Station 2: Ascites

Presenting complaints:

- abdominal swelling

HOPC:

- duration: acute versus gradual
- associated features: pain
- site: localized or generalized
- other symptoms:
  - jaundice
  - hamatemesis
  - per rectal bleeding/malaena
  - stool ? pale coloured stool
  - urine  ? dark -coloured urine, frothy urine, oliguria
  - any change in bowel habit
  - systemic symptoms: lethargy, loss of appetite, weight change
  -  cardiac symptoms: SOB/chest pain/ orthopnae/PND or LL oedema
  - heat or cold intolerance
  - fever
  - any lumps in the body

- screening for risk factor: alcohol, h/o hepatitis B and C in the past, medication  (ie: traditional medication)
 
Past medical history:

- h/o liver, renal, cardiac or thyroid disorder
- h/o malignancy
- h/o blood clots in the past ie: DVT/PE, use of OCP
- CV risk factor: DM, HTN, HLD
- is patient on dialysis support?
- previous abdominal surgery

Medication and drug allergies


Social history:

- alcohol history
- h/o illicit drug use
- sexual history
- travel history
- not to forget about occupation, relationship status, family history and smoking history


ICE:
- ask about patient Idea, Concern and Expectation


Differential diagnosis:

1. Cirrhosis with/without portal HTN  (from alcoholic liver disease, chronic hepatitis, autoimmune hepatitis, haemochromatosis, PBC, PSC, NASH, Wilson's diease, crytogenic) * transudate
2. Systemic causes including cardiac (CCF, constrictive pericarditis), renal (ESRF, nephrotic syndrome), hypothyroidsmn, malabsorption * transudate
3.  Intra-abdominal malignancy (ie: liver, ovarian, colon cancer, metastatic) *exudate
4. Chronic pancreatitis *exudate
5. Infective causes: TB peritonitis *exudate
6. If tender and subacute consider Budd-chiari syndrome from malignancy * exudate

** transudate, total protein< 30g/L and exudate > 30g/L

Investigation:

1. Blood test
- FBC, renal panel, LFT including albumin coagulation studies, inflammatory marker (CRP, procal), amylase and lipase, TFT, coagulation profile
- work-up for hepatitis including Hep B, C serology, AFP
- ascitic tap to send for FEME, cell count, ascites fluid albumin, C/S, cytology, AFB smear and C/S, amylase

2. Scan
- US abdomen
- pan-CT
- 2Decho

Management:

1. Not all ascites need to be tap, sometime done for therapeutic purposes with (in transudate) or without albumin cover (exudate)
2. strict I/O charting, daily weight
3. Low Na diet
4. Fluid restriction
5. Diuretic, spironolactone
6. Antibiotic if fever, abdominal pain (risk of spontaneous bacterial peritonitis) - usually with IV Rocephine + flagyl after full septic work-up
7. Treat or optimize underlying causes, alcohol cessation

The end