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Ascites Related
Complications
Chaired by : Dr. Ardaman Singh
Presented by: Dr. Amith Kumar S
Ascites
 derived from Greek term “askos”
Other Etiologies of Ascites (account for <2% of all cases)
Complications
 Ascitic Fluid Infections
 Hepatic Hydrothorax
 Refractory Ascites
 Hepatorenal Syndrome
 Miscellaneous
Ascitic Fluid Infections
When to suspect…
 Fever
 Abdominal pain
 Abdominal Tenderness
 Rebound tenderness
 Altered sensorium
 Leucocytosis
Why to suspect….
 Prevalence of SBP
 33% of patients with SBP land up in renal
impairment
 Untreated mortality is 90% w...
Classification
 Culture Negative Neutrocytic Ascites
 Monomicrobial non-neutrocytic
bacterascites
 Polymicrobial Bacter...
Diagnosis
 Abdominal Paracentesis & Ascitic
fluid analysis
 Ascitic fluid culture
 Complete Blood count
 Renal functio...
Ascitic fluid culture
 Culture is positive in ~ 80% of cases
 Most common pathogens include Gram-
negative bacteria (GNB...
Blood agar plate inoculated with the ascitic fluid
showing a growth of Klebsiella pneumonia
Bacteriology
Frequency (%)
Organism SBP MNNB Sec BP SBP with SID
E. Coli 37 27 20 0
Klebsiella
pneumonia
17 11 7 7
Strep P...
Pathogenesis
Bowel Flora
Bacteria in mesentric LN,
abdominal lymphatics
and thoracic duct
Bactremia
Bacteria in Hepatic
Ly...
Culture Negative Neutrocytic
Ascites
1. Ascitic fluid culture grows no
bacteria
2. Ascitic fluid PMN count is > or = 250
c...
Monobacterial Non-neutrocytic
Bacterascites
1. Positive ascitic fluid culture for a
single organism
2. Ascitic fluid PMN c...
Polymicrobial Bacterascites
1. Multiple organisms are seen on gram
stain or cultured from the ascitic fluid
2. Ascitic flu...
Secondary Bacterial
Peritonitis
1. Ascitic fluid culture is positive for
multiple organisms
2. Ascitic fluid PMN count mor...
Spontaneous Bacterial Peritonitis
1. Positive ascitic fluid culture for a
single organism
2. Elevated ascitic fluid PMN co...
Risk Factors for SBP
 Cirrhosis
◦ Low ascitic fluid proteins
◦ Phagocytic dysfunction
 GI bleed
◦ 40 % cumulative probab...
SBP Vs Secondary Bacterial
Peritonitis
Ascitic Fluid PMN count > or =
250 cells/ mm3
Abdominal imaging
showing free air or...
Indications for Empirical Antibiotic
Therapy of Suspected
Spontaneous Ascitic Fluid
Infection
•Ascitic fluid neutrophil co...
Diagnosis Treatment
Monobacterial
Nonneutrocytic
bacterascites
Five days of intravenous antibiotic to
which the organism i...
 If preliminary cultures are negative,
paracentesis can be repeated after 48
hrs of therapy to assess the response of
PMN...
Treatment contd…
 Injectable amoxicillin clavulanic
acid, oral ofloxacin, ciprofloxacin
may be used instead of cephalospo...
Prognosis
 SBP is an indication of End Stage
Liver Disease
 33% of patients with SBP land up in
renal impairment
 No su...
Prevention
 Indications for preventive measures
◦ Ascitic fluid protein < 1.0 g/dl
◦ Variceal hemorhage
◦ Previous episod...
 Prior SBP
 Cirrhosis with gastrointestinal
hemorrhage
 Norfloxacin 400 mg orally once daily
until death or liver trans...
 Cirrhosis with ascitic fluid
◦ Total protein <1.5 g/dL and either
◦ Child-Turcotte-Pugh score ≥9 and total bilirubin
≥3 ...
 Cirrhosis with ascitic fluid total
protein <1.5 g/dL
Intervention :
Ciprofloxacin 500 mg orally daily x1 year
Outcome
•3...
Hepatic Hydrothorax
 Hepatic hydrothorax develops in
approximately 5%–10% of patients with
cirrhosis,
 Mechanism
◦ Hypoa...
Refractory Ascites
 Refractory ascites is defined as fluid
overload that is
I. Unresponsive to sodium-restricted diet
and h...
 Diuretic-resistant ascites
 ascites that cannot be mobilized or the early
recurrence of which cannot be prevented
becau...
 Treatment duration
 Patients must be on intensive diuretic therapy
(spironolactone 400 mg/d and
furosemide160mg/d) for ...
