Ascites

Question 1

pathogenesis of ascites

Answer 1

• portal HTN
• splanchnic arterial vasodilation
• decreased effective circulating volume
• activation of RAA, SNS, ADH
• Na and H20 retention
• increased plasma volume
• persistent Na retention
• ascites

Question 2

hepatic vein obstruction

Answer 2

• leads to ascites formation

Question 3

portal vein obstruction

Answer 3

• almost never develops into ascites

Question 4

HVPG magic number for ascites

Answer 4

• > 12 mmHg is necessary for ascites to develop and is associated with low sodium excretion

Question 5

diagnosis of ascites

Answer 5

• shifting dullness, fluid wave
• US to confirm
• paracentesis

Question 6

indications of abdominal paracentesis

Answer 6

• new onset of ascites
• repeated as part of admission PE
• repeated during hospitalization if signs of infection

Question 7

ascites fluid analysis

Answer 7

• DO AT BEDSIDE

- routinely do albumin, protein, PMN cell count

Question 8

serum-ascites albumin gradient

Answer 8

• SAAG = serum albumin - ascites albumin
• if > 1.1 = portal HTN
• if < 1.1 = non-portal HTN
• specimens of serum and ascites should be obtained on the same day

Question 9

decreased accuracy of SAAG

Answer 9

• patient is hypotensive

- during open abdominal surgery

Question 10

SAAG > 1.1 and ascites protein < 2.5

Answer 10

• sinusoidal HTN

- cirrhosis and late Budd-Chiari

Question 11

SAAG > 1.1 and ascites protein > 2.5

Answer 11

• post-sinusoidal HTN
• cardiac ascites
• early Budd-Chiari
• veno-occlusive disease

Question 12

SAAG < 1.1 and ascites protein > 2.5

Answer 12

• peritoneal pathology
• malignancy or TB
• ovarian malignancy is a big cause of ascites that doesnt come from the liver

Question 13

indications of cultures

Answer 13

• DO AT BEDSIDE
• new onset ascites
• admission PE
• signs of infection

Question 14

definition of uncomplicated ascites

Answer 14

• ascites responsive to diuretics in the absence of infection and renal dysfunction

Question 15

management of uncomplicated ascites

Answer 15

• salt restriction
• diuretics (spironolactone based)
• large volume paracentesis

Question 16

side effects of spironolactone therapy

Answer 16

• GYNECOMASTIA

- renal dysfunction, hyponatremia, hyperkalemia, encephalopathy

Question 17

consider ascites refractory if

Answer 17

• spironolactone dose = 400mgs/day + furosemide 160 mgs/day without any significant weight loss

Question 18

indications of large volume paracentesis

Answer 18

• respiratory compromise (ascites pushing up on diaphragm)
• impending rupture of umbilical hernia
• severe peripheral venous stasis
• inconvenience: retaps required every 2-4 weeks

Question 19

fluid restriction as treatment for ascites

Answer 19

• unnecessary unless serum sodium very low (< 125 mEg/L)

Question 20

indications of peritoneo-jugular shunts

Answer 20

• refractory ascites

Question 21

benefits of TIPS

Answer 21

• immediately decreases portal pressure
• increases urine sodium excretion
• decreases plasma renin and angiotensin levels
• mobilizes ascites

Question 22

complications associated with TIPS

Answer 22

• increased risk of encephalopathy

Question 23

definition of spontaneous bacterial peritonitis

Answer 23

• acute bacterial infection of the ascitic fluid that occurs in the absence of an infection elsewhere in the body
• occurs most frequently in patients with cirrhotic ascites and carries a high mortality rate

Question 24

diagnosis of spontaneous bacterial peritonitis

Answer 24

• PMNS > 250 AND/OR positive culture

Question 25

organisms most common in spontaneous bacterial peritonitis

Answer 25

- E. coli most common | - Klebsiella, staph, strep

Question 26

risk factors for spontaneous bacterial peritonitis

Answer 26

- bilirubin > 2.5 - platelet count < 98,000 - GI bleeding - previous SBP - low protein ascites (< 1)

Question 27

treatment of spontaneous bacterial peritonitis

Answer 27

- avoid nephrotoxic meds such as aminoglycosides - consider repeat paracentesis in 48 hours to assess increase in PMNs, if unchanged consider new antibiotic - cefotaxime with ampicillin for 5 days is DOC

Question 28

prophylaxis for spontaneous bacterial peritonitis

Answer 28

- quinolones

Question 29

secondary bacterial peritonitis

Answer 29

- measurement of ascitic fluid total protein, glucose, and LDH has been reported to be of value in distinguishing spontaneous bacterial peritonitis from gut perforation into ascites

Question 30

if neutrocytic ascitic fluid meets two of the following three criteria, they are likely to have surgical peritonitis

Answer 30

- total protein > 1 g/dL - glucose < 50 mg/dL - LDH > the upper limit of NL for serum

Question 31

characteristics of hepatorenal syndrome

Answer 31

- renal failure in patients with cirrhosis, advanced liver failure, and severe sinusoidal portal HTN - absence of significant histological changes in kidney - vasodilation in extra-renal circulation - renal vasoconstriction leading to reduced glomerular filtration rate

Question 32

type 1 hepatorenal syndrome

Answer 32

- poor prognosis, need a liver transplant - rapidly progressive renal failure - doubling of creatinine to > 2.5 or halving of creatinine clearance to < 20ml/min

Question 33

type 2 hepatorenal syndrome

Answer 33

- slower progression - creatinine > 1.5 mg/dL or creatinine clearance < 40 ml/min - associated with refractory ascites

Question 34

diagnosis of hepatorenal syndrome

Answer 34

- advanced hepatic failure and portal HTN - creatinine > 1.5 or creatinine clearance of < 40 ml/min - no improvement in renal function after plasma volume expansion with 1.5 L of isotonic saline

Question 35

2 symptoms always present in hepatorenal syndrome

Answer 35

- ascites and hyponatremia | - if ascites is absent, renal failure is most likely due to another cause

Question 36

treatment of hepatorenal syndrome

Answer 36

- vasoconstrictors should always be used in combination with albumin - liver transplant has proven efficacy - hemodialysis DOES NOT WORK