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ASCITES

ASCITES. IT IS THE CONDITION OF PATHOLOGICAL ACCUMULATION OF FLUID IN ABDOMINAL CAVITY. CAUSES. Can Be Broadly Classified On The Basis Of : Normal peritoneum Diseased peritoneum. NORMAL PERITONEUM Portal hypertension Congestive Heart Failure Constrictive Pericarditis

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ASCITES

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  1. ASCITES IT IS THE CONDITION OF PATHOLOGICAL ACCUMULATION OF FLUID IN ABDOMINAL CAVITY

  2. CAUSES Can Be Broadly Classified On The Basis Of : Normal peritoneum Diseased peritoneum

  3. NORMAL PERITONEUM Portal hypertension Congestive Heart Failure Constrictive Pericarditis Tricuspid Insufficiency Budd-Chiari Syndrome Liver Cirrhosis Alcoholic Hepatitis Fulminant Hepatic Failure Massive Hepatic Metastases CAUSES

  4. NORMAL PERITONEUM Hypoalbuminemia Nephrotic Syndrome Protein-losing Enteropathy Severe Malnutrition with Anasarca CAUSES

  5. NORMAL PERITONEUM Miscellaneous conditions Chylous ascites Pancreatic ascites Nephrogenic ascites Meig’s syndrome CAUSES

  6. DISEASED PERITONEUM Infections Tuberculous Peritonitis Bacterial Peritonitis Fungal Peritonitis HIV associated peritonitis CAUSES

  7. DISEASED PERITONEUM Malignant conditions Peritoneum Carcinomatosis Hepatocellula Carcinoma Primary Mesothelioma Pseudomyxoma Peritonei CAUSES

  8. DISEASED PERITONEUM Other rare conditions Granulomatous Peritonitis Vasculitis CAUSES

  9. CLINICAL FEATURES PRESENTING COMPLAINTS Abdominal Distension Diffuse Abdominal Pain Bloated Feeling of Abdomen Dyspnoea and Orthopnea (due to elevation of daipharagm) Indigestion and Heart burn (due to inc intra abdominal pressure)

  10. PHYSICAL EXAMINATION Abdominal Distension Fullness of Flanks Umbilicus Flat and Everted Diverticulation of Recti Muscles Distended Abdominal Veins Shifting dullness (esp. when >1000ml of fluid) Fluid Thrill Puddle Sign CLINICAL FEATURES

  11. PHYSICAL EXAMINATION SIGNS RELATED TO SECONDARY EFFECTS OF ASCITES Scrotal Edema Pleural effusion (due to defect in the diaphragm and fluid pass into the pleural space) Edema Cardiac apex is shifted upward due to raised diaphragm) Distended neck veins due to inc rt atrial pressure) CLINICAL FEATURES

  12. CLINICAL FEATURES PHYSICAL EXAMINATION SIGNSRELATEDTOTHECAUSEOFASCITES LIVER DISEASE: Jaundice,Anemia,Palmar erythema,Spider angiomas,Hepatosplenomegaly, CARDIAC DISEASE: Elevated JVP MALIGNANCY: SISTER MARY JOSEPH NODUE in umblicus(peritoneal carcinomatosis like gastric, pancreatic and hepatic malignancies) VIRCHOW NODE (rt supraclavicular lymph node due to upper abdominal malignancy) NEPHROTIC SYNDROME: Edema or Anasarca

  13. STAGING Can Be Semi Quantified Into: Stage 1+is detectable only after careful examination. Stage 2+ is easily detectable but of relatively small volume. Stage 3+ is obvious ascites but not tense ascites. Stage 4+is tense ascites.

  14. Includes: Imaging studies Lab studies Laparoscopy INVESTIGATIONS

  15. INVESTIGATIONS 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

  16. 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 MISCELLENOUS BASELINE INVESTIGATIONS LIKE BLOOD CP,LFTS,PT APTT INVESTIGATIONS

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

  18. INVESTIGATIONS LAB STUDIES 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

  19. INVESTIGATIONS LAB STUDIES ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) TOTAL PROTEINS PROTEINS<2.5g/dl: TRANSUDATE PROTEINS>2.5g/dl: EXUDATE

  20. INVESTIGATIONS LAB STUDIES 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%

  21. INVESTIGATIONS LAB STUDIES ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) CYTOLOGY 58-75% HELPING FOR DETECTING MALIGNANT ASCITES CULTURE AND GRAM STAIN MORE IMPORTANT IN SBP

  22. INVESTIGATIONS LAB STUDIES ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) MISCELLENOUS GLUCOSE: low in TB peritonitis AMYLASE: HIGH IN PANCREATIC ASCITES PH: <7 SUGGEST BACTERIAL INFECTION RBCS: MORE THAN 50,000/microL SUGGESTS TB,MALIGNANCY OR TRAUMA

  23. INVESTIGATIONS LAPROSCOPY IN SOME PATIENTS FOR DIRCET VISUALIZATION TO TAKE BIOPSIES OF LIVER PERITONEUM INTRA ABDOMINAL LYMPHNODES

  24. MANAGEMENT COMPRISES OF: General care Medical care Surgical care

  25. MANAGEMENT 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

  26. MANAGEMENT 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 DIEURETICS 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

  27. MANAGEMENT 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.

  28. MANAGEMENT MEDICAL CARE TIPS(TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT) Becoming standard of care in dieuretic resistant ascites

  29. MANAGEMENT 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

  30. THE MOST COMMON COMPLICATION IS: SBP (Spontaneous Bacterial Peritonitis) COMPLICATIONS

  31. COMPLICATIONS SBP Most common bacteria is E. Coli.Bacteria are believed to gain access to peritoneum by hematogenous route. Low ascitic fluid albumin (<1g/dl) predisposes SBP Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Rebound Tenderness. Ascitic Fluid analysis shows wbcs >500/mm3l and Eutrophil>250/mm3 Third generation Cephalosporins 2g tid started empirically for 5 days till c/s report is available. Recurrence is common. Ciprofloxacin 750 mg once weekly can be given prophylacticaly.

  32. MCQs Q. No 1 IF SAAG IS >1.1 THEN THE CAUSE WOULD BE ALL EXCEPT: PORTAL HYPERTENSION MYXEDEMA NEPHROTIC SYNDROME TUBERCULOUS PERITONITIS

  33. MCQs Q. No 2 THE MOST EFFICACIOUS TREATMENT FOR REFRACTORY ASCITES IS MAXIMUM DOSE OF DIEURETICS THERAPEUTIC PARACENTESIS TIPS LEE VEEN SHUNT

  34. Q. No 3 SBP IS MORE LIKELY WHEN WBCS >250/microL NEUTROPHILS>250/microL LYMPHOCYTES>500/microL ALL OF THE ABOVE MCQs

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