March exam

This is online answer sheet for the month of March .

Few references are from online search articles and few from sleisenger gastroenterology book . 

QUESTION 1 

https://ashakiran923.blogspot.com/2021/03/60-years-old-male-fever-under-evaluation.html?m=1

a). What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?How specific is his dilated superficial Abdominal vein in making diagnosis?

Problem representation :

60 year old male ,chronic smoker and a chronic alcoholic 

Known CKD on medical management 

Presented with 

1- high grade fever with burning micturition 

2 -Acute shortness of breath 

Anatomical localization of each of his problems :

1 .Fever - UTI/ viral infection 

2- acute onset of shortness of breath ,with on and off facial puffiness 

Based on physical examination findings that revealed downward and outward apex impulse - left ventricular dilation is one possibility . 

With chronic history of smoking and alcohol -patient could have been developed dilated cardiomyopathy and the fever Could be inciting event for his acute onset of shortness of breath .

As history given that patient is known chronic kidney disease and on medical management patient could also be having metabolic acidosis ,and with underlying UTI ,it might got aggravated his kidney dysfunction and metabolic acidosis . 

b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? What is the cause of his hypoalbuminemia?Why is the SAAG low?

Patient developed fever ,burning micturition ,shortness of breath.

Examination findings - Dilated LV ventricle 

Ascites . 

LAB -Deranged LFT,RFT ,panctyopenia —-microcytic hypochromic anemia ,ascites with gallbladder wall edema ,mild spleenomegaly .

1- viral fever is one important differential that can be considered here.points favoring are high grade fever ,leucopenia and thrombocytopenia ,usg suggestive of GB wall edema and ascites -serositis 

Although dengue card test Is negative , sensitivity of dengue Card test is low . 

As his fever subsided ,patient leukocytes and thrombocytopenia recovered. 

2-With the given data usg abdomen revealed normal size and eco texture of liver, ascetic fluid Low SAAG  -so cirrhosis and portal hypertension ,as a cause of ascites is ruled out . 

As Albumin is a negative acute phase reactant Hypoalbuminemia could be due to acute illness. 

3-causes of Shortness of breath could be due to

Mechanical - due to ascites 

Metabolic acidosis due to ckd 

Serositis - pleural effusion ? 

c)Will PT,INR derangement preceed hypoalbuminemia in liver dysfunction??Share reference articles if any!

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112813/

INR and albumin are often regarded as important markers of synthetic function, and our study revealed a normal range of INR for all pre-cirrhotic stages. The INR was statistically significant for stage 4 fibrosis when compared to those individuals with no discernible liver disease; however, it remained near the upper limit of normal. Albumin is a major protein synthesized by the liver. We did not see a progressive decrease with advanced disease, and the albumin level in stage 4 remained close to the normal value and was not statistically significant. As such, makers for hepatic synthetic function (albumin and INR) do not appear to be a good measure of hepatic fibrosis.

d)What is the etiology of his fever and pancytopenia?

Viral etiology -? Dengue 

e)Can there be conditions with severe hypoalbuminemia but no pedal edema? Can one have hereditary analbuminemia and yet have minimal edema? Please go this article https://www.frontiersin.org/articles/10.3389/fgene.2019.00336/full and answer the question.

When the hypoalbuminemia is due to acute conditions ,patient need not essentially have pedal edema .

Hereditary analbuminemia - is autosomal recessive disorder,ver Rare ,almost 1 in every 10 lake individuals,with only 93 cases discovered all over the world . CAA can lead to serious consequences in the prenatal period, because it can cause miscarriages and preterm birth, which often is due to oligohydramnios and placental abnormalities. Neonatally and in early childhood the trait is a risk factor that can lead to death, mainly from fluid retention and infections in the lower respiratory tract.

Clinically, in addition to the low level of albumin, the patients almost always have hyperlipidemia, but they usually also have mild oedema, reduced blood pressure and fatigue. The fairly mild symptoms in adulthood are due to compensatory increment of other plasma proteins.

f) What is the efficacy of each of the drugs listed in his current treatment plan

QUESTION 2

45year old female with abdominal distension

https://navyamallempalli.blogspot.com/2021/02/dr_6.html

a). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings?

 

45 year old female with rapidly progressive abdominal distension 

Shortness of breath and pedal edema . 

Anatomical localization :

Liver - cirrhosis (high SAAG)

Shortness of breath can be due to abdominal distension ,moderate pleural effusion 

Right pleural effusion -? Pleuroperotoneal  fistula -hepatic hydrothorax 

b) What is the etiology of her refractory ascites and pleural effusion? and how would you as a member of the treating team arrive at a diagnosis?

