Beruflich Dokumente
Kultur Dokumente
lateral aspect of the abdomen with the patient in supine) if puncture the bowel unless the bowel is adherent to a scar or
flank dullness is absent, checking for shifting is unnecessary. severe gaseous distention is present
o Approx. 1500 ml of fluid must be present before dullness is TECHNIQUE: DIAGNOSTIC PARACENTESIS (diagnosing
detected. (lesser amount thru UTZ) portal hypertension)
o Ascites is difficult to assess in patients with ovarian Asepsis (aseptic technique) – minimum requirement is the
masses, gaseous distention and who are obese; may use of sterile gloves
need ultrasound to confirm Z tract ( old term, confusing) – technique of needle insertion
o Some clues in the determining etiology of ascites: is accomplished by displacing one gloved hand the skin
o Portal hypertension from cirrhosis: presence of approx.. 2cm downward and then slowly inserting the needle
palmar erythema, large pulsatile spider angioma mounted on the syringe held in the other hand
(atleast 6), large abdominal wall collateral veins, or o The hand holding the syringe stabilizes the syringe and
fector hepaticus. retracts its plunger simultaneously; a steady hand and
o Peritoneal carcinomatosis: an immobile mass in the experience are needed. Skin is released only after the
umbilicus , the sister mary joseph nodules. needle has penetrated the peritoneum and fluid flows
o Cardiac cirrhosis: neck vein engorgement. o When the needle is ultimately removed, the skin
resumes its original position and seals the needle
DIAGNOSIS: PARACENTESIS pathway
INDICATIONS Needles should be advanced slowly through the abdominal
All inpatients and outpatients with new onset ascites wall approx. 5 mm increments
Because of the possibility of ascetic fluid infection in a o Allows the operator to see blood if a vessel is entered
cirrhotic patient admitted to the hospital, a surveillance and allows the bowel to move away from the needle
paracentesis performed on admission may detect o Slow insertion also allows time for the elastic peritoneum
unexpected infection to “tent” over the end of the needle and be pierced by
Not all patients with ascetic fluid infection are symptomatic; it.
may have subtle symptom, such as mild confusion Approx. 30 ml of fluid is obtained
noticed only by the family Use of 5- to 10- ml syringe for the initial portion of a
Early detection of infection at the asymptomatic stage may diagnostic tap and then twist this syringe off the needle and
reduce mortality replace it with 20-to 30- ml syringe to obtain the remainder
CONTRAINDICATIONS of the sample
Coagulopathy should preclude paracentesis only when The initial use of small syringe allows the operator to have a
clinically evident fibrinolysis or disseminated better control and to see the fluid more easily as it
intravascular coagulation (DIC) is present; rare enters the hub of the syringe
No deaths or infection caused by paracentesis; no episodes A sterile needle is then placed on a larger syringe, and
of hemoperitoneum or entry of the paracentesis needle into an appropriate amount of fluid is inoculated into each of a
the bowel pair of prepared blood culture bottles.
Complications have included only abdominal wall hematomas Usually 5-10 ml is inoculated into 50-ml bottles and 10-
in approx. 2% of paracentesis 20 ml into 100-ml bottles
Transfusion of blood products (fresh frozen plasma or The next aliquot is placed into a “purple-top” or
platelet) routinely before paracentesis in cirrhotic patients ethylenediaminetetraacetic acid tube for a cell count.
with coagulopathy is not supported by the data And the final aliquot is placed into “red-top” plane tube for
PATIENT POSITION AND CHOICE OF ENTRY OFNEEDLE chemistries
SITE Inoculating the culture bottles with the sterile needle
Large volume of ascites and thin abdominal wall: supine minimizes contamination
position with the head of the bed or examining table TECHNIQUE: THERAPEUTIC PARACENTESIS
elevated slightly Similar process but using a large bore needle to remove
Less fluid: lateral decubitus position and tapped in the larger amount of fluid
midline or in the right or left lower quadrant while supine Preferred size: use a standard metal 1.5 inch, 16-18 gauge
Small amounts of fluid: face-down position or with Obese patients may require a larger needle: 3.5 inches
ultrasound guidance and 18 gauge
Obese: (with abdominal wall usually is substantially thicker A set of 15-gauge five-hole needles has been produced
in the midline than in the lower quadrant): ultrasound specifically for therapeutic abdominal paracentesis: these
examination is helpful in confirming the presence of fluid and needle may replace the spinal needles used currently for
guiding the paracentesis needle paracentesis in obese patients
Avoid tapping in the site of surgical scars: ultrasound The 15-gauge needle have a removable sharpd inner
guidance may be required in patients with multiple component and a blunt outer cannula; they range in length
