5. Peritoneal carcinomatosis
5
Protein rich fluid by tumor cells lining
the peritoneum
ECF enters the peritoneal cavity to maintain oncotic
balance
Tuberculosis
Also causes production of protein rich fluid
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6. Sister Mary Joseph's nodule
6
Hard periumbilical nodule
Metastatic
Pelvic
disease
or gastrointestinal
primary tumor
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16. Obstruction of hepatic lymphatics
16
Cause exudation of
hepatic lymph from the
surface
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17. Increased hepatic lymph
17
Normal physiology
Lymph
To
produced in the hepatic sinusoids
systemic circulation by the thoracic duct
When sinusoidal pressures rise
Lymph
spills over from the surface of the
liver to the peritoneal cavity
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18. PATHOGENESIS OF ASCITES
18
Splanchnic vasodilatation
Chief factor contributing to ascites
Increased hydrostatic pressure within the
splanchnic capillary bed
Exudation of lymph from the surface of the
cirrhotic liver
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39. Elevated ascitic WBC count – other causes
39
Tuberculous peritonitis
2. Peritoneal carcinomatosis
Predominance of lymphocytes
1.
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40. SAAG
40
Serum ascites albumin gradient
Serum albumin in g/dL minus ascites albumin in g/dL
To differentiate cirrhotic ascites from
other causes of ascites
Better than total protein content in the ascitic fluid
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41. High SAAG (> 1.1 g/dL)
41
Uncomplicated cirrhotic ascites
Serum albumin concentration
At
least 1 g/dL higher than that of the
ascitic fluid albumin concentration.
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42. SAAG - indirect but accurate index of portal
pressure
42
1.1 g/dL or more
Portal hypertension
Accuracy
97%
< 1.1 g/dL
No portal hypertension
Accuracy
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97%
43. Accuracy > 97%
43
Even with
Ascitic
fluid infection
Diuresis
Paracentesis
IV albumin
Varying causes of liver disease
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44. High SAAG
44
Does not confirm cirrhosis
Indicates
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portal hypertension
45. Typical of cirrhosis
45
4.
SAAG >1.1 g/dL
WBC count < 500 cells/mm3
Predominant lymphocytes
Specific gravity less than 1016
5.
Urine Na low
1.
2.
3.
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46. High gradient (transudative) ascites
46
Right heart failure
Another
common cause
Nephrotic syndrome
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52. Salt restriction
52
Most important treatment of
cirrhotic ascites
Normal diet contains
5 to 15 grams of sodium chloride
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53. Spironolactone plus furosemide produce a diuresis
in most patients
53
If sodium restriction alone does not
cause diuresis and weight loss
Spironolactone
Drug of choice
Furosemide
Risk
of excessive diuresis
Hypokalemia
Precipitate
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encephalopathy
54. Fluid intake
54
Restricted only if there is
dilutional hyponatremia
High
levels of antidiuretic hormone
Diagnosis
Serum
sodium < 130 mEq/L in the
presence of ascites
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62. Treatment
62
Vasoconstrictor drugs
Norepinephrine, midodrine,
terlipressin or alpha-adrenergic
agents
In combination with albumin
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64. SBP
64
No obvious primary source of
infection
Contrast-enhanced CT
To
exclude an intra-abdominal
source for infection
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65. Cefotaxime and an aminoglycoside
65
90 %
Monomicrobial
Enteric GNB
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66. What is the diagnosis
66
A 30-year-old male is admitted with mild
abdominal swelling, fever, and loss of weight.
Ascitic fluid shows the following changes.
Macroscopic appearance - hemorrhagic.
Proteins = 3 grams/dl. SAAG = < 1.1 g/dl.
Cells = WBCs in plenty. 70% of cells are
lymphocytes. Few mesothelial cells are also
present. He occasionally takes alcohol. What
is the most probable diagnosis?
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