Management
a) Serial large volume therapeutic
paracentesis,
b) Liver transplantation,
c) Transjugular intrahepatic
portasy...
Hepatorenal Syndrome
 Potentially reversible functional renal
failure in the setting of liver
dysfunction (cirrhosis with...
International Ascites Club
Consensus Criteria
 Cirrhosis with ascites
 Serum Creatinine level > or = to 1.5 mg/dl
(133 m...
Classification
 Type 1 Hepatorenal Syndrome
 Serum creatinine doubles to a value
higher than, 2.5mg/dl, in a period of
t...
Drugs Dosage Endpoint Duration
Terlipressin Started at a dose of 1 mg/4–6
h and increased to a maximum
of 2 mg/4–6 h if th...
Drugs Dosage Endpoint Duration
Noradrenaline 0.1 – 0.7 microgm
/kg/min as i/v infusion,
with an increase the
dose by 0.05
...
Heal The World
Make It A Better Place
For You And For Me
And The Entire Human Race
There Are People Dying
If You Care Enou...
Ascites related complications final
Ascites related complications final
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Ascites related complications final

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Spontaneous Bacterial Peritonitis, Hepatic hydrothorax

Published in: Education, Health & Medicine
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Ascites related complications final

  1. 1. Ascites Related Complications Chaired by : Dr. Ardaman Singh Presented by: Dr. Amith Kumar S
  2. 2. Ascites  derived from Greek term “askos”
  3. 3. Other Etiologies of Ascites (account for <2% of all cases)
  4. 4. Complications  Ascitic Fluid Infections  Hepatic Hydrothorax  Refractory Ascites  Hepatorenal Syndrome  Miscellaneous
  5. 5. Ascitic Fluid Infections
  6. 6. When to suspect…  Fever  Abdominal pain  Abdominal Tenderness  Rebound tenderness  Altered sensorium  Leucocytosis
  7. 7. Why to suspect….  Prevalence of SBP  33% of patients with SBP land up in renal impairment  Untreated mortality is 90% which is reduced to 20% with early diagnosis and prompt treatment.  No survivors have been reported when the diagnosis of SBP has been made after Serum Creatinine is more than 4 mg/dl or after shock had developed Prevalence Outpatients 1.5 –3.5% In hospital >10%
  8. 8. Classification  Culture Negative Neutrocytic Ascites  Monomicrobial non-neutrocytic bacterascites  Polymicrobial Bacterascites  Secondary Bacterial Peritonitis  Spontaneous Bacterial Peritonitis
  9. 9. Diagnosis  Abdominal Paracentesis & Ascitic fluid analysis  Ascitic fluid culture  Complete Blood count  Renal function tests  Blood culture  GI endoscopy  X ray abdomen erect
  10. 10. Ascitic fluid culture  Culture is positive in ~ 80% of cases  Most common pathogens include Gram- negative bacteria (GNB), usually Escherichia coli and Gram-positive cocci  Ascitic fluid culture methods: ◦ Conventional - chocolate agar and thioglycolate broth ◦ Modified - inoculation of 10 ml of ascitic fluid in a tryptic soy broth blood culture bottle at the patient's bedside
  11. 11. Blood agar plate inoculated with the ascitic fluid showing a growth of Klebsiella pneumonia
  12. 12. Bacteriology Frequency (%) Organism SBP MNNB Sec BP SBP with SID E. Coli 37 27 20 0 Klebsiella pneumonia 17 11 7 7 Strep Pneumonia 12 9 0 29 Strep viridans 9 2 0 0 Staph aureus 0 7 13 0 Misc gram neg 10 14 7 7 Misc gram positive 14 30 0 50 Polymicrobial 1 0 53 7
  13. 13. Pathogenesis Bowel Flora Bacteria in mesentric LN, abdominal lymphatics and thoracic duct Bactremia Bacteria in Hepatic Lymph Bacterascites SBP CNNA Sterile Non neutrocytic ascites Respiratory tract infection Complement deficiency Urinary tract infection RE system dysfunction Poor opsonic activity Good opsonic activity Modr opsonic activity
  14. 14. Culture Negative Neutrocytic Ascites 1. Ascitic fluid culture grows no bacteria 2. Ascitic fluid PMN count is > or = 250 cells/mm3 3. No antibiotics has been prescribed 4. No other explanation for an elevated ascitic PMN count
  15. 15. Monobacterial Non-neutrocytic Bacterascites 1. Positive ascitic fluid culture for a single organism 2. Ascitic fluid PMN count lower than 250 cells/mm3 3. No evidence of an intra abdominal surgically treatable source of infection
  16. 16. Polymicrobial Bacterascites 1. Multiple organisms are seen on gram stain or cultured from the ascitic fluid 2. Ascitic fluid PMN count is lower than 250 cells per mm3 Associated with traumatic paracentesis
  17. 17. Secondary Bacterial Peritonitis 1. Ascitic fluid culture is positive for multiple organisms 2. Ascitic fluid PMN count more than 250 cells per mm3 3. Intrabdominal surgically treatable primary source of infection
