Spider Jaundice,Anemia,Palmar erythema,Spider angiomas,Hepatosplenomegaly,angiomas,Hepatosplenomegaly,CARDIAC DISEASE:

Elevated JVPElevated JVPMALIGNANCY:

SISTER MARY JOSEPH NODUE in umblicus(peritoneal SISTER MARY JOSEPH NODUE in umblicus(peritoneal carcinomatosis like gastric, pancreatic and hepatic carcinomatosis like gastric, pancreatic and hepatic malignancies)malignancies)

VIRCHOW NODE (rt supraclavicular lymph node due to VIRCHOW NODE (rt supraclavicular lymph node due to upper abdominal malignancy)upper abdominal malignancy)

NEPHROTIC SYNDROME:NEPHROTIC SYNDROME: Edema or AnasarcaEdema or Anasarca

STAGINGSTAGING

Can Be Semi Quantified Into:Can Be Semi Quantified Into:

Stage 1+Stage 1+ is detectable only after careful is detectable only after careful examination. examination.

Stage 2+ Stage 2+ is easily detectable but of relatively is easily detectable but of relatively small volume. small volume.

Stage 3+ Stage 3+ is obvious ascites but not tense is obvious ascites but not tense ascites.ascites.

Stage 4+Stage 4+ is tense ascites.is tense ascites.

Includes:Includes:

Imaging studiesImaging studiesLab studiesLab studiesLaparoscopyLaparoscopy

INVESTIGATIONSINVESTIGATIONS


IMAGING STUDIESIMAGING STUDIESCHEST AND ABDOMINAL PLAIN FILMSCHEST AND ABDOMINAL PLAIN FILMSDetects ascites if >500ml fluidDetects ascites if >500ml fluidElevated diaphragmElevated diaphragmPleural effusion (hepatic hydrothorax)Pleural effusion (hepatic hydrothorax)Diffuse abdominal hazinessDiffuse abdominal haziness

USG ABDOMENUSG ABDOMENcan detect as small as 5ml fluidcan detect as small as 5ml fluidcan identify the cause like liver cirrhosiscan identify the cause like liver cirrhosis

CT SCAN:CT SCAN:can identify the cause like malignanciescan identify the cause like malignancies

LAB STUDIESLAB STUDIESASCITIC FLUID ANYALYSIS(DIAGNOSTIC ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)PARACENTESIS)

Ascitic Fluid Ascitic Fluid should be analyzed forshould be analyzed forAPPEARANCEAPPEARANCECELL COUNTCELL COUNTTOTAL PROTEINSTOTAL PROTEINSSAAG(SERUM ASCITIC ALBUMIN GRADIENT)SAAG(SERUM ASCITIC ALBUMIN GRADIENT)CYTOLOGYCYTOLOGYCULTURECULTUREMISCELLENOUSMISCELLENOUSBASELINE INVESTIGATIONS LIKE BLOOD BASELINE INVESTIGATIONS LIKE BLOOD CP,LFTS,PT APTTCP,LFTS,PT APTT



