302 Pathophysiology and cytopathology of ascites

Question 1

What are the 6 causes of ascites?

Answer 1

Fluid
Flatus
Faeces
Fat
Faetus

Neoplasia, Inflammation, Infection, or rarities like sarcoidosis

Question 2

What are the clinical presentations of ascites?

Answer 2

Flank dullness on examination, shifting dullness, a fluid wave, evidence of pleural effusions

Question 3

What causes caput medusae?

Answer 3

Portal hypertension
Dilated superficial (superior and inferior) epigastric veins radiating from a central large venous varix

Question 4

What is paracentesis?

Answer 4

the perforation of a cavity of the body or of a cyst or similar outgrowth

Question 5

What is the equation for filtration/reabsorption rate?

Answer 5

Qf = P eff (Difference between hydrostatic/blood pressure minus oncotic pressure) x K f (permeability x exchange area

Affected by:
Change in hydrostatic pressure
Change in oncotic pressure
Change in permeability
Change in exchange area

Question 6

What are serous membranes?

Answer 6

The outer lining of organs and body cavities of the abdomen and chest, including the stomach

Eg. Pericardium, pleura, peritoneum, tunica vaginalis of testis

Question 7

What are the limitations for clinical detection of effusions in different serous membranes?

Answer 7

Ascites 500 ml
pleura 300 ml
pericardium 50ml

Effusions are always pathological

Question 8

What is a transudate effusion?

Answer 8

Plasma filtrate with low protein content

Caused by change in hydrostatic or oncotic pressure

Question 9

What is an exudate effusion?

Answer 9

Unfiltered plasma with high protein content

Caused by change in vascular permeability or exchange area

Question 10

What are the causes of portal hypertension?

Answer 10

liver cirrhosis (80%)
alcoholic hepatitis
chronic cardiac failure
constrictive pericarditis

Question 11

What are the causes of hypoalbuminaemia?

Answer 11

nephrotic syndrome
protein losing enteropathy
malnutrition

Question 12

What is the role of albumin?

Answer 12

Helps keep fluid from leaking out of your blood vessels into other tissues

Question 13

What are the different causes of ascites?

Answer 13

Portal hypertension liver cirrhosis (80%)
= hydrostatic

Hypoalbuminaemia
= oncotic

Peritoneal disease
= permeability
= exchange area

Others:
chylous ascites (lymphatic blockage e.g. in malignancy)
haemoperitoneum
pancreatic disease
sarcoidosis

Question 14

What is peritoneal disease?

Answer 14

A pattern of metastatic disease where cancer has spread from where it initially started into the lining of the abdominal cavity

Question 15

What is SAAG?

Answer 15

SAAG = serum albumin – ascites albumin

A high gradient (SAAG >1.1 g/dL) indicates portal hypertension and suggests a nonperitoneal cause of ascites

Question 16

What does Pale yellow and watery ascites fluid indicate?

Answer 16

Transudate from CCF cirrhosis protein etc

Question 17

What does turgid and yellow to white ascites fluid indicate?

Answer 17

Infection, malignancy, pancreatitis

Question 18

What does milky/white/ green ascites fluid indicate?

Answer 18

Chylous effusion caused by cholesterol from TB, rheumatoid disease or an old effusion

Question 19

What is a chylous effusion?

Answer 19

An accumulation of chyle in the pleural space due to disruption or obstruction of the thoracic duct

Question 20

What does brown ascites fluid indicate?

Answer 20

Haemorrhage (trauma, pancreatitis, malignancy) or melanin

Question 21

What does green ascites fluid indicate?

Answer 21

Bile from biliary tract disease or ruptured bowel

Question 22

What does gelatinous ascites fluid indicate?

Answer 22

Hyaluronic acid from mesothelioma or mucin in pseudomyxoma peritonei

Question 23

Which cells are present in effusions?

Answer 23

Mesothelial
Macrophages
Lymphocytes
Eosinophils
Neutrophils
Plasma Cells
Strangers

Question 24

How do mesothelial cells present in ascites fluid?

