Some slides for the topic for SSS ID (Kahov) today!

2. This gentleman has
abdominal distention, please
examine him.

3. Before you start doing PE,
think……

4. Before you start doing PE,
think……
 What is the differential diagnosis of abdominal
distention?

5. Before you start doing PE,
think……
 What is the differential diagnosis of abdominal
distention?
 Remember 5F’s
 Fat
 Flatulence
 Feces
 Fluid
 Fetus

6. Before you start doing PE,
think……
 What is the differential diagnosis of abdominal
distention?
 Remember 5F’s
 Fat
 Flatulence
 Feces
 Fluid
 Fetus
 What are some of the causes of ascites?

7. Ascites
 GIT (Liver diseases)
 CVS (CCF)
 Nephro
 Lymph
 Etc…
Bear these in your mind so that you know
what to look for…

9. General condition
+ Yellow discoloration of skin
+ Cachetic appearance

10. Upper Limbs
+ Finger clubbing
+ Palmar erythema
o Liver flap
o Leukonychia
o Dupuytren’s contracture
+ Scratch marks
+ Scars on cubital fossa
+ Tattoo scar on shoulder

11. Head
+ Yellow discolouration of sclera
o Pallor of conjunctiva
o Kayser-Fleischer ring
o Puffy eye
o Parotid swelling
o Lymphadenopathy
o Oral candidiasis

12. Neck
+ Virchow node
o JVP distention

13. Chest
+ Virchow node
+ Gynaecomastia
+ Spider naevi
+ Loss of axillary hair
o Apex beat displacement
Dual rhythm, no murmur (DRNM)
o Gallop rhythm (S3/S4)

14. Abdomen
+ Abdominal distention
+ Scar on abdomen
+ Dilated veins
+ Inverted umbilicus

15. Abdomen
+ Hepatomegaly, describe:
tender, hard, nodular, 2 FB below costal
margin. Liver span 12cm
+ Splenomegaly, dull sound on Traube’s space
Try to ballot the kidney
+ Hepatic bruit + Bowel sound
o Splenic rub o Renal bruit

16. Abdomen
Check shifting dullness
Check fluid thrills

17. Lower limbs
+ Bilateral pedal edema until level below
the knee

18. Complete your PE with:
 Check the testes
 Check for lymphadenopathy
 Per rectum (PR) examination
 Some investigations to find underlying
cause

19. How to present &
conclude?
 Your findings
 Possible Dx, DDx
 Severity
 Functional status, failure?
 Complication?
 Etiology
 Associating syndrome

20. For example…

21. For example…
 Findings : Stigmata of chronic liver disease
sign of risk factor

22. For example…
 Findings : Stigmata of chronic liver disease
sign of risk factor
 Dx, lesion: Cirrhosis, Hepatosplenomegaly

23. For example…
 Findings : Stigmata of chronic liver disease
sign of risk factor
 Dx, lesion: Cirrhosis, Hepatosplenomegaly
 Severity : Child-Pugh Score

24. For example…
 Findings : Stigmata of chronic liver disease
sign of risk factor
 Dx, lesion: Cirrhosis, Hepatosplenomegaly
 Severity : Child-Pugh Score
 Fx status : Ascites, liver failure

25. For example…
 Findings : Stigmata of chronic liver disease
sign of risk factor
 Dx, lesion: Cirrhosis, Hepatosplenomegaly
 Severity : Child-Pugh Score
 Fx status : Ascites, liver failure
 Complic : Hepatocellular carcinoma (HCC)
no hepatic encephalopathy

26. For example…
 Findings : Stigmata of chronic liver disease
sign of risk factor
 Dx, lesion: Cirrhosis, Hepatosplenomegaly
 Severity : Child-Pugh Score
 Fx status : Ascites, liver failure
 Complic : Hepatocellular carcinoma (HCC)
no hepatic encephalopathy
 Etiology : Hep B / Hep C

27. For example…
 Findings : Stigmata of chronic liver disease
sign of risk factor
 Dx, lesion: Cirrhosis, Hepatosplenomegaly
 Severity : Child-Pugh Score
 Fx status : Ascites, liver failure
 Complic : Hepatocellular carcinoma (HCC)
no hepatic encephalopathy
 Etiology : Hep B / Hep C
 Assoc : Portal Hypertension

28. Empahsize…
 Stigmata of chronic liver disease
 Risk factors: IVDU, tattoo  Hep B/C
 HCC (hepatic bruit), is there encephalopathy
 Child-Pugh score if have investigation result
 Portal hypertension (splenomegaly)
 Probable cause: Hep B/C  confirm with Ix
 Provide suitable negative sign to exclude
other DDx