APPEARANCEAPPEARANCE TRANSPARENT AND TINGEDTRANSPARENT AND TINGED:: NORMAL NORMAL

STRAW COLORED: STRAW COLORED: CIRRHOSISCIRRHOSIS

HEAMORRHGIC: HEAMORRHGIC: MALIGNANCYMALIGNANCY

CLOUDY: CLOUDY: INFECTIONINFECTION

BILE STAINED: BILE STAINED: BILIARY CONTAMINATIONBILIARY CONTAMINATION

CHYLOUS: CHYLOUS: LYMPHATIC OBSTRUCTIONLYMPHATIC OBSTRUCTION




CELL COUNTCELL COUNTWBCS <500/mm3 and NEUTROPHILS<250/mm3: WBCS <500/mm3 and NEUTROPHILS<250/mm3: NORMALNORMAL

NEUTROPHILS>250/microL: NEUTROPHILS>250/microL: suggests SBPsuggests SBP

LYMPHOCYTES PREDOMINANCE:LYMPHOCYTES PREDOMINANCE: ABDOMINAL TB ABDOMINAL TB OR MALIGNANCYOR MALIGNANCY



TOTAL PROTEINSTOTAL PROTEINSPROTEINS<2.5g/dl:PROTEINS<2.5g/dl: TRANSUDATE TRANSUDATE

PROTEINS>2.5g/dl:PROTEINS>2.5g/dl: EXUDATE EXUDATE



SAAG (Serum Ascitic Albumin SAAG (Serum Ascitic Albumin Gradient)Gradient)The Difference bw Serum Albumin and Ascitic fluid The Difference bw Serum Albumin and Ascitic fluid AlbuminAlbuminBest single test to differentiate between ascites due to Best single test to differentiate between ascites due to portal hypertension and non-portal hypertensionportal hypertension and non-portal hypertensionWhen saag >1.1g/dl: When saag >1.1g/dl: strongly suggest portal strongly suggest portal hypertensionhypertensionWhen saag < 1.1g/dl: When saag < 1.1g/dl: non portal hypertensive non portal hypertensive causescausesAccuracy more than 97%Accuracy more than 97%



CYTOLOGYCYTOLOGY58-75% HELPING FOR DETECTING MALIGNANT 58-75% HELPING FOR DETECTING MALIGNANT ASCITESASCITES

CULTURE AND GRAM STAINCULTURE AND GRAM STAINMORE IMPORTANT IN SBPMORE IMPORTANT IN SBP



MISCELLENOUSMISCELLENOUSGLUCOSE:GLUCOSE: low in TB peritonitis low in TB peritonitis

AMYLASE:AMYLASE: HIGH IN PANCREATIC ASCITES HIGH IN PANCREATIC ASCITES

PH:PH: <7 SUGGEST BACTERIAL INFECTION <7 SUGGEST BACTERIAL INFECTION

RBCS: RBCS: MORE THAN 50,000/microL SUGGESTS MORE THAN 50,000/microL SUGGESTS TB,MALIGNANCY OR TRAUMATB,MALIGNANCY OR TRAUMA


LAPROSCOPYLAPROSCOPY IN SOME PATIENTS FOR DIRCET VISUALIZATIONIN SOME PATIENTS FOR DIRCET VISUALIZATION

TO TAKE BIOPSIES OFTO TAKE BIOPSIES OF LIVERLIVER

PERITONEUMPERITONEUM

INTRA ABDOMINAL LYMPHNODESINTRA ABDOMINAL LYMPHNODES

MANAGEMENTMANAGEMENT

COMPRISES OF:COMPRISES OF:

General careGeneral care

Medical careMedical care

Surgical careSurgical care


GENERAL CAREGENERAL CAREMONITORING OF MONITORING OF INPUT OUT PUTINPUT OUT PUT

ABDOMINAL GIRTHABDOMINAL GIRTH

WEIGHTWEIGHT

DIETRY MODIFICATIONSDIETRY MODIFICATIONSSODIUM RESTRICTION UPTO 1g/daySODIUM RESTRICTION UPTO 1g/day

WATER RESTRICTION (If Serum Sodium Level Is WATER RESTRICTION (If Serum Sodium Level Is <120mmol/L Hyponatremia)<120mmol/L Hyponatremia)

BED REST:BED REST:Improves renal perfusion which leads to diuresisImproves renal perfusion which leads to diuresis


MEDICAL CAREMEDICAL CARE THE AIM OF THE THERAPY IS WT LOSS OF BODY WIGHT THE AIM OF THE THERAPY IS WT LOSS OF BODY WIGHT

DAILYDAILY300g-500g IF ONLY ASCITES300g-500g IF ONLY ASCITES800g-1000g IF ASCITES AND EDEMA 800g-1000g IF ASCITES AND EDEMA

DIEURETICSDIEURETICS MAINSTAY THERAPY FOR ASCITESMAINSTAY THERAPY FOR ASCITES

SPIRONOLACTONESPIRONOLACTONE 25-200 mg/d PO qd or divided bid 25-200 mg/d PO qd or divided bid FUROSEMIDE:FUROSEMIDE:20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for 20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states severe edematous states AMILORIDE:AMILORIDE:5-20 mg PO qd 5-20 mg PO qd COMBINATION THERAPY:COMBINATION THERAPY:

SPIRONOLACTONE + FUROSEMIDESPIRONOLACTONE + FUROSEMIDE FUROSEMIDE + AMILORIDEFUROSEMIDE + AMILORIDE


MEDICAL CAREMEDICAL CARETHERAPEUTIC PARACENTESISTHERAPEUTIC PARACENTESIS

In patients with massive ascites (grade 3 or In patients with massive ascites (grade 3 or 4)4)

In ascites refractory to dieureticsIn ascites refractory to dieuretics

If cardio respiratory distress due to ascitesIf cardio respiratory distress due to ascites

3-5litres can be removed with the 3-5litres can be removed with the replacement of salt free albumin.replacement of salt free albumin.