Recommended site: left lower quadrant (LLQ) two from 3.25 to 5.9 inches
finger breadths (3cm) cephalad and two finger breadth A tiny scalpel nick is required to permit the large needle to
medial to the anterior superior iliac spine enter the skin
Material: standard metal 1.5 in, 22- gauge needle, Use of vaccum bottles (1-2 L) connected to the needle
obese patients require the use of longer needle, inches and with noncollapsible tubing is much faster; use of a pump is
gauge 22 even faster than the vaccum bottles
Steel needles: are preferable to plastic-sheathed cannulas With respiratory movement, the needle may gradually works
because plastic sheath may shear off to the peritoneal cavity its way out of the peritoneal cavity and into the soft tissue,
with the potential to kink and obstruct the flow of fluid and some serosanguineous fluid may appear in the needle
after the metal cannula is removed; metal needles do not hub or tubing; when this happens, the pump should be
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turned off or a clamp placed on the tubing connected to the Tuberculous, secs
vaccum bottle Peritoneal
carcinomatos
ASCITIC FLUID ANALYSIS (refer at the back pages) is:
predominance
of
lymphocytes
Leakage of 1 PMN is
blood into the subtracted
peritoneal from the
cavity leads to absolute
RBC
an elevated ascetic fluid
ascetic fluid PMN count
WBC count for every 250
RBC
SAAG >1.1 SAAG does
g/dl (11 g/L): not explain
portal the
hypertension pathogenes
with an is of ascites
accuracy of formation,
approx. 97%: nor does not
because of the explain
FINDINGS/R ascetic fluid where the
ITEM NORMAL REMARKS
ESULT abumin conc. albumin
ANC <1000/ cannot be came from
mm³ greater than – that is, liver
(1.0x109/L): the ascetic or bowel;
clear fluid total simply gives
Transparent,
ANC >5000/ protein conc. the dr. an
sl yellow,
mm³ <1.1 g/dl: indirect but
PMN’s
(5.0x109/L): unlikely to accurate
<250/mm³
cloudy have portal index of
[0.25 x
ANC >50,000/ hypertension portal
109/L]
mm³ Serum pressure
(50.0x109/L): hyperglobuline The accuracy
resembles mia (serum of the SAAG
mayonnaise globulin is also
SERUM
RBC count greater than reduced
ASCITES
GROSS about 10,000/ 5g/dl) leads to when
ALBUMIN
APPEARAN mm³ (10.0x a high ascetic specimens of
GRADIENT
CE 109/L): pink fluid globulin serum and
RBC
appearance conc. and can ascites are
>20,000/ mm³ narrow the not obtained
(20.0x109/L) albumin nearly
distinctly red gradient by simultaneousl
>200-1000 contributin to y; specimens
mg/dl (2.26- the oncotic should be
11.3 mmol/L) forces: to obtained on
opaque, correct the same
milky Corrected day,
LIPID
>100-200 SAAG = preferably
mg/dl )1.13- uncorrected within the
2.26 mmol/L) SAAG x 0.16 same hour
dilute skim x (serum Arterial
milk globulin in hypertension
Spontaneous Dipstick g/dl 2.5) may result in
bacterial count can a decrease in
peritonitis detect an portal
PMN’s <250/ (SBP) most ascetic fluid pressure and
CELL a narrowing
mm³ common cause PMN count
COUNT of the SAAG.
(0.25x109/L) of elevated greater than
WBC of 70% 250/ mm³ The SAAG
PMNs (0.25x109/L) needs to be
in 90-120 determined
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Ceftriaxone 1g daily for 7 days is given in the setting of GI of hyponatremia does not develop in
bleeding cirrhotic patients until Serum Na
Co-trimoxazole has been proven to be effective in animal <110mmol/L
models Bed rest Not necessary
Strict bed rest may lead to decubitis
(Refer Table 91.10) ulcer formation in emaciated patients
Crea is checked to assess adequacy
TYPES DESCRIPTION of the collection: men 15-20mg/kg/day,
Cellulitis Risk factors include obesity, homelessness, women 10-15mg/kg/day
greater degree of edema Urine A suboptimal decline in body weight may
Tense “Total ascites”, even more than 22L appears to examination be a result of inadequate natriuresis,
ascites be safe failure to restrict Na or both
Pleural Usually unilateral and right-sided, but may be Patients who are adherent to an
effusion bilateral and larger on the left 88mmol/day Na restricted diet and
Unilateral pleural effusion suggests excretes more than 78mmol/day should
tuberculosis lose weight; if weight is increasing despite
Hepatic hydrothorax: a large effusion in a urinary losses, patient is consuming more
patient with cirrhotic ascites usually presenting Na than prescribed
with shortness of breath Random urine Na > K: 24 hour urine
The fluid analysis is similar but not specimen will reveal Na excretion >
identical; total protein conc is higher (by Urine Na to K 78mmol per day in 90% cases
approx. 1 g/dL (10g/L) in the pleural fluid ratio Random urine Na:K > 1 predicts that
Treatment of hepatic hydrothorax: Na patient should lose weight; if patient does
restriction + diuretics, TIPS, liver transplant; not lose weight with a Random Urine Na:K
chest tube with pleurodesis, peritoneovenous >1, then he is not adherent to diet
