Flashcards in Week 5 Deck (142)
What is hepatic disorder: ascites?
An abnormal/pathological accumulation of fluid within the peritoneal cavity as a result of some disease process. Volume of > 1.5 liters can be detected by physical exam
What defines the progression of ascites?
The amount of accumulation of fluid
What are the presentations of grade 1 ascites?
Small accumulation, no symptoms, diagnosed by abdominal US (req. 100 mL fluid)
What are the presentations of grade 2 ascites?
At least 1000 mL fluid, ↑ abdominal girth, weight gain
What are the presentations of grade 3 ascites?
• Diffuse abdominal pressure,
• Dyspnea (if diaphragm elevated by fluid)
• Pain uncommon
• Difficulty breathing
What is the extreme progression of ascites?
Infectious (spontaneous bacterial peritonitis): new abdominal discomfort and fever. The fluid has now become infected by bacteria
What are the hepatic causes of ascites?
• Portal hypertension (>90% of cases), usually due to
• Chronic hepatitis
• Severe alcoholic hepatitis w/o cirrhosis
• Hepatic vein obstruction (Budd-Chiari syndrome)
In what other conditions is ascites present?
• Heart failure
• Abdominal malignancies
• Nephrotic syndrome
The pathogenesis of ascites is not well known. However the hybrid theory prevails in what we know about, what does this theory entail?
Continuous injury to liver from combined exogenous factors (i.e., chronic alcohol or viral injury) or in the setting of an appropriate genetic disposition, which then increases the resistance to blood flow through the liver & can lead to increased pressure on the portal vein, and causes fluid to leak from the venous system, into the free abdominal cavity.
• Continued micro-processes of inflammation, necrosis, and collagen deposition/regeneration
• Above three may combine to transform liver from a low-resistance to high-resistance system & can lead to increased pressure on the portal vein (i.e., portal hypertension)
What is the process in the setting of portal HTN?
In the setting of portal HTN, additional accumulation of vasodilatory substances, accumulate along with the increased fluid retention from the angiotensin aldosterone system, causing a further leak to occur
What are some medical history and clinical exam findings a patient with ascites will present with?
• Signs: shifting dullness w/abdominal percussion & fluid wave across the abdomen
• Volumes < 1500 mL may not cause physical signs
• Massive: causes tautness of abdominal wall & flattening of umbilicus
• May have peripheral edema
When diagnosing ascites, a physician may perform a diagnostic paracentesis. What does this entail?
Diagnostic tap analyzing cell count, total protein, albumin, cytology & cultures within the fluid in the stomach, done with a needle.
In what type of patient is it mandatory to perform a diagnostic paracentesis?
This is mandatory in cases of new ascites or in cases of individual with a change in clinical status that includes fever, abdominal pain, and new onset of or worsening hepatic encepalopathy, or any sign or symptom of infection
Depending on the presentation and physical appearance of a patient with ascites, what are the lab exams that can be ordered?
Laboratory exams including full liver screen
• Lactate dehydrogenase (LDH) cholesterol, amylase, total protein, and triglycerides
What type of imaging is used in the case of ascites and why?
US or CT. This is used in cases of new onset ascites and to rule out portal vein thrombosis or hepatocellular carcinoma
What will prompt the screen for an infection in the presence of ascites?
Pain & fever present
Why may the peritoneal fluid found in the presence of ascites be infected?
The interface between the bowel, the intestinal micro-flora, and the acidic fluid is dynamic, with a constant translation of bacteria across the bowel wall
What does the medical treatment of ascites depend on?
The determined etiology of the disease
What are the medical treatments of ascites that was caused by cirrhosis?
• Treatment of underlying liver disease initiated ASAP
• Cessation of medications/alcohol that worsen ascites (angiotensin-converting enzyme inhibitors, NSAIDS, aminoglycosides)
What are the medical treatments of ascites that was caused by cirrhosis, that will be done in the hospital?
• Moderate sodium restriction to 80-120 mmol/day
• Use of diuretics (Spironolactone is one of choice w/ or w/o addition of furosemide); monitor weight loss, creatinine, & sodium levels
• Therapeutic paracentesis if volume large
What are the medical treatments of ascites in cases where the ascites keeps coming back(refractory cases), even after Na-restrictions & max dose diuretics?
• Assoc. w/one-year mortality of 40%
• Large volume paracentesis
• Work-up for liver transplantation along w/TIPS (transjugular intra-hepatic portosystemic shunt) as
a bridge to transplant
Another condition that can happen in the case of severe ascites is pulmonary complications. How does this work?
Ascites fluid can collect in the pleural space, happening in about 10% of cirrhosis cases
Cirrhotic patients with a significant amount of pleural cavity have what type of symptoms?
• SOB and cough
The accumulation of the fluid can lead to:
What are the renal complications that can be seen in cases of ascites?
Acute to chronic renal injury.
- Very common in decompensated cirrhotic patients
Vascular tone, immune function, and related infections
What principle does the TIPS (transjugular intra-hepatic portosystemic shunt) procedure rely on?
The principle of establishing a direct continuity or low resistance from the large portal branch vein to the hepatic vein, by way of a shunting stent, which then bypasses the cirrhotic/high resistant fibrotic tissue(which generates the portal HTN and causes the ascites)
What are the benefits of the TIPS (transjugular intra-hepatic portosystemic shunt) procedure?
• Decreased requirements for diuretics
• Improved quality of life
• Improved mortality when compared to repetitive therapeutic paracentesis in patients with refractory ascites
What is the medical treatment of ascites in the case of infection?
Immediate use of a cephalosporin via IV
What are the PT considerations for treating a pt with ascites?
• Increased resting comfort in high Fowler position (HOB raised 18-20 in. above the level position w/knees elevated)
• Monitor for peripheral edema
• Patients may have more muscle wasting than evident due to the masking effect of edema
• Be aware of medical complications of medications used to decrease fluid retention
What is cirrhosis?
Chronic disease state characterized by hepatic parenchymal cell destruction & necrosis and the regeneration of tissue w/fibrosis or scar tissue formation. This may take years to develop