MEDICAL CAREMEDICAL CARETIPS(TRANSJUGULAR INTRAHEPATIC TIPS(TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT)PORTOSYSTEMIC SHUNT)

Becoming standard of care in dieuretic Becoming standard of care in dieuretic resistant ascitesresistant ascites


SURGICAL CARESURGICAL CARELEE VEEN SHUNT:LEE VEEN SHUNT:It is a peritoneovenous shuntIt is a peritoneovenous shuntAlternative for medically intractable ascitesAlternative for medically intractable ascitesImproves Cardiac Out Put, renal Blood Flow, Improves Cardiac Out Put, renal Blood Flow, Glomerular Filtration Rate, Urinary Volume, Glomerular Filtration Rate, Urinary Volume, And Sodium Excretion And Decreased Plasma And Sodium Excretion And Decreased Plasma Renin Activity And Plasma Aldosterone Renin Activity And Plasma Aldosterone Concentration Concentration DoesnDoesn’’t Improve Patientt Improve Patient’’s Survival So With s Survival So With The Advent Of Tips ItThe Advent Of Tips It’’s Becoming Obsoletes Becoming Obsolete

THE MOST COMMON THE MOST COMMON COMPLICATION IS:COMPLICATION IS:

SBP (Spontaneous Bacterial Peritonitis)SBP (Spontaneous Bacterial Peritonitis)

COMPLICATIONSCOMPLICATIONS

COMPLICATIONSCOMPLICATIONS

SBPSBPMost common bacteria is E. Coli.Bacteria are believed to gain Most common bacteria is E. Coli.Bacteria are believed to gain access to peritoneum by hematogenous route. access to peritoneum by hematogenous route.

Low ascitic fluid albumin (<1g/dl) predisposes SBP Low ascitic fluid albumin (<1g/dl) predisposes SBP

Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Rebound Tenderness.Rebound Tenderness.

Ascitic Fluid analysis shows wbcs >500/mm3l and Ascitic Fluid analysis shows wbcs >500/mm3l and Eutrophil>250/mm3Eutrophil>250/mm3

Third generation Cephalosporins 2g tid started empirically for 5 Third generation Cephalosporins 2g tid started empirically for 5 days till c/s report is available. days till c/s report is available.

Recurrence is common. Ciprofloxacin 750 mg once weekly can Recurrence is common. Ciprofloxacin 750 mg once weekly can be given prophylacticaly. be given prophylacticaly.

MCQsMCQs

Q. No 1Q. No 1IF SAAG IS >1.1 THEN THE CAUSE IF SAAG IS >1.1 THEN THE CAUSE WOULD BE ALL EXCEPT:WOULD BE ALL EXCEPT:PORTAL HYPERTENSIONPORTAL HYPERTENSION

MYXEDEMAMYXEDEMA

NEPHROTIC SYNDROMENEPHROTIC SYNDROME

TUBERCULOUS PERITONITISTUBERCULOUS PERITONITIS

MCQsMCQs

Q. No 2Q. No 2THE MOST EFFICACIOUS THE MOST EFFICACIOUS TREATMENT FOR REFRACTORY TREATMENT FOR REFRACTORY ASCITES ISASCITES ISMAXIMUM DOSE OF DIEURETICSMAXIMUM DOSE OF DIEURETICS

THERAPEUTIC PARACENTESISTHERAPEUTIC PARACENTESIS

TIPSTIPS

LEE VEEN SHUNTLEE VEEN SHUNT

Q. No 3Q. No 3SBP IS MORE LIKELY WHENSBP IS MORE LIKELY WHENWBCS >250/microLWBCS >250/microL

NEUTROPHILS>250/microLNEUTROPHILS>250/microL

LYMPHOCYTES>500/microLLYMPHOCYTES>500/microL

ALL OF THE ABOVEALL OF THE ABOVE

MCQsMCQs

ascites it is the condition of pathological accumulation of fluid in abdominal cavity

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