29. Investigation
Basic:
 FBC,
 RP, U&E, LFT
 Coag profile
 Urine protein
 US, CT

30. Investigation
Specific:
 Hep B, C
 αFP
 ANA, AMA, ASMA, ALKMA
 Iron profile
 Urine Cu, serum ceruloplasmin
 Diagnostic peritoneal tap
 Liver biopsy
 OGDS

32. Main causes of ascites?

33. Main causes of ascites?
 Portal hypertension in cirrhosis
 Abdominal malignancy
 CCF

34. Less common causes?

35. Less common causes?
 Nephrotic syndrome
 Constrictive pericarditis
 TB peritonitis
 Chylous ascites
 Budd-Chiari syndrome (BCS)
 Meig’s syndrome

36. Transudate / Exudate?

37. Transudate / Exudate?
 Protein < 25 g/l  Transudate
 Protein > 25 g/l  Exudate

38. What is ‘serum-ascites
albumin gradient’ (SAAG)?

39. What is ‘serum-ascites
albumin gradient’ (SAAG)?
 SAAG = serum alb – ascitic alb

40. What is ‘serum-ascites
albumin gradient’ (SAAG)?
 SAAG = serum alb – ascitic alb
 > 11g/l  + Portal HPT (transudative)
 < 11g/l  o Portal HPT (exudative)

41. SAAG > 11 SAAG < 11
 Cirrhosis  Peritoneal
 Alcoholic hep carcinomatosis
 CCF  Peritoneal TB
 BCS
 Nephrotic syndrome
 Fulminant liver
 Serositis
failure  Pancreatic / biliary
ascites

42. +Pedal o Pedal edema
edema
 Portal HPT  TB ascites
 CCF  BCS
 Nephrotic syndrome  Malignancy:
 Hypoalbuminenia Hepatoma
Stomach
Pancreas
Ovarian

43. Possible complications in this

44. Possible complications in this
Ascites:
 Breathing problem
 Spontaneous bacterial peritonitis (SBP)
Chronic liver disease:
 Hepatocellular carcinoma (HCC)
 Hepatic encephalopathy
Portal HPT:
 Upper GI bleeding (UGIB)
 Hemorrhoid

45. When can you dx SBP?

46. When can you dx SBP?
 Symptoms: fever, abd pain,
no bowel sound, altered mental
status
 In ascitic fluid there is either:
>500 WBC / µl, or
>250 PMN / µl
 No local infectious source

47. 1o & 2o prophylaxis in UGIB due
to oesophgeal varices rupture?

48. 1o & 2o prophylaxis in UGIB due
to oesophgeal varices rupture?
 1o prophylaxis: no UGIB yet
need to prevent it from
happening

49. 1o & 2o prophylaxis in UGIB due
to oesophgeal varices rupture?
 1o prophylaxis: no UGIB yet
need to prevent it from
happening
 2o prophylaxis: got UGIB already
need to prevent recurrence

50. 1o & 2o prophylaxis in UGIB due
to oesophgeal varices rupture?
 1o prophylaxis: no UGIB yet
need to prevent it from
happening
 2o prophylaxis: got UGIB already
need to prevent recurrence
 Propanolol

51. 1o & 2o prophylaxis in UGIB due
to oesophgeal varices rupture?
 1o prophylaxis: no UGIB yet
need to prevent it from
happening
 2o prophylaxis: got UGIB already
need to prevent recurrence
 Propanolol
 Endoscopic banding

52. How will you manage this
pt?

53. How will you manage this
pt?
 Sodium restriction
 Fluid restriction
 Diuretic: Lasix + Spironolactone
 Peritoneal tap + albumin infusion
 TIPSS
 LeVeen’s Peritoneojugular shunt
 Liver transplant

54. Treating chronic liver
diseases
 Viral hep : Antiviral
 Autoimm. hep : Steroids
 Alcoholism : Stop alcohol

55. When need liver
transplant?

56. When need liver
transplant?
Milan criteria for cirrhosis / HCC:
 1 lesion <5 cm, or
2-3 lesions <3 cm
 No extra-hepatic manifestation
 No vascular invasion

57. When need liver
transplant?
Milan criteria for cirrhosis / HCC:
 1 lesion <5 cm, or
2-3 lesions <3 cm
 No extra-hepatic manifestation
 No vascular invasion
Other criteria:
 King’s College Hospital Criteria

58. When need liver
transplant?
Milan criteria for cirrhosis / HCC:
 1 lesion <5 cm, or
2-3 lesions <3 cm
 No extra-hepatic manifestation
 No vascular invasion
Other criteria:
 King’s College Hospital Criteria
 Model of End-stage Liver Disease (MELD)

59. Thank
You
Not only you
can have ascites