  18. 18. Spontaneous Bacterial Peritonitis 1. Positive ascitic fluid culture for a single organism 2. Elevated ascitic fluid PMN count of more than 250 cells/mm3 3. No evidence of surgically treatable source of infection
  19. 19. Risk Factors for SBP  Cirrhosis ◦ Low ascitic fluid proteins ◦ Phagocytic dysfunction  GI bleed ◦ 40 % cumulative probablity of infection ◦ Risk peaks 48 hrs after bleed  Systemic infections  Earlier episodes of SBP
  20. 20. SBP Vs Secondary Bacterial Peritonitis Ascitic Fluid PMN count > or = 250 cells/ mm3 Abdominal imaging showing free air or extravasations of contrast media Any two out of the following three 1. Ascitic Fluid protein > 1 g/dL 2. Ascitic fluid glucose < 50 mg/dL 3. LDH > ULN Spontaneous Bacteria Peritonitis Perforation peritonitis Non perforating secondary peritonitis Ye s No Yes No
  21. 21. Indications for Empirical Antibiotic Therapy of Suspected Spontaneous Ascitic Fluid Infection •Ascitic fluid neutrophil count ≥ 250/mm3 or positive “dipstick” test •Convincing symptoms or signs of infection Inj. Cefotaxim 2 gm i/v q8h
  22. 22. Diagnosis Treatment Monobacterial Nonneutrocytic bacterascites Five days of intravenous antibiotic to which the organism is highly susceptible Culture negative neutrocytic ascites Five days of intravenous third generation cephalosporin Secondary bacterial Peritonitis Surgical intervention plus approx 2 weeks of intravenous cephalosporin plus anti anaerobic drug (metronidazole) Polymicrobial Bacterascites intravenous third generation cephalosporin plus anti anaerobic drug (metronidazole) Spontaneous Bacterial Peritonitis Five days of intravenous antibiotic to which the organism is highly susceptible
  23. 23.  If preliminary cultures are negative, paracentesis can be repeated after 48 hrs of therapy to assess the response of PMN count to antibiotics  Patients with cirrhosis and ascites with convincing features of infections should be put on antibiotics even if ascitic fluid PMN count is less than 250 cells/mm3
  24. 24. Treatment contd…  Injectable amoxicillin clavulanic acid, oral ofloxacin, ciprofloxacin may be used instead of cephalosporin  Intravenous albumin – 1.5 gm/kg on the day of diagnosis, with a second dose of 1.0 gm/kg on the day three.
  25. 25. Prognosis  SBP is an indication of End Stage Liver Disease  33% of patients with SBP land up in renal impairment  No survivors have been reported when the diagnosis of SBP has been made after Serum Creatinine is more than 4 mg/dl or after shock had developed
  26. 26. Prevention  Indications for preventive measures ◦ Ascitic fluid protein < 1.0 g/dl ◦ Variceal hemorhage ◦ Previous episode of SBP
  27. 27.  Prior SBP  Cirrhosis with gastrointestinal hemorrhage  Norfloxacin 400 mg orally once daily until death or liver transplantation  66% Reduction in recurrence Intervention •Norfloxacin 400 mg orally twice daily x 7 days •Ceftriaxone 1 g intravenously/day x 7 days Outcome •73% Reduction in infection •67% Reduction in infection compared with norfloxacin
  28. 28.  Cirrhosis with ascitic fluid ◦ Total protein <1.5 g/dL and either ◦ Child-Turcotte-Pugh score ≥9 and total bilirubin ≥3 mg/dL, or ◦ Creatinine ≥1.2 mg/dL, or ◦ Blood urea nitrogen ≥25 mg/dL, or serum sodium ≤130 mEq/L Intervention • Norfloxacin 400 mg/day orally x1 year Outcome •89% Reduction in SBP •32% Reduction in hepatorenal syndrome •52% Increase in 3-month survival •25% Increase in 1-year survival
  29. 29.  Cirrhosis with ascitic fluid total protein <1.5 g/dL Intervention : Ciprofloxacin 500 mg orally daily x1 year Outcome •31% Reduction in infection •30% Improvement in survival
  30. 30. Hepatic Hydrothorax  Hepatic hydrothorax develops in approximately 5%–10% of patients with cirrhosis,  Mechanism ◦ Hypoalbuminemia ◦ Azygous vein hypertension ◦ Leakage of ascitic fluid through diaphragmatic defect ◦ Trans diaphragmatic migration of fluid via lymphatics  Pleural effusion is right-sided in 85%, left-sided in 13%, and bilateral in 2% of
  31. 31. Refractory Ascites  Refractory ascites is defined as fluid overload that is I. Unresponsive to sodium-restricted diet and high-dose diuretic treatment (400 mg/day spironolactone and 160 mg/day furosemide) or II. Recurs rapidly after therapeutic paracentesis
  32. 32.  Diuretic-resistant ascites  ascites that cannot be mobilized or the early recurrence of which cannot be prevented because of lack of response to dietary sodium restriction and maximal doses of diuretics  Diuretic-intractable ascites  ascites that cannot be mobilized or the early recurrence of which cannot be prevented because of the development of diuretic- induced complications that preclude the use of effective diuretic dosages.
