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Real Doctors (Life Makers)  |  Clinical  |  Medicine & medical subspecialities  |  39 years old male with (bloody ascitis) « previous next »
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dr_b.e.s.m
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39 years old male with (bloody ascitis)
« on: /November/ 07, 2005, 03:23:49 PM »

39 yo AAM with a PMH of a new onset ascites 1 week ago, Cirrhosis, ESRD on HD is admitted to the hospital from the HD unit after he was found to have fever of 39 C.
He has no complaints apart from a chronic abdominal pain for 4 years which was attributed to chronic pancreatitis. He has an extensive past medical history, which is described in the PMH section below.

The patient had a work-up for his new onset ascites about 1 week ago and the ascites tap showed a bloody fluid, cultures were negative and the SAAG was less than 1.1. PPD was negative and the cytology of the ascitic fluid did not show any malignant cells.

A laparoscopy was suggested to look for the cause of his bloody ascites but due to his extensive
abdominal surgery history it was decided that an explorative laparotomy would be more appropriate.

The patient had the laparotomy 5 days before this admission. During the procedure the liver was found to be enlarged, biopsy showed bridging fibrosis and one liter of bloody ascites was drained. No malignant or any other cause for the bloody ascites was found.

No N/V/D/C, no headache, no cough, no sick contacts.

PMH:
Chronic pancreatitis, Multiple admissions for abdominal pain over the last 4 years, ERCP in 2001 and EGD in 2002 were normal, ESRD on CAPD [continous ambulatory peritoneal dialysis] for 8 years with multiple bouts of peritonitis, due to this, he was started on HD for the last 1 year, Hepatitis C with always normal LFT through the years

PSH:
Right nephrectomy after a MVA in 1982, Cholecystectomy, Ventral hernia repair, AV graft for HD

Meds:
Renagel, Colace, Nephrocaps, ASA, Plavix, Protonix, Metoprolol, Neurontin, Benadryl

SH:
EtOH, cocaine and marijuana, denies IV drug use

Physical exam:
WD/WN in NAD
VS 38.7-16-117-126/61
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: Soft, diffuse tenderness, no rebound, old surgical scars from R nephrectomy, cholecystectomy, new surgical scars from the laparotomy in the midabdomen, not infected, no rebound, diminished BS, ascites
Ext: no edema, RUE AV graft with +thrill/bruit

What do you think is going on?
SBP?
Peritonitis after surgery?
Abdominal abscess?
C.diff. colitis?
HD related sepsis?
DVT?
Endocarditis?

What labs would you order?

CBCD, CMP, INR/PTT, CXR, BC x 2
CT of the abdomen?

Would you tap the ascites?
He had a U/S guided paracentesis during which 700 cc of bloody fluid was drained and sent to the lab

Paracentesis report:? http://photos1.blogger.com/img/250/1358/1024/Ascites-US%20guided%20tap.jpg

Paracentesis labwork:? http://photos1.blogger.com/img/250/1358/1024/Ascites%20labs.jpg

Metabolic profile:? http://photos1.blogger.com/img/250/1358/1024/Ascites-BMP1.jpg

Chest X-ray: http://photos1.blogger.com/img/250/1358/1024/Ascites-CXR.jpg

Chest X-ray report: http://photos1.blogger.com/img/250/1358/1024/Ascites%20-%20CXR.jpg


What happened?
He was started on Ciprofloxacin and given one dose of Vanco (1 gm IV x 1)


CXR showed gas under the diaphragm, which can be normal after a laparotomy (also after a laparoscopy or even a PEG tube placement)

SAAG is simply Serum Albumin - Ascitic albumin.
If it is more than 1.1 (high) indicates ascites due to portal hypertension (high SAAG = high pressure).
If SAAG is less than 1.1, the reason may be peritonitis, TB or malignancy.
Our patient's SAAG (calculate from the labs, that's why we posted ascites labs and BMP together) is 0.8.
The PPD was negative and the cytology showed just inflammatory cells and no malignant cells.

BC grew GPC, Latex/coagulase negative but only 1 of 4 - most likely a contaminant
ID consult was called.
Patient's condition imroved and the fever subsided.
A CT scan of the abdomen and a WBC scan did not show any source of infection.

