questions 2

Ascites

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Topic updated on 08/06/17 8:13am

Snap Shot
  •  A 65-year-old man presents to the emergency department with worsening abdominal distention. He has a long history of alcohol abuse. On physical exam, shifting dullness and a fluid wave is present. An image of his abdomen is given.
Introduction
  • Peritoneal edema as a result of
    • portal hypertension
    • hypoalbuminemia
Presentation
  • Symptoms
    • abdominal distention
  • Physical exam
    • shifting dullness
    • fluid wave
Evaluation
  • Paracentesis
    • send ascitic fluid for WBC count, gram stain, culture, glucose, protein
  • Serum Albumin Ascites Gradient (SAAG) 
    • SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid)
    • if > 1.1 g/dL) indicates the ascites is due to portal hypertension with 97% accuracy
    • if < 1.1 g/dL indicates causes of ascites not associated with increased portal pressure
Treatment
  • Order of treatment involves
    • salt and water restriction
      • limit to approximately 2 L per day
    • diuretic therapy
      • spironolactone
      • loop diuretic added
    • ascitic fluid taps
      • 2-4 L drained often with albumin infusion during procedure
Prognosis, Prevention, and Complications
  • Complications
    • hepatorenal syndrome
      • severe complication result from over aggressive diuresis or tapping
    • spontaneous bacterial peritonits
      • check peritoneal fluids for infection and treat with broad spectrum antibiotics
      • diagnosis made by > 500 PMNs in the peritoneal fluid
      • glucose is low and protein is high with bacterial peritonitis
    • abdominal hernias


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Qbank (2 Questions)

TAG
(M3.GI.35) Mrs. Jones is a 56-year-old female that is admitted to a general medicine floor of the local university hospital. She is noted to have new onset ascites of unknown origin. Peritoneal fluid was sent for cell count (<50 leukocytes), albumin level (4.8), culture (pending), total protein (2.0), and Gram stain (pending). Serum albumin was noted to be 4.0. Of the options below, what is the most likely cause of this patient's ascites? Topic Review Topic

1. Congestive heart failure
2. Alcoholic hepatitis
3. Cirrhosis
4. Pancreatitis
5. Vascular occlusion

PREFERRED RESPONSE ▶
TAG
(M2.GI.13) A 55-year-old former longtime alcoholic presents to clinic complaining of new onset increasing abdominal girth and no other complaints. He had been a Child's Class A cirrhotic for some time. His wife, who has accompanied him on this visit, reports that his mental status is unchanged and that he is eating well and attending his Alcoholics Anonymous meetings. On physical exam, his vital signs are stable. His abdomen is distended and tense without appreciable hepatomegaly. There is a fluid wave and shifting dullness. You conduct abdominal paracentesis in the office and aspirate 3L of clear fluid. If sodium and water restriction fails to control this patient's symptoms, what would be the next step in management? Topic Review Topic

1. Add nadalol
2. Add hydrochlorothiazide
3. Add spironolactone
4. Add acetazolamide
5. Create a transjugular intrahepatic portosystemic shunt

PREFERRED RESPONSE ▶


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