  33. 33.  Treatment duration  Patients must be on intensive diuretic therapy (spironolactone 400 mg/d and furosemide160mg/d) for at least 1 wk and on a saltrestricted diet of less than 90 mmol/d  Lack of response  Mean weight loss of < 0.8 kg over 4 days and urinary sodium output less than the sodium intake.  Early Ascites Recurrence ◦ There is an reappearance of grade 2 or 3 ascites (clinically detectable) within 4 wk of initial mobilization.
  34. 34. Management a) Serial large volume therapeutic paracentesis, b) Liver transplantation, c) Transjugular intrahepatic portasystemic stent-shunt (TIPSS) d) Peritoneovenous shunt e) Experimental medical therapy
  35. 35. Hepatorenal Syndrome  Potentially reversible functional renal failure in the setting of liver dysfunction (cirrhosis with ascites, acute liver failure and severe alcoholic hepatitis), in the absence of intrinsic renal disease.
  36. 36. International Ascites Club Consensus Criteria  Cirrhosis with ascites  Serum Creatinine level > or = to 1.5 mg/dl (133 micromol/L) or creatinine clearance of < 40 ml/min  No or insufficient improvement in serum creatinine level, 48 hours after diuretic withdrawal and adequate volume expansion with intravenous albumin  Absence of shock  No evidence of recent use of nephrotoxic agents  Absence of intrinsic renal disease
  37. 37. Classification  Type 1 Hepatorenal Syndrome  Serum creatinine doubles to a value higher than, 2.5mg/dl, in a period of two week or less  Type 2 Hepatorenal Syndrome  Observed in patients with diuretic resistant ascites  Serum creatinine less than 2.5 mg/dl
  38. 38. Drugs Dosage Endpoint Duration Terlipressin Started at a dose of 1 mg/4–6 h and increased to a maximum of 2 mg/4–6 h if there is no reduction in serum creatinine of at least 25% compared to the baseline value at day 3 of therapy Slowly progressive reduction in serum creatinine (to below 1.5 mg/dl, and an increase in arterial pressure, urine volume, and serum sodium concentration. Maximum of 14 days/ Sr. Creatinine < 1.5 / Liver Transplant Midodrine Initiate at a dose of 2.5 – 5.0 mg orally three times daily and may be increased to a max dose of 15 mg three times daily. An increase in mean arterial pressure of atleast 15 mm Hg Sr. Creatinine < 1.5 / Liver Transplant And Octreotide 100 microgm s/c three times daily and increase to a max of 200 microgm s/c thrice daily An increase in mean arterial pressure of atleast 15 mm Hg Sr. Creatinine < 1.5 / Liver Transplant 25 microgm i/v bolus and a continuous infusion at a rate of
  39. 39. Drugs Dosage Endpoint Duration Noradrenaline 0.1 – 0.7 microgm /kg/min as i/v infusion, with an increase the dose by 0.05 microgm/kg/min every 4 hours Titrate to an increase in MAP of 10 mm Hg or an increase in 4 hour urine output to more than 200 ml Sr. Creatinine < 1.5 / Liver Transplant Intravenous albumin Bolus of 1gm/kg at presentation (max of 100 gm). Continue at a dose of 20 – 60 gm daily as needed to maintain central venous pressure between 10 and 15 cm of H20 Continue at a dose of 20 – 60 gm daily as needed to maintain central venous pressure between 10 and 15 cm of H20. To be discontinued if serum albumin concentration exceeds 4.5g/dl or in case of pulmonary edema Sr. Creatinine < 1.5 / Liver Transplant
  40. 40. Heal The World Make It A Better Place For You And For Me And The Entire Human Race There Are People Dying If You Care Enough For The Living Make A Better Place For You And For Me…

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