Refractory Ascites - NCBI - NIHwww.ncbi.nlm.nih.gov › pmc › articles › PMC2886420

Diagnostic Criteria of Refractory Ascites

1 Lack of response to maximal doses of diuretic (spironolactone 400 mg/d and furosemide 160 mg/d) for at least 1 week

2 Diuretic-induced complications in the absence of other precipitating factors

3 Early recurrence of ascites within 4 weeks of fluid mobilization

4 Persistent ascites despite sodium restriction

5 Mean weight loss <0.8 kg over 4 day

Refractory ascites is divided into 2 types 

Type 1- diuretic resistant 

Type 2-diuretic intractable 

Etiological causes of cirrhosis 

c) Approach to a patient with ascites?Clinically is there any way to differentiate pre hepatic, post hepatic and hepatic causes?

d)Causes of budd chiari syndrome?Why did the patient undergo bone biopsy?

Budd-Chiari syndrome: Etiology, pathogenesis and diagnosis

Budd chairing is congestive hepatopathy caused by blockage of hepatic veins starting anywhere in between hepatic venues to IVC - Right atrium junction after excluding hepatic venocclusive disease and cardiac disease .

Syndrome is rare and occurs,1 in 1 lakh 

75 % patients have hyper coagulable state 

25% patients have more than one etilogical factors 

60% Asians have  membranous obstruction of IVC ,as sequelae of IVC thrombosis without portal vein thrombosis  .

2 hepatic veins must be blocked for the clinical evidence of disease 

Liver congestion and hepatocyte hypoxia leads to centrilobular fibrosis 

Clinical presentation : 

Acute - signs and symptoms - pain abdomen ,ascites ,hepatomegaly .Chronic symptoms may be related to portal hypertension .

Etiology 

BCS can be primary Or secondary 

1-Primary if involving hepatic vein - Thrombosis is major cause of hepatic vein obstruction .

Obstructionis mainly caused by intravascular thrombosis . 

 -Primary myeloproliferative disorders are leading cause of thrombosis ,diagnosed in 20% of the cases . Prevelance increases to 45-53% if latent or occult disease Is considered . If occult disease is considered then peripheral smear can be normal , but a particular anomaly of bone marrow progenitor cells-spontaneous erythroid colony formation-could be detected- seen In 87% of idiopathic BCS 

⁃ Polycythemia Vera 

⁃ Essenstial thrombocythemia 

⁃ Myelofibrosis 

⁃ Factor 5 and 2 gene mutation.

⁃ Anticardiolipin antiodies

⁃ Hyperhomocysteinemia 

⁃ Protein c ,s , antithrombin deficiency  

⁃ Ocp - high estrogen containing pills 

⁃ Paroxysmal Nocturnal hemoglobinuria 

⁃ Behçet disease 

⁃ Abdominal trauma ,ulcerative colitis ,celiac dies ease 

Secondary BCS 

Compression by tumors of adjacent organs / pckd

Parasitic liver disease- hydatid cyst or amebic liver abscess 

Diagnosis - 

BCS should be suspected in patients with:

 (1) Abrupt onset of ascites and painful hepatomegaly;

 (2) Massive ascites with relatively preserved liver functions; 

(3) Sinusoidal dilation in liver biopsy without heart disease;

 (4) Fulminant hepatic failure associated with hepatomegaly and ascites;

 (5) Unexplained chronic liver disease; 

(6) Liver disease with thrombogenic disorder.

Investigations - Doppler usg - 85% sensitivity and specificity - technique of choice for initial investigations - hepatic veins without flow signal ,spider web appearance ,collateral hepatic venous circulation and stagnant ,reversed turbulent flow indicative of BCS 

MRI - second line

3D CE MRI has similar sensitivity to hepatic venography 

CT-Unvisualized hepatic veins are suggestive of disease on CT, but false-positive or indeterminable results can occur in 50% of cases

Hepatic venography is the reference procedure for the evaluation of hepatic veins, extent of thrombosis and caval pressures. Inferior cavography should be performed to demonstrate stenosis or occlusion of the IVC. The diagnosis of BCS is confirmed by a spider-web pattern on hepatic venography.

Why did the patient undergo bone biopsy?- to look for any  primary myeloproliferative disease  and determination of total red cell mass .

d) Management strategies for refractory ascites and Budd chiari syndrome? Share the potential advantages and disadvantages of Peritoneal dialysis catheter placement in refractory ascites?

Management of budd chairi : management of budd chairi involves medical and surgical 

Etiology of Buddchairi aids in appropriate management strategy 

-Medical management alone is usually not sufficient for most of the patients 

It includes management of ascites with paracentesis ,diuretics,anticoagulant and supportive therapy like fluid and salt restriction.

⁃ surgical and radiological management 

Surgical shunt : 

Main aim is to decompress the liver by conversion of portal vein from an inflow vessel into outflow tract.This is accomplished by 

1- mesenteric - systemic shunts 

2- Porto systemic shunts 

Survival rates for these stunts in some studies mentioned as 75- 95% at 5 years 

 novel solution for patients with BCS with caval obstruction proposed was to create a direct connection between the superior mesenteric vein and the right atrium , with 5‐year patient survival of 68%.primary latency rates was 46% 

TIPS : 

Insertion of a TIPS has been shown to be an effective means of decompressing the congested liver in patients with BCS.

