Ascites Evaluation and Management Quiz

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Questions and Answers

What is the characteristic of Grade I ascites?

Transmitted thrill upon examination

Only detectable by ultrasound (USS) (correct)

Marked abdominal enlargement noticeable by sight

Moderate symmetrical enlargement of abdomen

What physical examination finding is associated with Grade II ascites?

Complete abdominal distension

Shifting dullness (correct)

No abdominal enlargement

Transmitted thrill

Which of the following is NOT part of the initial evaluation for newly discovered ascites?

Thorough history taking and physical examination

Obtain a detailed family medical history (correct)

Abdominal ultrasound (USS)

LFTs, Urea, and Creatinine assessment

What describes Grade III ascites?

Marked abdominal enlargement with transmitted thrill Signup and view all the answers

Which laboratory tests are included in the initial assessment of ascites?

LFTs, Urea, Creatinine and serum electrolytes Signup and view all the answers

In which of the following situations is a diagnostic paracentesis indicated?

In patients hospitalized for complications of cirrhosis Signup and view all the answers

What is the primary reason for performing a diagnostic paracentesis in patients with ascites?

To analyze the ascitic fluid for potential causes Signup and view all the answers

Which grade of ascites warrants a diagnostic paracentesis upon new onset?

Both grades 2 and 3 Signup and view all the answers

Which of the following groups of patients should definitely receive a diagnostic paracentesis?

Patients with worsening ascites or complications of cirrhosis Signup and view all the answers

Which condition is NOT an indication for performing a diagnostic paracentesis?

Grade 1 ascites without complications Signup and view all the answers

What does a serum-ascites albumin gradient (SAAG) greater than 1.1 indicate?

Portal hypertension related ascites Signup and view all the answers

Which total protein level in ascitic fluid is suggestive of cirrhotic ascites?

Less than 2.5 g/dL Signup and view all the answers

Which condition is NOT indicated by a SAAG measurement of less than or equal to 1.1?

Portal hypertension Signup and view all the answers

What is the significance of the difference in albumin concentration between serum and ascitic fluid?

It helps diagnose the type of ascites Signup and view all the answers

A patient presents with ascites and a SAAG of 1.0. What does this likely suggest?

Cirrhotic ascites Signup and view all the answers

What is the recommended sodium intake for managing Grade II Ascites?

80–120 mmol/day Signup and view all the answers

Which dietary approach is advised for individuals managing Grade II Ascites?

Restricting salt intake to avoid pre-prepared meals Signup and view all the answers

What level of salt restriction is indicated for effective management of ascites?

Moderate restriction with specific sodium intake levels Signup and view all the answers

Why is it important to avoid pre-prepared meals for individuals with Grade II Ascites?

They often contain high levels of sodium Signup and view all the answers

Which of the following statements about salt restriction in ascites is true?

A no added salt diet is recommended to manage sodium intake. Signup and view all the answers

What condition necessitates the discontinuation of all diuretics?

Severe hyponatremia with encephalopathy Signup and view all the answers

In which patient situation should diuretics be maintained despite severe hyponatremia?

If the patient has preexisting cirrhosis Signup and view all the answers

Which of the following is NOT a common etiology of acute liver failure (ALF)?

Alcoholic liver disease Signup and view all the answers

What is a critical serum sodium concentration threshold that indicates severe hyponatremia?

Less than 1.5 mEq/L Signup and view all the answers

Which time frame is significant for considering the discontinuation of diuretics in patients with acute liver failure?

Less than 26 weeks disease duration Signup and view all the answers

Which viral hepatitis is primarily transmitted via fecal-oral route?

Hepatitis A Signup and view all the answers

Which condition is characterized by the obstruction of hepatic venous outflow?

Budd-Chiari syndrome Signup and view all the answers

Which syndrome is specifically associated with pregnancy and involves hepatic dysfunction?

Acute fatty liver of pregnancy Signup and view all the answers

Which types of hepatitis are classified as autoimmune conditions?

Autoimmune hepatitis only Signup and view all the answers

Which of the following conditions is considered a secondary cause of hepatitis?

Budd-Chiari syndrome Signup and view all the answers

Study Notes

Management of Cirrhotic Ascites and its Complications

Ascites is the most common complication of cirrhosis.
60% of compensated cirrhosis patients develop ascites within 10 years.
Ascites development signifies a poor prognosis and impairs quality of life.
Two types of ascites: uncomplicated and complicated.
Complicated ascites are associated with poor prognosis.

Definition of Ascites

Pathological accumulation of fluid within the peritoneal cavity.

Pathogenesis of Ascites in Cirrhosis

Portal hypertension
Vasodilator factors (NO, endocannabinoids, CO).
Splanchnic arterial vasodilatation.
Abnormal distribution of blood volume.
Reduced effective arterial blood volume.
Stimulation of antinatriuretic/vasoconstrictor systems.
Increased tubular sodium reabsorption.
Positive sodium balance.
Sodium and fluid retention.

Grading of Ascites

Grade I: Only detectable by ultrasound (USS).
Grade II: Moderate symmetrical abdominal enlargement—shifting dullness.
Grade III: Marked abdominal enlargement—transmitted thrill.

Initial Evaluation of Ascites

Thorough history taking.
Physical examination.
Abdominal ultrasound (USS).
Liver function tests (LFTS).
Urea, creatinine, and serum electrolytes.
Diagnostic paracentesis for Grade 2 or 3 ascites, and for worsening ascites or cirrhosis complications.

