Ascites resident survival guide: Difference between revisions

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{{familytree | | | | | | | | A01 |A01=<div style="text-align: left;"><b><u>History and symptoms:</u></b><br>
{{familytree | | | | | | | | A01 |A01=<div style="text-align: left;"><b><u>History and symptoms:</u></b><br>
❑&nbsp;&nbsp;Hints for etiology (i.e. cirrhosis, malignancy)?<br>
❑&nbsp;&nbsp;Hints for etiology (i.e. cirrhosis, malignancy)?<br>
❑&nbsp;&nbsp;Abdominal distension/abdominal discomfort?
❑&nbsp;&nbsp;Abdominal distension/abdominal discomfort?<br>
❑&nbsp;&nbsp;Duration and onset of illness/ symptoms?
❑&nbsp;&nbsp;Duration and onset of illness/ symptoms?<br>
❑&nbsp;&nbsp;Severity and triggers?
❑&nbsp;&nbsp;Severity and triggers?<br>
❑&nbsp;&nbsp;Weight loss/weight gain/early satiety?
❑&nbsp;&nbsp;Weight loss/weight gain/early satiety?<br>
❑&nbsp;&nbsp;Presence of peripheral [[edema]], [[anasarca]]?
❑&nbsp;&nbsp;Presence of peripheral [[edema]], [[anasarca]]?<br>
❑&nbsp;&nbsp;Problems with breathing at night/ sleep?
❑&nbsp;&nbsp;Problems with breathing at night/ sleep?<br>
❑&nbsp;&nbsp;[[Fever]], abdominal tenderness, and altered mental status?
❑&nbsp;&nbsp;[[Fever]], abdominal tenderness, and altered mental status?<br>
❑&nbsp;&nbsp;[[Diarrhea]] and [[steatorrhea]], [[malnutrition]], [[nausea]], enlarged lymph nodes
❑&nbsp;&nbsp;[[Diarrhea]] and [[steatorrhea]], [[malnutrition]], [[nausea]], enlarged lymph nodes<br>
❑&nbsp;&nbsp;Medical history<br>
❑&nbsp;&nbsp;Medical history<br>
:❑&nbsp;&nbsp;Prior hospitalizations?
:❑&nbsp;&nbsp;Prior hospitalizations?<br>
:❑&nbsp;&nbsp;Medication?<br></div>}}
:❑&nbsp;&nbsp;Medication?<br></div>}}
{{familytree | | | | | | | | B01 |B01=<div style="text-align: left;"><b><u>Physical examination:</u></b><br>
{{familytree | | | | | | | | B01 |B01=<div style="text-align: left;"><b><u>Physical examination:</u></b><br>
❑&nbsp;&nbsp;Vital signs:<br>
❑&nbsp;&nbsp;Vital signs:<br>
:❑&nbsp;&nbsp;Pulse (strength and regularity)
:❑&nbsp;&nbsp;Pulse (strength and regularity)<br>
:❑&nbsp;&nbsp;Blood pressure  
:❑&nbsp;&nbsp;Blood pressure <br>
:❑&nbsp;&nbsp;Respiratory rate<br>
:❑&nbsp;&nbsp;Respiratory rate<br>
❑&nbsp;&nbsp;General appearance:<br>
❑&nbsp;&nbsp;General appearance:<br>
:❑&nbsp;&nbsp;BMI(weight loss/weight gain)
:❑&nbsp;&nbsp;BMI(weight loss/weight gain)<br>
:❑&nbsp;&nbsp;[[Jaundice]], muscle wasting, [[gynecomastia]], and leukonychia, lymphadenopathy
:❑&nbsp;&nbsp;[[Jaundice]], muscle wasting, [[gynecomastia]], and leukonychia, lymphadenopathy<br>
:❑&nbsp;&nbsp;Peripheral [[edema]]
:❑&nbsp;&nbsp;Peripheral [[edema]]<br>
:❑&nbsp;&nbsp;[[JVD]]
:❑&nbsp;&nbsp;[[JVD]]<br>
❑&nbsp;&nbsp;Heart: <br>
❑&nbsp;&nbsp;Heart: <br>
:❑&nbsp;&nbsp;Murmur
:❑&nbsp;&nbsp;Murmur<br>
:❑&nbsp;&nbsp;Carotid and peripheral pulses
:❑&nbsp;&nbsp;Carotid and peripheral pulses<br>
❑&nbsp;&nbsp;Lungs:<br>
❑&nbsp;&nbsp;Lungs:<br>
:❑&nbsp;&nbsp;Rales?
:❑&nbsp;&nbsp;Rales?<br>
:❑&nbsp;&nbsp;[[Pleural effusion]]?<br>
:❑&nbsp;&nbsp;[[Pleural effusion]]?<br>
❑&nbsp;&nbsp;Abdomen:<br>
❑&nbsp;&nbsp;Abdomen:<br>
:❑&nbsp;&nbsp;[[Hepatomegaly]]
:❑&nbsp;&nbsp;[[Hepatomegaly]]<br>
:❑&nbsp;&nbsp;pulsatile liver and/or [[ascites]] (volume overload) <br>
:❑&nbsp;&nbsp;pulsatile liver and/or [[ascites]] (volume overload) <br>
:❑&nbsp;&nbsp;Flank dullness, shifting dullness, a fluid wave, evidence of pleural effusions  
:❑&nbsp;&nbsp;Flank dullness, shifting dullness, a fluid wave, evidence of pleural effusions <br>
:❑&nbsp;&nbsp;Stigmata of [[cirrhosis]] (spider angioma, palmar erythema, and abdominal wall collaterals)
:❑&nbsp;&nbsp;Stigmata of [[cirrhosis]] (spider angioma, palmar erythema, and abdominal wall collaterals)<br>
:❑&nbsp;&nbsp;Umbilical nodule that is not bowel or omentum
:❑&nbsp;&nbsp;Umbilical nodule that is not bowel or omentum<br>
</div>}}
</div>}}
{{familytree | | | | | | | | C01 |C01=<div style="text-align: left;"><b><u>Laboratory findings:</u></b><br>
{{familytree | | | | | | | | C01 |C01=<div style="text-align: left;"><b><u>Laboratory findings:</u></b><br>
Line 104: Line 104:
:❑&nbsp;&nbsp;Liver function tests<br>
:❑&nbsp;&nbsp;Liver function tests<br>
:❑&nbsp;&nbsp;Glucose<br>
:❑&nbsp;&nbsp;Glucose<br>
:❑&nbsp;&nbsp;Fasting lipid profile, hypoalbuminemia, decreased gamma globulin levels?
:❑&nbsp;&nbsp;Fasting lipid profile, hypoalbuminemia, decreased gamma globulin levels?<br>


