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Flashcards in 26.8.2013(ascites) Deck (78):
0

New onset umbilical or inguinal hernia

Ascites

1

Abdominal distension with abdominal pain

Peritonitis
Pancreatitis

2

6 Fs of abdominal swelling

Fluid
Flatus
Feces
Foetus
Fat
Fatal growth

3

Normal volume of small intestine gas

200ml

4

Composition of intestinal gas

Aerophagy
Nitrogen
Oxygen
Bacterial fermentation
Hydrogen
Methane

5

Cause of apparent abdominal distension

Increased lumbar lordosis

6

Pulsatile abdominal mass

Abdominal aortic aneurysm

7

Abdominal distension with nausea,vomiting,inability to pass feces or flatus

Intestinal obstruction
Severe constipation
Illeus

8

Increased eructation and Flatus with abdominal distension

Aerophagia
Increased intestinal production of gas

9

History taking in abdominal distension

Symptoms suggestive of malignancy
Bowel obstruction
Flatus
Liver disease
Heart failure
TB

10

General examination findings in abdominal distension

Liver disease
Dilated superficial abdominal veins
Spider angioma
Palmar erythema
Gynacomastia
Virchow node
Elevated JVP,kussmaul sign,pericardial knock,TR

11

Auscultation in abdominal distension

Absent bowel sounds- illeus
High pitched localised bowel sounds- intestinal obstruction
Umbilical venous hum- portal hypertension
Bruit- HCC,alcoholic hepatitis

12

USG can detect _______ ml of Ascites

100

13

Lab tests in abdominal distension

Liver enzymes
Serum albumin
Prothrombin time
Serum amylase and lipase
Urinary protein quantitation

14

Blood count in cirrhosis

Cytopenias

15

Pathogenesis of Ascites in cirrhosis

Resistance to blood flow
Hepatic fibrosis- disruption of hepatic sinusoids
Activation of hepatic stellate cells
Decreased eNOS
Splanchnic vasodilation
Increased systemic NO,TNF,VEGF
Decreased effective circulating volume sensed as hypovolemia by kidneys

16

Causes of Ascites in the absence of cirrhosis

Peritoneal carcinomatosis
Pancreatitis
Peritoneal infection

17

Causes of peritoneal carcinomatosis

Primary
Mesothelioma
Sarcoma
Intraabdominal
Gastric
Colonic
Metastasis
Breast
Lung
Melanoma

18

Mechanism of non cirrhotic Ascites

Malignancy and TB - exudation of protein rich fluid
Pancreatitis- release of pancreatic enzymes

19

Cirrhosis accounts for _______ % of cases with Ascites

84

20

Infectious causes of Ascites

TB
Fitz Hugh Curtis
Chlamydia
Gonorrhoea

21

Rare causes of Ascites

Hypothyroidism
Familial Mediterranean fever

22

Quadrant preferred for paracentesis

Left lower quadrant

23

Complications of paracentesis

Rare even in the presence of coagulopathy
Hypotension
Infections
Abdominal wall hematoma
Hepatorenal syndrome

24

Hallmark of chylus Ascites

Triglycerides >200mg/dl

25

Dark brown ascitic fluid

High bilirubin concentration
Billiary tract perforation

26

Black color ascitic fluid

Pancreatic necrosis
Metastatic Melanoma

27

Turbid ascitic fluid

Infections
Malignancy

28

Measurements in ascitic fluid

Albumin
Total protein levels
Cell and differential count
Gram stain and culture if infection is suspected
Serum albumin should also be sent

29

________ correlates with hepatic venous pressure gradient

SAAG

30

Does SAAG change with diuresis

No

31

Causes of low SAAG ascites

TB
Billiary leak
Nephrotic syndrome
Pancreatitis
Peritoneal carcinomatosis

32

Causes of high SAAG Ascites

Ascitic protein >= 2.5g/dl
Congestive heart failure
Constrictive pericarditis
Early budd chiari
Venoocclusive disease
IVC obstruction
Ascitic protein <2.5g/dl
Cirrhosis
Late budd chiari
Massive liver metastasis

33

What does an ascitic fluid protein count of >=2.5g/dl indicate?