Paracentesis and Ascites Workup

Routine tests: Ascitic fluid cell count, protein, and albumin levels.
Serum ascites albumin gradient (SAAG): Serum albumin concentration minus ascitic fluid albumin concentration.
SAAG > 1.1: Indicates portal hypertension-related ascites.
Total protein < 2.5 g/dL: Suggests cirrhotic ascites.
Total protein ≥ 2.5 g/dL: Suggests cardiac ascites (congestive heart failure, constrictive pericarditis), or Budd-Chiari syndrome
SAAG < 1.1: Indicates non-portal hypertension-related ascites
Total protein < 2.5 g/dL: Suggests nephrotic ascites.
Total protein ≥ 2.5 g/dL: Suggests peritoneal carcinomatosis, tuberculous ascites, or other conditions.
Polymorphonuclear (PMN) leukocyte count ≥ 250 cells/mm³ indicates infection, often spontaneous bacterial peritonitis (SBP).

Diagnostic Paracentesis

Determining presence and progression of ascites associated with certain causes, such as cirrhosis.

Grade II Ascites Treatment

Salt restriction: 80-120 mmol sodium/day.
Diuretics (Spironolactone +/– Furosemide): Treatment of choice, focuses on negative sodium balance.
- Starting dose: 100 mg/day spironolactone. Increasing dose (100 mg steps) until response.
- Furosemide is added if the aldosterone antagonist is insufficient (40 mg/day increase, max 160 mg/day).
Fluid Restriction: Only needed if serum sodium is abnormal.

Grade III Ascites Treatment

Large volume paracentesis (LVP): 5 liters of ascitic fluid at one session (treatment of choice).
Albumin administration: Prevents post-paracentesis circulatory dysfunction and prevents re-accumulation.

Refractory Ascites

Ascites not responding to medical treatment.
Median survival of patients with refractory ascites is approximately 6 months.
Liver transplantation should be considered if medical management fails.
Common causes: SBP, HRS, severe hyponatremia, portal vein thrombosis (PVT), hepatocellular carcinoma (HCC).
- Diuretic-resistant ascites: poor response to sodium restriction and diuretic treatment
- Diuretic-intractable ascites: response to treatment is further blocked by induced complications

Diagnostic Criteria for Refractory Ascites

Intensive diuretic therapy (spironolactone 400 mg/day + furosemide 160 mg/day) with a low-sodium diet (<90 mmol/day) for at least 1 week.
< 0.8 kg weight loss over 4 days.
Reappearance of grade 2 or 3 ascites within 4 weeks of initial mobilization.
Diuretic-induced encephalopathy absence of other precipitating factors.
Renal impairment
Hypo/hyperkalemia: despite appropriate measures
Hyponatremia

Treatment Options for Refractory Ascites

LVP plus albumin: Not effective or inducing complications in >90% of patients.
TIPSS (Transjugular Intrahepatic Portosystemic Shunt): Considered with frequent or large-volume paracentesis.
Liver Transplantation: Treatment of choice for refractory ascites

Spontaneous Bacterial Peritonitis (SBP)

Diagnosis: Paracentesis is essential in all patients.
- Critical assessment: of all high-risk patients with cirrhosis and ascites is encouraged
Treatment: Third-generation cephalosporins (first-line treatment).
Prophylaxis: High-risk groups (acute gastrointestinal hemorrhage, low total protein in ascites, prior history of SBP)

Hepatorenal Syndrome (HRS)

Renal dysfunction in advanced liver disease without other causes.
Diagnostic criteria crucial for early recognition and treatment
Treatment of possible causes must be performed before HRS diagnosis
Treatment: Albumin infusion, antibiotics for SBP
Sepsis screen: Early identification of bacterial infection (blood, urine, and ascitic fluid cultures).
- Maintain prophylactic antibiotics (if prescribed) in patients without signs of infection

HRS types and their criteria (Old and New Classification):

There are new and old classifications for HRS types with different criteria and their definitions.

Hepatic Encephalopathy (HE)

Brain dysfunction caused by liver and/or portal-systemic insufficiency.
Pathogenesis: Ammonium accumulation.
- Abnormal neurotransmission. Alterations in permeability of Blood brain barrier.
Classification: Varies from minimal to coma.
Grading: Grades 0-4 based on clinical abnormalities.
Diagnosis: Exclusion of other causes of encephalopathy.
Precipitating factors
- Several factors may influence the severity
Treatment:
- Treat the precipitating factor alongside supportive measures
- Lactulose, rifaximin, L-ornithine L-aspartate (LOOA), and other medications.

Acute Liver Failure (ALF)

Severe liver injury, coagulopathy (INR >1.5), and encephalopathy within 26 weeks.
Etiologies: Viral hepatitis, drug-induced injury, autoimmune hepatitis, vascular causes, and others.
Clinical features: Often begins with malaise, nausea, jaundice, abdominal pain, and pruritus. Can demonstrate stigmata of chronic liver disease and physical findings
Investigations (LAB): CBC, renal, hepatic panels, INR, arterial blood gases, serum lactate, viral serologies, autoimmune antibodies.
Investigations (Imaging): Ultrasound, Doppler, MRI/CT, head CT.
Treatment: ICU admission, supportive care (treat precipitating factors, manage fluid and electrolyte disturbances) and liver transplantation.
Management considerations for pre-procedure treatments
- Coagulopathy and thrombocytopenia: Treatment only when bleeding is present or prior to procedures.
- GI bleeding: PPI for prophylaxis
- Refractory hypotension: Vasopressors (norepinephrine)

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Description

Test your knowledge on the characteristics, evaluation, and management of ascites. This quiz covers topics such as grading of ascites, diagnostic procedures, and lab tests related to ascitic fluid. Perfect for medical students and healthcare professionals alike.