patient with jaundice and ascites
DESCRIPTION
management of a patient with jaundice and ascites.TRANSCRIPT
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CLINICAL SOLVING PROBLEM
PATIENT WITH JAUNDICE AND
ASCITES
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ASCITES
DEFINITION Pathological accumulation of fluid in the
peritoneal cavity.
AETIOLOGY Abdominal Malignancy * C
- Mesothelionia
- Metastatic spread from tumours
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Infections esp. TB * Albumin eg. Nephrotic syndrome Congestive cardiac failure C Constrictive pericarditis Pancreatitis * Myxoedema Cirrhosis P C Budd Chiari syndrome * P
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IVC or portal vein thrombosis P Meigs’ syndrome Portal nodes P
≥ 30 g/l in diseases marked *
Ascites with portal hypertension P
Common causes C
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PATHOGENESIS
Two theories have been proposed. Underfilling theory: this suggests that
the primary abnormality is inappropriate sequestration of fluid within the splanchnic vascular bed due to portal hypertention. This results in a decrease in intravascular volume and the kidney responds by retaining salt and water.
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The overflow theory: the primary abnormality is inappropriate retention of salt and water by the kidney in the absence of volume depletion.
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MECHANISMS OF ASCITES FORMATION Combination of liver failure and portal
hypertension. Liver failure decreases renal blood flow, resulting in retention of salt and water.
Secondary hyperaldosteronism due to increased renin release and decreased metabolism of aldosterone by the liver.
Decreased metabolism of antidiuretic hormone
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Hypoalbuminaemia which decreases colloid oncotic pressure.
Lymphatic obstruction resulting in a ‘weeping’ liver
Over production of nitric oxide.
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CLINICAL FEATURES
History – Abdominal distention Symptoms – pain in the abdomen (spontaneous
bacterial peritonitis, malignancy). Heart failure, renal failure, or liver
disease TB(peritoneal tuberculosis) Malignancy ? Primary tumour
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EXAMINATION(SIGNS)
Look for stigmata of underlying disease. Eg. Cirrhosis, cardiac failure, renal failure or malignancy.
Full flanks and umbilicus Presence of shifting dullness and or fluid
thrill.
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INVESTIGATION Diagnostic paracentesis for – proteins
- albumin
- cell count
- cell type
- cytology Ultrasonography of the abdomen Peritoneal biopsy Laparascopy
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Serum – ascitic albumin gradient
- Serum albumin conc- ascitic fluid albumin conc.
-Correlates directly with portal pressure
-Gradient > 1.1 g/dl = portal hypertension.
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COMPLICATIONS
Respiratory embarrassment may complicate large amounts of ascites.
Spontaneous bacterial peritonitis
-ascitic fluid leucocyte count of 500 cells per µl
- > 250 polymorrphonuuclear cells per µl
- Rx with non nephrotoxic antibiotics
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MANAGEMENT The most important treatments are: Sodium restriction Diuretics Sodium restriction to 88 mmol per day Fluid restriction is usually not necessary
unless the serum sodium cooncentration drops below 120 mmol/l
When the patient has tense ascites, 5 liters or more of ascitic fluid should be removed to release shortness of breath.
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To diminish early satiety. To prevent pressure related leakage of
fluid from the site of a previous paracentesis.
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DIURETIC THERAPY The most effective diuretic regimen is a
combination of spironolactone and furosenide > 90% of patients respond to this therapy.
Diuretic resistant ascites ie when patients do not respond to diuretic therapy- 300 mg spironolactone or 120 mg furosemide/day
Therapeutic paracentesis with infusion of salt free albumin. This decreases hospital stay.
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Peritoneovenous shunting- limited by high rate of infection and DIC.
Transjugular intrahepatic portosytemic stent shunt (TIPS)
-Non- surgical side to side shunt -Consists of a stented channel between a
main branch of the portal vein and the hepatic vein.
Extracorporeal ultrafiltration of ascitic fluid with reinfusion.
Liver transplantation.
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PROGNOSIS
Ascites indicates decompensation of previously asymptomatic chronic liver disease.
It is a poor prognostic sign.
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JAUNDICE
DEFINITION Yellow pigmentation of skin, sclera and mucosae
due to plasma bilirubin. Visible at Bilirubin > 35µmol/L Classified by: a) the site of the problem Prehepatic Hepatocellular Cholestatic / obstructive
b)The type of circulating bilirubin -conjugated or unconjugated.
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UNCONJUGATED HYPERBILIRUBINAEMIAS
Overproduction – haemolysis eg. Drugs antimalarials.
Impaired hepatic uptake - drugs – contrast agents
- Rifampicin
- congestive
cardiac failure Impaired conjugation- glucoronyl tansferase
deficiency
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- Gilbert’s syndrome
- Crigler Najjar syndrome
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CON JUGATED HYPERBILIRUBINAEMIA Hepatocellular dysfunction
-There is hepatocyte damage usually with some cholestasis.
-Causes: 1) Viruses – Hepatitis A,B,C,D,E
- CMV
- EBV
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2) Drugs – Paracetamol overdose - Isoniazid, rifampicin, pyrazinamide - Monoamine oxide inhibitors 3) Alchoholic hepatitis4) Liver metastases5) Abscesses6) Autoimmune hepatitis7) Septicaemia
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8) Leptospirosis
9) alpha1 – antitrypson deficiency
10) Budd- Chiari
11) Rotor syndrome
12) Toxins eg. Carbon tetrachloride
13) Fungi (Amanita phalloides)
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Impaired hepatic excretion
-Primary biliary cirrhosis
-Extrinsic compression of bile duct.
-Drug induced cholestasis Flucloxacillin- may occur weeks after
treatment Co- amoxiclav Steroids (anabolic, the pill ) Sulphonylureas Prochloperazine Chlorpromazine
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Common bile duct gall stones Pancreatic cancer Lymph nodes at the porta hepatis Choledochal cyst Biliary atresia Mirrizi’s syndrome – obstructive jaundice
from common bile duct compression by a gall stone impacted in the cystic duct often associated with cholangitis.
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Associated with – dark urine
- pale stools
- intractable pruritus
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CLINICAL FEATURES History: Blood transfusions Intravenous drug use Body piercing, tattoos Sexual activity, travel abroad. Jaundicel contacts Family history Alcohol consumption Drugs
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Tests: Urine – Prehepatic – Bilirubin absent :
acholuric jaundice
-Urobilinogen abscent in obstructive jaundice Haematology – FBC
- Clotting
- Blood film
- Reticulocyte count
- Coomb’s test
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Biochemistry – U and E
- LFT US Scan – dilated bile ducts > 6 mm
obstruction Liver biopsy CT MRI
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CAUSES OF JAUNDICE IN PATIENTS WITH ASCITES DUE TO CIRRHOSIS. Sepsis (UTI, pneumonia, peritonitis) Malignancy eg. HCC Alcohol Drugs