Intact hepatic sinusoids

34

Indication for ascitic glucose and LDH levels

Secondary peritonitis from perforated viscus

35

Diff btw SBP and secondary peritonitis

Secondary peritonitis
Glucose< 50mg/dl
Ascitic LDH>serum LDH
Multiple pathogens on ascitic fluid culture

36

Ascitic amylase in pancreatic Ascites

>1000mg/dl

37

How much ascitic fluid should be sent for cytology

50ml

38

ADA level in Ascites

In the absence of cirrhosis,ADA level of more than 30-45 U/L has a sensitivity of 90% for TB

39

Initial treatment of cirrhotic Ascites

Restriction of sodium intake

40

Drug to be used when painful gynacomastia develops due to spironolactone

Amiloride 5-40mg/day

41

Ratio of frusemide:spironolactone in Ascites

40:100

42

Maximum dose of spironolactone and frusemide

Spironolactone 400mg
Frusemide 160mg

43

Refractory Ascites

Persistence of Ascites despite sodium restriction and maximal diuretic therapy

44

Rx of refractory ascites

Large volume paracentesis
TIPS

45

Comparison of TIPS over LVP for refractory Ascites

Decreased reoccurrence
No difference in mortality
Increased risk of hepatic encephalopathy

46

Rx of malignant Ascites

serial LVP
Transcutaneous drainage catheter
Peritoneovenous shunt

47

Causes of SBP

Cirrhosis
Cardiac
Nephrotic
Acute hepatitis
Acute liver failure
Rare in malignant ascites

48

Presentation of SBP

Increase in abdominal girth
Abdominal tenderness(40%)
Rebound tenderness is rare
Fever
Nausea
Vomiting
Exacerbation of preexisting hepatic encephalopathy

49

Common pathogens in SBP

E.coli
Klebsiella
Streptococci
Enterococci

50

Presence of multiple pathogens in ascitic fluid without elevated polymorphs

Bowel perforation by paracentesis needle

51

Rx of SBP

IV Cefotaxime for 5 days if pt improves

52

SBP prophylaxis

Previous H/O SBP
Ascitic fluid protein <1g/dl
Active GI bleeding

53

Prophylaxis of SBP

Oral norfloxacin

54

How diuresis decreases the risk of SBP?

Increases the activity of ascitic fluid protein opsonins

55

Chest tube placement in heptic Hydrothorax

Avoided

56

Three most common causes of cirrhosis

Alcoholism
Hepatitis C
NASH

57

NASH with decompensation and body weight

Patient loses weight..hence previous h/o obesity must be sought for

58

Pt with long history of stable cirrhosis with sudden Ascites

HCC

59

Pain in Ascites

Malignancy related Ascites
Alcoholic hepatitis
SBP

60

Manifestation of tuberculous peritonitis

Fever
Abdominal pain

61

Ascites and anasarca developing in setting of DM

Nephrotic ascites

62

Ascites due to pancreatitis

Acute pancreatitis with necrosis
Chronic pancreatitis with rupture of duct (also due to trauma)

63

Amount of fluid that must be present in Ascites for flank dullness

1500ml

64

USG can detect as little as ____ ml of fluid in abdomen

100 ml

65

Ascites mimics

Gaseous distension(tympanitic)
Panniculus(develops over months or years)
Ovarian mass(flank resonance,central dullness)

66

Important historical question helpful in differentiating Ascites from panniculus

Rate of increase of abdominal girth- days to weeks in ascites

67

Sites of mechanoreceptors mediating Dyspnea

Face
Upper airway

68

Hyperventilation syndrome

Light headedness
Tingling of hands and feet
Tachycardia
Inversion of T waves in ECG

69

Breathing discomfort at rest that disappears with activity

Anxiety

70

Cause of sensation of chest tightness

Stimulation of Vagal irritant receptors

71

Chest tightness is seen in

Asthma
MI

72

Pts with pulmonary Edema suffer from a sensation of

Air hunger

73

Pts with COPD and hyperinflation complain of

Inability to take a deep satisfying breath

74

Causes of acute Dyspnea

Acute LVF
Pulmonary Edema
Thromboembolic event
Pneumonia
Spontaneous pneumothorax
Asthma
Injury to chest wall or intra thoracic structures
ARDS
pleural effusion
Pulmonary hemorrhage

75

Causes of chronic progressive Dyspnea

COPD
LVF
Diffuse interstitial fibrosis
Asthma
Pleural effusions
Pulmonary thromboembolic disease
Pulmonary vascular disease
Psychogenic Dyspnea
Severe Anemia
Post intubation tracheal stenosis
Hypersensitivity disorders

76

Physiological correlates of Dyspnea

Ventilatory performance
Minute ventilation
Maximal voluntary ventilation
Breathing reserve

77

Which is a stronger stimulus for Dyspnea? Hypercapnia or hypoxia

Acute Hypercapnia