shunt and direct surgical repair are ineffective Avoidance of May lead to cystitis and bacteremia
Abdominal Usually umbilical or Incisional Urinary Should be inserted only in ICU setting and
wall Elective surgical treatment should be Bladder only for a short period of time
hernias considered; ascitic fluid should be removed Catheters
preoperatively because hernias recur in up to Spironolactone: mainstay of
73% of cases treatment but increases natriuresis
Laparoscopic surgery is done usually with TIPS slowly
or liver transplant Recommendations: Spironolactone
Surgery is done urgently if with skin ulceration, 100mg, Furosemide 40mg; dose may be
crusting or black discoloration and emergently for increases to as high as Spironolactone
refractory incarceration or rupture Diuretics 400mg, Furosemide 160mg
TREATMENT OF ASCITES Amiloride 10mg/day has a more rapid
Low-Albumin-Gradient Ascites effect and does not cause gynecomastia
Peripheral edema is managed with diuretics IV diuretics can cause acute decrease in
Non-ovarian peritoneal carcinomatosis is managed with GFR and should be avoided
outpatient therapeutic paracentesis Paracentesis is done if rapid weight
Tuberculous peritonitis: anti-TB medications loss is desired:
Pancreatic ascites may resolve spontaneously but may Target: 0.5kg/day weight loss
require endoscopic placement of PD or may respond to Discontinue if: encephalopathic, Serum
Somatostatin Na <120mmol/day, Serum Crea > 2mg/dL
Post-op lymphatic leak may resolve spontaneously but (180mmol/L), significant drop in blood
may require surgical intervention or placement of pressure from baseline WITH confusion or
peritoneovenous shunt azotemia
Chlamydia peritonitis is cured by tetracycline Patients who have demonstrated response
Lupus serositis responds to steroids to regimen may be discharged
Dialysis-related ascites respond to aggressive dialysis Role of Na Usually used in mild renal tubular
Hospitalization Large volume ascites and those who Bicarbonate acidosis
are resistant to outpatient treatment Na bicarbonate is recommended but
usually require hospitalization should not be routinely used
Precipitation Correct the underlying cause: saline Used to increase urinary water
cause infusion, Na bicarbonate infusion Aquaretics excretion and increase serum Na
Diet education Recommended: 2g/day (88mmol); concentration
severely sodium restricted diet, ie, No clear benefit
500mg/day (22mmol) is not palatable Monitor: body weight, orthostatic
Protein is not restricted unless patient has symptoms, serum electrolytes, urea,
hepatic encephalopathy refractory to two Outpatient creatinine
drug and on a vegetable protein diet management 24-hour urine collection may be done if
Fluid Restrict Na not fluids needed
restriction Attempts to correct hyponatremia rapidly Diuretic doses and dietary Na intake
can lead to more complications; symptoms may be titrated to achieve weight
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HEPATIC ENCEPHALOPATHY
Transient and reversible neurologic and psychiatric CLINICAL FEATURES
manifestations Portosystemic encephalopathy syndrome test (PSET)
Develops 50-70 % of patients with cirrhosis and is a poor evaluates the attention , concentration, fine motor skills,
prognostic indicator orientation; led to the recognition of the syndrome of
Triggered by an inciting event that results in a rise in minimal HE (not readily available)
serum ammonia not necessary to hep. Enceph. diagnosis Magnetic resonance spectrometry has been used to
measure brain concentration of choline and glutamine
TREATMENT
Primary treatment is to eliminate or correct precipitating
factors, reduce blood ammonia levels and avoid the toxic
effect of ammonia on the CNS
Protein restriction is not recommended; vegetable and
dairy proteins are preferred because of more favourable
calorie-to-nitrogen ration
Branched chain amino acids may improve symptoms but
benefit does not justify its routine use
Lactulose or lactitol: nonabsorbable disaccharides are
metabolized by the colonic bacteria to by products that
induce catharsis decreasing intestinal pH inhibiting ammonia
absorption; improve symptoms but has not been shown to
improve test performance or mortality
o Side effects: abdominal cramping, flatulence, diarrhea,
PATHOPHYSIOLOGY electrolyte imbalance
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HEPATORENAL SYNDROME
Part of a cascade of events associated with intense dilatation
of the splanchnic arterial vasculature in the setting of
cirrhosis or acute liver injury resulting in profound renal
arterial vasoconstriction and progressive renal failure
Appears to be an extension of the pathophysiology prerenal
azotemia and is potentially reversible
HRS develops in ~30% of cirrhotic patients who are admitted
with SBP or other infection, 25% who are hospitalized for
severe alcoholic hepatitis, 10% who require large-volume
paracentesis
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