:❑&nbsp;&nbsp;Coagulation testing (i.e. INR)</div>}}
:❑&nbsp;&nbsp;Coagulation testing (i.e. INR)</div>}}

Revision as of 17:30, 11 March 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Steven Bellm, M.D. [2]

Ascites resident survival guide Microchapters
Overview
Classification/Causes
Diagnosis
Treatment
Do's
Dont's

Overview

Accumulation of fluid within the peritoneal cavity results in ascites. Most important for a successful treatment of ascites is an accurate diagnosis of its cause. Most common causes are portal hypertension, malignancy and heart failure. The diagnosis is made with a combination of physical examination and abdominal imaging. The next step is typically a paracentesis to evaluate the ascitic fluid for causes.[1]

Classification/Causes

Ascites can be classified based on the underlying causes. Common causes are:[1]

 
 
 
 
 
 
 
Causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Portal hypertension:

❑  Cirrhosis
❑  Alcoholic hepatitis
❑  Acute liver failure
❑  Hepatic veno-occlusive disease (eg, Budd-Chiari syndrome)
❑  Heart failure
❑  Constrictive pericarditis

❑  Hemodialysis-associated ascites (nephrogenic ascites)
Hypoalbuminemia:

❑  Nephrotic syndrome
❑  Protein-losing enteropathy

❑  Severe malnutrition
 
 
Peritoneal disease:

❑  Malignant ascites
❑  Infectious peritonitis
❑  Eosinophilic gastroenteritis
❑  Starch granulomatous peritonitis

❑  Peritoneal dialysis
 
Other etiologies:

❑  Chylous ascites
❑  Pancreatic ascites (eg, from a disrupted pancreatic duct)
❑  Myxedema

❑  Hemoperitoneum
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

 
 
 
 
 
 
 
History and symptoms:

❑  Hints for etiology (i.e. cirrhosis, malignancy)?
❑  Abdominal distension/abdominal discomfort?
❑  Duration and onset of illness/ symptoms?
❑  Severity and triggers?
❑  Weight loss/weight gain/early satiety?
❑  Presence of peripheral edema, anasarca?
❑  Problems with breathing at night/ sleep?
❑  Fever, abdominal tenderness, and altered mental status?
❑  Diarrhea and steatorrhea, malnutrition, nausea, enlarged lymph nodes
❑  Medical history

❑  Prior hospitalizations?
❑  Medication?
 
 
 
 
 
 
 
Physical examination:

❑  Vital signs:

❑  Pulse (strength and regularity)
❑  Blood pressure
❑  Respiratory rate

❑  General appearance:

❑  BMI(weight loss/weight gain)
❑  Jaundice, muscle wasting, gynecomastia, and leukonychia, lymphadenopathy
❑  Peripheral edema
❑  JVD

❑  Heart:

❑  Murmur
❑  Carotid and peripheral pulses

❑  Lungs:

❑  Rales?
❑  Pleural effusion?

❑  Abdomen:

❑  Hepatomegaly
❑  pulsatile liver and/or ascites (volume overload)
❑  Flank dullness, shifting dullness, a fluid wave, evidence of pleural effusions
❑  Stigmata of cirrhosis (spider angioma, palmar erythema, and abdominal wall collaterals)
❑  Umbilical nodule that is not bowel or omentum
 
 
 
 
 
 
 
Laboratory findings:

❑  Complete blood count

❑  Chemistry:

❑  Troponin, BNP or NT-proBNP
❑  Serum electrolytes (including calcium and magnesium)
❑  Kidney function tests: Blood urea nitrogen, serum creatinine, GFR
❑  Liver function tests
❑  Glucose
❑  Fasting lipid profile, hypoalbuminemia, decreased gamma globulin levels?
❑  Coagulation testing (i.e. INR)
 
 
 
 
 
 
 
A01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
B01
 
 
 
 
 
 
 
B02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D01
 
D02
 
 
 
 
 
D03
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E01
 
 
 
 
 
 
E02
 
 
E03
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
F01
 
 
F02

Treatment

shown

hidden

Do's

Dont's

References

  1. 1.0 1.1 1.2 Runyon BA, AASLD (2013). "Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012". Hepatology. 57 (4): 1651–3. doi:10.1002/hep.26359. PMID 23463403.