Clinical Correlation #2 4/14/04
Alexa Turner P&S ’04
Massive Ascites Case
Goals of this session:
ƒ To review the pathophysiology of ascites and hepatic cirrhosis
ƒ To review the relevant physical findings of cirrhosis
ƒ To place cirrhosis/ascites into a clinical context with a case presentation
ƒ To introduce a symptom-based approach to thinking about pathophys., i.e., differential diagnosis
Pathophysiology review:
ƒ Ascites is the collection of fluid in the peritoneal cavity
ƒ Portal-Hypertension related: Serum-ascites albumin gradient (SAAG) >1.1
9 Sinusoidal: cirrhosis (81%), hepatitis, massive liver mets, HCC
9 Post-sinusoidal: right sided CHF, Budd-Chiari
ƒ Pathophysiology:
9 “Underfill Theory”: portal hypertention→transudation of fluid into
peritoneum→↓plasma volume→renal Na retention
9 “Overflow Theory”: hepatorenal reflex→Na retention
9 Peripheral Vasodilation Theory: portal htn→systemic vasodilation (due to release of
NO?)→↓effective arterial volume→renal Na retention
9 ↓Plasma oncotic pressure with decreased albumin
ƒ Cirrhosis is fibrosis and nodular regeneration from hepatocellular injury
ƒ Etiologies: Alcohol, viral hepatitis, autoimmune hepatitis, metabolic diseases, biliary tract diseases
ƒ Portal HTN: Varices, melena, splenomegaly, caput medusae, ascites, testicular atrophy,
hemorrhoids
ƒ Liver cell failure: Encephalopathy, scleral icterus, spider nevi, gynecomastia, jaundice, asterixis,
anemia, pedal edema, loss of sexual hair, palmar erythema
CC: referred by GI clinic for ↑SOB, fluid overload
HPI: 62 y/o male with HCV, EtOH cirrhosis, polysubstance abuse with h/o hepatic encephalopathy,
ascites. Cirrhosis dx clinically and via US 12/03. Pt. has noted increased weight gain, SOB, ascites, pedal
edema and poor response to outpatient diuresis. A few weeks ago 3-4L therapeutic paracentesis performed
at outside hospital. Referred by GI to inpatient for therapeutic paracentesis, diuretics, possible TIPS and
Liver tx evaluation.
Pt. also c/o some fever/chills at home without cough, abdominal pain, melena or hematemesis.
ER: Tmax 98.6 BP 108/70 P91 RR20 O2 sat 91% RA→98% on 4L NC
PE: 2/6 Systolic ejection murmur, decreased breath sounds B/L, LLQ with erythematous macules
PMH: Hep C/EtOH cirrhosis, polysubstance abuse, EGD: varices, ulcer
PSH: s/p surgical repair of gunshot wound to face
Medications: Lasix, Aldactone, Lactulose, Methadone, Protonix, Lexapro NKDA
SH: past IVDA, EtOH (stopped 1y ago), quit smoking FH: N/A
PE: afebrile BP 126/46 P 95 RR20 O2 sat 96% 4LNC
Gen: calm, comfortable, mild respiratory distress, mild jaundice
HEENT: PERRLA, EOMI, anicteric
Neck: supple, no JVD
CV:S1, S2 regular rate and rhythm, no murmurs/gallops/rubs
Lungs: ↓BS on R to mid-lung fields, on L to base
Abd: soft, nontender, massively distended with gross ascites, + shifting dullness, + fluid wave
Ext: b/l LE edema, chronic venous stasis changes
Neuro: A/O x3, mild asterixis noted
Labs: K 5.7, BUN/Cr 37/1.2, INR 1.95, AFP 3.6, NH3 74, AST/ALT 70/40 (nl<40), Tbili 4.7 (nl<1.5),
Dbili 1.6 alkphos nl. Alb 2.2 (nl >3.4)