Final diagnosis: SBP

What did we learn from this case?
How to order relevant labs for ascites work-up.
Not all gas under the diaphragm is due to a perfotated viscus.
« Last Edit: /November/ 07, 2005, 03:50:41 PM by dr_b.e.s.m » Logged


 
cleo_md
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Re: 39 years old male with (bloody ascitis)
« Reply #1 on: /November/ 07, 2005, 03:57:41 PM »

That was an excellent presentation of this case Dr BESM
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dr_b.e.s.m
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A simple approach to ascitis
« Reply #2 on: /November/ 11, 2005, 01:53:27 PM »

A simple approach to ascitis



Definition
Accumulation of fluid within the peritoneal cavity. Small amounts may be asymptomatic; increasing amounts cause abdominal distention and discomfort, anorexia, nausea, early satiety, heartburn, flank pain, and respiratory distress.


Detection
PHYSICAL EXAMINATION???Bulging flanks, fluid wave, shifting dullness, ?puddle sign? (dullness over dependent abdomen with pt on hands and knees). May be associated with penile or scrotal edema, umbilical or inguinal herniation, pleural effusion. Evaluation should include rectal and pelvic examination, assessment of liver and spleen. Palmar erythema and spider angiomata seen in cirrhosis. Periumbilical nodule (Sister Mary Joseph's nodule) suggests metastatic disease from a pelvic or GI tumor.

ULTRASONOGRAPHY/CT???Very sensitive; able to distinguish fluid from cystic masses.


Evaluation
Diagnostic paracentesis (50?100 mL) essential; use 22-gauge needle in linea alba 2 cm below umbilicus or with ?Z-track? insertion in LLQ or RLQ. Routine evaluation includes inspection, protein, albumin, glucose, cell count and differential, culture, cytology; in selected cases check amylase, LDH, triglycerides, culture for TB. Rarely, laparoscopy or even exploratory laparotomy may be required. Ascites due to CHF (e.g., pericardial constriction) may require evaluation by right-sided heart catheterization.

DIFFERENTIAL DIAGNOSIS ??More than 90% of cases due to cirrhosis, neoplasm, CHF, tuberculosis.
1.HuhDiseases of peritoneum: Infections (bacterial, tuberculous, fungal, parasitic), neoplasms, connective tissue disease, miscellaneous (Whipple's disease, familial Mediterranean fever, endometriosis, starch peritonitis, etc.).
2.HuhDiseases not involving peritoneum: Cirrhosis, CHF, Budd-Chiari syndrome, hepatic venocclusive disease, hypoalbuminemia (nephrotic syndrome, protein-losing enteropathy, malnutrition), miscellaneous (myxedema, ovarian diseases, pancreatic disease, chylous ascites).

PATHOPHYSIOLOGIC CLASSIFICATION USING SERUM-ASCITES ALBUMIN GRADIENT???Difference in albumin concentrations between serum and ascites as a reflection of imbalances in hydrostatic pressures: Low gradient (serum-ascites albumin gradient <1.1): 2? bacterial peritonitis, neoplasm, pancreatitis, vasculitis, nephrotic syndrome. High gradient (serum-ascites albumin gradient >1.1 suggesting increased hydrostatic pressure): cirrhosis, CHF, Budd-Chiari syndrome.


Complications
SPONTANEOUS BACTERIAL PERITONITIS???Suspect in cirrhotic pt with ascites and fever, abdominal pain, worsening ascites, ileus, hypotension, worsening jaundice, or encephalopathy; low ascitic protein concentration (low opsonic activity) is predisposing factor. Diagnosis suggested by ascitic fluid PMN cell count >250/?L and symptoms or PMN count >500/?L; confirmed by positive culture (usually Enterobacteriaceae, group D streptococci, Streptococcus pneumoniae, S. viridans). Initial treatment: Cefotaxime 2 g IV q8h; efficacy demonstrated by marked decrease in ascitic PMN count after 48 h; treat 5?10 days or until ascitic PMN count is normal. Risk of recurrence can be reduced with norfloxacin 400 mg PO qd, trimethoprim-sulfamethoxazole 1 double-strength PO bid 5 days a week, or possibly ciprofloxacin 750 mg PO once a week. Consider prophylactic therapy (before first episode of peritonitis) in pts with cirrhotic ascites and an ascitic albumin level <10 g/L (<1 g/dl).

