Dr Monika Pathania Ascitis Derived from greek word

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Dr. Monika Pathania

Dr. Monika Pathania

� Ascitis - Derived from greek word askos (bag or sack) � Pathologic fluid

� Ascitis - Derived from greek word askos (bag or sack) � Pathologic fluid accumulation in peritoneal cavity.

� Liver Disease : Recent Theory: Peripheral arterial vasodilation hypothesis First. Prtal hypertension ---

� Liver Disease : Recent Theory: Peripheral arterial vasodilation hypothesis First. Prtal hypertension --- inc. NO ---Vasodilation—inc plasma levels of vasoconstictors, sod. retention Ascites develops

� Malignacy – peritoneal carcinomatosis causes ascitis by production of protienaceous fluid by tumor

� Malignacy – peritoneal carcinomatosis causes ascitis by production of protienaceous fluid by tumor cells----ECF enters peritoneal cavity 2 maintain oncotic balance. Same machanism in Tb, Chlamydia etc. . � Cardiac failure: dec. effective arterial blood volume—inc. renin-aldosterone & symapathetic system—renal vasoconstrctn. , fluid retention

HEPATIC RENAL CARDIAC INFECTIO US PANCREA TIC CIRRHOSIS NEPHROTIC SYNDROME HEART FAILURE ABSCESS PANCREATITIS

HEPATIC RENAL CARDIAC INFECTIO US PANCREA TIC CIRRHOSIS NEPHROTIC SYNDROME HEART FAILURE ABSCESS PANCREATITIS PORTAL VEIN OBSTRUCTIVE OBSTRUCTION UROPATHY CONSTRICTIVE TB PERICARDITIS RUPTURED PANCREATIC DUCT FULMINANT HEPATIC FAILURE PERFORATION INFERIOR OF URINARY VENA CAVA TRACT CHLAMYDIA MISCELLA N. BUDD CHIARI SYNDROME PERITONEAL DIALYSIS NEOPLAS M GYNECOL OGIC SLE, VP SHUNT, EOSIN OPHILLIC ASCITIS LYMPHOMA OVARIAN TUMORS CHYLOUS ASCITES NEUROBLAST OMA OVARIAN TORSION HYPOTHYROID ISM HEPATOCELLU LAR CA.

� >80% - cirrhosis (US) � Causes of cirrhosis: alcohol, c/c hep. C, NASH

� >80% - cirrhosis (US) � Causes of cirrhosis: alcohol, c/c hep. C, NASH � 20% - non cirrhotic � Present with abdominal distension � History : question for risk factors for liver disease: alcohol , IV Drug abuse, tatoos, bld. Transfusion, cardiac failure,

� 5 1. 2. 3. 4. 5. classical signs: Bulging flanks Flank dullness Shifting

� 5 1. 2. 3. 4. 5. classical signs: Bulging flanks Flank dullness Shifting dullness Fluid wave Puddle sign

History, appearance of abdomen Percussion of flanks If dull (1500 ml), look for shift

History, appearance of abdomen Percussion of flanks If dull (1500 ml), look for shift USG- 100 ml of fluid

� Look 4 stigmata of liver disease: spider angiomata, large abd wall veins, palmar

� Look 4 stigmata of liver disease: spider angiomata, large abd wall veins, palmar erythema � Features of ccf : neck veins, pedal edema � Anasarca – in ccf, renal disease � Malignancy- lymphnodes, sister mary joseph’s nodule

� History + examination + ABDOMINAL PARACENTESIS � Indications 4 paracentesis: ALL patients with

� History + examination + ABDOMINAL PARACENTESIS � Indications 4 paracentesis: ALL patients with new onset ascites � Contraindications: coagulopathy,

� Gross appearance: transparent & slightly yellow � Cloudy – due to excess neutrophils

� Gross appearance: transparent & slightly yellow � Cloudy – due to excess neutrophils � Blood tinged- traumatic , hepatocellular ca. . , rarely tb, pancreatitis � Milky – chylous ascitis

� Chylous ascites - turbid, milky, or creamy peritoneal fluid due to the presence

� Chylous ascites - turbid, milky, or creamy peritoneal fluid due to the presence of thoracic or intestinal lymph. � Seen in : lymphatic disruption or obstruction 4 om cirrhosis, tumor, trauma, tuberculosis, filariasis, congenital anomaly � Fluid shows Sudan-staining fat globules microscopically and an increased triglyceride content by chemical examination. TG >200 mg/dl � Diff 4 om : tubidity due 2 leukocyte n tumor cells by alkalinization or ether. � Mucinous ascitis : pseudomyxoma peritonei , colloid carcinoma of the stomach or colon with peritoneal implants

� Cell count : WBC< 500 cells/mm CIRRHOSIS ABSOLUTE PMN COUNT <250/DL INC. IN

� Cell count : WBC< 500 cells/mm CIRRHOSIS ABSOLUTE PMN COUNT <250/DL INC. IN SBP, infection � CORRECTION 4 TRUMATIC TAP : For every 250 RBC , subtract 1 PMN from absolute PMN count.

� SAAG – Serum-ascites albumin gradient = SERUM ALBUMIN – ASCITIC ALBUMIN � GRADIENT

� SAAG – Serum-ascites albumin gradient = SERUM ALBUMIN – ASCITIC ALBUMIN � GRADIENT CORRELATES DIRECTLY WITH PORTAL PRESSURE � CLASSIFICATION: � HIGH GRADIENT - >= 1. 1 g/dl – PORTAL HYPERTENSION (accuracy of detection-97%) � LOW GRADIENT - <= 1. 1 G/dl

� CIRRHOSIS � ALCOHOLIC HEPATITIS � CCF � HEPATIC METASTASIS � CONSTRICTIVE PERICARDITIS �

� CIRRHOSIS � ALCOHOLIC HEPATITIS � CCF � HEPATIC METASTASIS � CONSTRICTIVE PERICARDITIS � BUDD-CHIARI SYNDROME

� PERITONEAL CARCINOMATOSIS � TUBERCULAR PERITONITIS � PANCREATITIS � PYOGENIC PERITONITIS � NEPHROTIC SYNDROME

� PERITONEAL CARCINOMATOSIS � TUBERCULAR PERITONITIS � PANCREATITIS � PYOGENIC PERITONITIS � NEPHROTIC SYNDROME

ASCITIC FLUID IN VARIOUS CONDITIONS Condition Gross Ap Protein, g/L Straw/bile- <25 stained SAAG

ASCITIC FLUID IN VARIOUS CONDITIONS Condition Gross Ap Protein, g/L Straw/bile- <25 stained SAAG Cirrhosis >1. 1 Neoplasm Straw, hem >25 orrhagic, mucinous, or chylous Tuberculou Clear, >25 s turbid, peritonitis hemorrhagi c, chylous Pyogenic Turbid or peritonitis purulent Cell Count Other Tests <250; mesot Cirrhosis helia <1. 1 >1000; vari Cytology, p able eritoneal biopsy <1. 1 >1000; >70% lymphocyt es If purulent, <1. 1 >25 Peritoneal biopsy, stain and culture for acid-fast bacilli Predom. PM Positive N Gram's stain, culture

“The purpose of the doctor : To cure sometimes, To relieve often, To comfort

“The purpose of the doctor : To cure sometimes, To relieve often, To comfort always”--Socrates THANKS

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