Answer 24

Variable nuclear number, size, N:C ratio
Perinuclear cytoplasmic density
Peripheral lacy border

Mesodermal epithelium
Have microvilli
Single and grouped
Clusters, balls, papillae, cell-in-cell, single cell files

If malignant = mesothelioma

Question 25

How do macrophages present in ascites fluid?

Answer 25

Usually present
Can be difficult to separate from mesothelial cells (esp. degenerate)
Usually single or in loose aggregates
Foamy pale cytoplasm
Eccentric bean shaped nucleus
Lack moulding, windows

Question 26

How do lymphocytes present in ascites fluid?

Answer 26

Usually a few present
More frequent in longstanding effusions
May be a range of maturation
Lymphocytic effusions are associated with obstructed circulation through lymph nodes and associated with tuberculosis or lymphoma

Question 27

How do neutrophiles present in ascites fluid?

Answer 27

If non-infectious may be well preserved
If infectious then often degenerate
If masses then usually benign

Present in:
Infection
Infarction
Gastrointestinal disease
Foreign body
Beware early tuberculous
Malignancy

Question 28

What are degenerate cells?

Answer 28

A pathological condition that causes cells to change in structure and function

Question 29

What is a charcot leyden crystal?

Answer 29

Charcot Leyden crystals are hexagonal bipyramidal structures localised in the primary granules of the cytoplasm of eosinophils and basophils

Their presence, along with eosinophilic infiltrate, is an indirect evidence of parasitic infestation

Question 30

How do eosinophils present in ascites fluid?

Answer 30

Eosinophilia < 10 %
Pleura mostly
Generally not specific
Mostly benign but rarely malignant
Air is a stimulus so more common with repeated aspiration

Question 31

What are Ferruginous Bodies?

Answer 31

A characteristic finding of asbestos exposure is the ferruginous body, a microscopic rod-shaped body with clubbed end

Question 32

What is the architecture of malignant cells?

Answer 32

Groups – Clumps, Balls, Papillae, Glands
vs
Normally dispersed single cells
with pleomorphism

Question 33

How does malignancy appear in the lung?

Answer 33

Range of patterns of differentiation (large cell/adeno/squame)
Dense cytoplasm
Papillary groups
May be highly vacuolated

Question 34

Vacuolated meaning

Answer 34

Formed into or containing one or more vacuoles or small membrane-bound cavities within a cell

Question 35

How does malignancy appear in the stomach?

Answer 35

Usually dispersed single cells but may form papillae or acini
Signet ring or columnar cells
Signet ring cells have many tiny vacuoles
Can be rather bland with cells like macrophages

Question 36

What are the features of mesothelioma?

Answer 36

Diffuse nodular pleural thickening (versus discrete)

Often unilateral (versus bilateral)

Thickening of fissures (versus intraparenchymal nodules)

Question 37

What is an FNA test?

Answer 37

A fine needle aspiration (FNA)

Question 38

What are the benefits of performing a fine needle aspiration?

Answer 38

Easily repeated allowing sampling of several areas with minimal trauma

Minimal disturbance of tissue planes
Confirms malignancy leaving lesion intact

May be therapeutic for cysts and abscesses

Quick feedback enables planning of other investigations

Monitor therapy by repeated sampling

Question 39

What is formalin?

Answer 39

A solution of formaldehyde and water

It destroys all cytology

Question 40

What is the difference between fixed and air dried cytology?

Answer 40

Dried with air or alcohol

Question 41

What are cytospins?

Answer 41

Tissue pellet for further special stains or immunochemistry or molecular biologic tests

Question 42

What is Reactive lymphadenopathy?

Answer 42

When lymph glands respond to infection by becoming swollen

Eg. Non-specific lymphoid hyperplasia
HIV-associated
Mononucleosis
RA, SLE, Syphilis
Dermatopathic changes

Question 43

What is Granulomatous lymphadenitis?

Answer 43

A chronic inflammatory condition that can be associated with lymphoproliferative, infectious and autoimmune diseases

Caused by eg.
TB
Cat scratch, leprosy, paracoccidioidomycosis, histoplasmosis, leishmaniasis, LGV, brucellosis
Foreign body (talc, silica)
Lymphoma
Carcinoma
Sarcoid

Question 44

What is a granuloma?

Answer 44

A collection of activated epithelial histiocytes