HEPATORENAL SYNDROME???Progressive renal failure characterized by azotemia, oliguria with urinary sodium concentration <10 mmol/L, hypotension, and lack of response to volume challenge. May be spontaneous or precipitated by bleeding, excessive diuresis, paracentesis, or drugs (aminoglycosides, NSAIDs, ACE inhibitors). Thought to result from altered renal hemodynamics, elevated serum thromboxane and endothelin levels, and decreased urinary prostaglandin levels. Prognosis poor. Treatment: Trial of plasma expansion; TIPS of doubtful benefit; liver transplantation in selected cases.
« Last Edit: /November/ 11, 2005, 01:59:27 PM by dr_b.e.s.m » Logged
 
eman
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Re: 39 years old male with (bloody ascitis)
« Reply #3 on: /November/ 11, 2005, 03:23:15 PM »

 thannnnnnnnnnnnnnk you dr besm  for this simple approch  but i want to understand some things

# difference between buddchiary synd and venooclusive disease in the aetiology

#what is z track insertion ,is it mean in z shape

#how can i study the internal medicine simply...........

thank you
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dr_b.e.s.m
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Re: 39 years old male with (bloody ascitis)
« Reply #4 on: /November/ 12, 2005, 06:51:45 AM »

How are you Dr Eman, I am glad you found my post useful.



-While doing tapping of ascitis one can go straight penetrating skin and abdominal muscles at one point , also we can penetrate the skin with the needle then move a little under the skin then penetrate the muscle at a different point ( so that the hole in skin and hole in muscle are not overlapping) the track created by the needle looks like "Z".
After we finish aspiration and remove the needle , there'll be like a seal for the track, prevents leakage and prevents introducion of infection. If the two punctures are overlapping then leakage will occur. The same technique is used during IM injection of iron preparation.




-You know the hepatic circulation, simply : portal vein --- >? sinusoids --- > cental vein ---> hepatic venules --- > hepatic veins --- > IVC.? Budd Chiari is occlusion of hepatic veins or IVC , while veno occlusive disease affects venules. Budd Chiari is thrombotic (so it's common with hypercoagulable states) while veno occlusive is more like sclerosis of the venules (occurs with cytotoxics, iradiation and some herbs). I think clinical picture and management are similar but will read more and post it to you later.



-About how to study IM , first be sure that IM is the most useful , most interesting subject you'll ever study in the medical school ! that's my opinion , it's really and interesting subject with a lot of applicable info , a lot of correlation , a lot of thinking. So you must like it and do a great effort studying it, it really deserves the effort and time. It'll be useful to you in any spciality you choose later.

Also you better find a good source (one main source ) to study from, better to be of average size , I used notes but there are a lot of good books. Then you can have another bigger source beside your main book or notes, this big source can be Davidson or Harrison or even the internet , don't read the whole source , just use it as a reference to understand a point that isn't clear or to get more info about something.

There are good lectures on CDs (Dr Osama Mahmoud , Ain shams university) , I see they are really really good , you can have a look , you may find it useful.

Also you can see a lot of cases , I don't mean cases like you see in rounds and exams but cases in out patient clinic , emergency or in the wards. Cases we see in the rounds are very limited and cover only few of the subjects you study in IM. Then after you see the case (as regard history , C/P , investigations and treatment) , you read it when you go home , it'll be great and you won't forget it , insha`allah. Many people will tell you that this is like a waste of time and you better study now and will see the case while you are emtiaz , so you must organize your time well and I don't think few hours per week will be a real waste of time , also seeing cases helps your academic study and improves memorization (so it'll be useful for the exam anyway).

You can read case studies on the internet , a very interesting way of learning , for example you finished neurology this month then you can read some neurology cases and see how can your knowlage be applied to practice, again this improves memorization , understanding and also you will learn something new from every case you read. Also notice that when you apply what you study , this makes you like the subject and makes it easier for you to study it. This website contains a lot of links to case studies arranged by speciality? http://www.mic.ki.se/MEDCASES.html

These are things that works for me , may be some of them are useful for you insha`allah.

Good luck.
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eman
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Re: 39 years old male with (bloody ascitis)
« Reply #5 on: /November/ 12, 2005, 10:23:20 AM »

thank you Dr  b e s m  for your help,iam happy with your words bec i think like it , but the problem in the first step that is choosing the books ,i hear about el fatatry and magdy eshak and samih labib ,also the biggest problem is our doctors here in mansoura university and bec most lectures end in 4th and 5th year (old system),i love int medicine very much and i love study on internet,but in shaa allah i will be good in IM.


thaaaaaaaaaaaaaaaaaaaaaaaank you for the good link of cases,please i you know a name of a simple radiology book tell me .


eman
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