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ASCITES Abnormal accumulation of fluid in the peritoneal cavity Common causes Malignant Disease

ASCITES Abnormal accumulation of fluid in the peritoneal cavity Common causes Malignant Disease Hepatic Peritoneal Cardiac failure Hepatic cirrhosis . Pathogenesis Ascites occurs because of the imbalance between the formation & resorption of peritoneal fluid.

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ASCITES Abnormal accumulation of fluid in the peritoneal cavity Common causes Malignant Disease

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  1. ASCITES • Abnormal accumulation of fluid in the peritoneal cavity Common causes • Malignant Disease • Hepatic • Peritoneal • Cardiac failure • Hepatic cirrhosis

  2. Pathogenesis Ascites occurs because of the imbalance between the formation & resorption of peritoneal fluid. In Cirrhosis of liver, Ascites is due to • Increased hydrostatic pressure - due to portal hypertension causes transduction of fluid in peritoneal cavity. • Sodium & water retention due to activation of rennin - angiotensinogen - aldosterone system • Low plasma osmotic pressure due to low protein synthesis in liver

  3. Causes Transudative (protein <2.5g.dl) • Portal HTN • Cirrhosis • Fulminant hepatic failure • Alcoholic hepatitis • Congestive heart failure • Constrictive pericarditis • Hypoalbuminemia • Nephrotic syndrome • Protein losing enteropathy • Severe malnutrition

  4. Exudative (protein >2.5 g/ dl) • Infections – tuberculosis, bacterial peritonitis • Malignancy – hepatic or peritoneal

  5. C/F Symptoms • Abdominal distention with fullness of flanks • Decrease urinary output • Pressure symptoms – Dyspnoea • Symptoms according to cause

  6. Signs Inspection • Abdominal distention • Everted umbilicus • Fullness of flanks Palpation • Difficult organ palpation • Fluid thrill – present Percussion • Shifting dullness – present Auscultation • Inaudible/Diminished bowel sound

  7. Investigation • TC, DC, ESR, Hb • Aspiration and analysis of ascitic fluid • USG of Abdomen • CT of Abdomen • Investigation according to cause

  8. Causes of Ascites according to SAAG (Serum Ascites Albumin Gradient ) • SAAG = (albumin concentration of serum) - (albumin concentration of ascitic fluid). Saag >1.1 g/dl • Portal HTN • Cirrhosis Saag <1.1 g/dl • Infections • Malignancy

  9. Rx • Bed rest till ascites subsides • Diet – Restriction of salt • Restriction of water (500ml + Previous day urine output) • Diuretics • Spironolactone (100-400mg/day) • Paracentesis (Therapeutic fluid aspiration) 3-5 liters over 1-2 hr. for immediate relieve of cardio-respiratory distress. • 5. Rx of cause

  10. D/D • Fatty person • Pregnancy • Intestinal obstruction • Neoplastic mass in the abdomen (Fibroid, ovarian cyst) • Full bladder/chronic Urine retention Complications: • Spontaneous bacterial peritonitis • Hernia • Cardio-respiratory distress

  11. Spontaneous Bacterial peritonitis • Infection of ascitic fluid (SBP) is common in patients with cirrhosis as a part of their susceptibility to infection. Organisms • Escherichia coli • Klebsiella pneumoniae • Enterococcus • Streptococcus pneumoniae • Viridians streptococci

  12. C/F • Fever • Abdominal pain & tender • Ascites • Features of Chronic Liver Disease • Bowel sound diminished or absent • Hepatic Encephalopathy

  13. Investigations • TC, DC, ESR, Hb • Ascitic fluid analysis (gram stain & culture for isolation of organism) (most commonly E coli) • Blood culture Treatment • Therapeutic antibiotics • Broad spectrum Antibiotics (Cefotaxime 1gm IV 8 hrl for 5- 7 days) Or • Amoxicillin – Clavunic acid 1.2 gm IV 8 hrly

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