TIPS has been used successfully in the emergent setting of managing patients with BCS with fulminant hepatic failure.

Liver transplantation 

Current management of refractory ascites in patients with cirrhosis

1- Large volume paraacentesis - removing more than 5 L of ascites controls massive ascites ,but has no effect on mortality .Removal of large volume is associated with PICD- paracentesis induced circulatory dysfunction ,prevented by infusing 7-8 gm of albumin for every liter of acsitic fluid tapped . 

Patients with a blood platelet count <50,000/mm3, Child-Pugh class C, and those suffering from alcoholism are at increased risk of PICD

Patients with refractory ascites should continue to receive diuretics if tolerated, unless there are major complications or the urinary sodium level is <30 mmol/day

2- TIPS - If more than 4 Paracentesis is required or if ascites is not controlled with paracentesis 

TIPS is one good option ,directly decreases portal vein pressure 

Two types of stents - Bare and covered 

Bare stents - stenosis or obstruction occurs in 70% of cases within 1 year 

Covered stents use polytetrafluoroethylene (PTFE)-covered and these have a lower frequency of dysfunction than do bare stents.The chance of survival also increased with these covered stents 

Disadvantage - Hepatic encephalopathy 

Patients older than 65 years who had a history of previous HE and had a Child-Pugh score ≥ 10 were more likely to develop post-TIPS HE.

3-Vasoconstrictive drugs -In refractory ascites 

These increase systemic atrial volume by inducing vasoconstriction 

Midodrine - alpha one agonist 

 CLonidine- alpha 2 agonist 

Vaptans 

 4- ALFA PUMP 

This device is subcutaneously implanted and battery-powered, and moves ascites from the peritoneal cavity to the urinary bladder to facilitate removal of fluid by urination. Design enables to function during daytimes and stop during night . When there is no ascites in the peritoneal cavity or the bladder is full, the ALFApump will stop working.Its accepted by patients and improves quality of life than compared to LVP 

5- liver transplantation 

Share the potential advantages and disadvantages of Peritoneal dialysis catheter placement in refractory ascites?

potential alternative to LVP is the placement of an intraperitoneal catheter, in the same manner that a peritoneal dialysis (PD) catheter, to drain ascites. The procedure has a high technical insertion success rate with minimal complications and is routinely done at the bedside by nephrologist under local anesthesia. PD catheter placement for ascites drainage has many potential advantages, including the ability for it to be done at home by the patient and avoid visits to clinics or hospitals; the frequency of drainage can be timed to patient symptoms, and perhaps have less complication rates than LVP. However, the efficacy and safety of this approach in decompensated cirrhosis when compared to periodic LVP (current standard of care) has not been tested in a randomized trial.

e) What is the efficacy of each of the drugs listed in his current treatment plan 

Fluid and salt restriction as a part of supportive treatment to prevent further accumulation of fluid in peritoneal cavity 

Diuretics  - Lasix and aldactone 

f)What is the current outcome?and what could be the etiology of her current outcome?

Possible etiologies could be 

1-Primary myeloproliferative disease causing membranous ivc obstrucution ,hence patient was planned for bone marrow biopsy . 

2- Hemochromatosis - liver biopsy would have helped us ,but the risk of bleeding and mortality has to be kept in mind . 

QUESTION 3

55year old male with SOB and abdominal distension,orthopnea

https://jayanth1802.blogspot.com/2021/02/55-year-old-farmer-with-sob-abdominal.html?m=1

a). What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?

55 year old farmer ,who was a chronic smoker and alcoholic and known right heart failure 

Presented with 

Shortness of breath ,pedal edema , abdominal distension

Anatomical localization - 

SOB ,with pedal edema ,abdominal distension,raised JVP ,associated with parasternal thrill and murmur -—- Right heart failure - COR PULMONALE 

b) What is the etiology of his ascites? and how would you as a member of the treating team arrive at a diagnosis?Chart out the sequence of events!

High SAAG , with dilated RA,RV ,PA, with PULM art hypertension ,LFT- congestive hepatopathy Usg - showing dilated  IVC and hepatic veins —- indicates Cardiac ascites 

Usg - no features of portal hypertension 

Sequence of events 

c)What is the efficacy of each of the drugs listed in his treatment plan?

Fluid and salt restriction ,diuretics were given to reduce preload 

Nebulisation for COPD component

VIT B 12 injections were started for Megaloblastic anemia .

d)What are his current outcomes ?

Patient could not be revived . 

QUESTION 4

4)Please go through the thesis presentation below and answer the questions below by also discussing them with the presenter

https://youtu.be/QlPrb1BSHGE

a)What was the research question in the above thesis presentation? 

 Will SAAG aid in etiological diagnosis of ascites . 

b) What was the researcher's hypothesis? 

SAAG is widely used ,simple bed side investigation to know the etiology of ascites .

SAAG is better than traditional methods like Total ascitic fluid proteins . 

It has better sensitivity and specificity in differentiating portal Hypertensive ascites vs non portal hypertensive . 

c)What is the current available sensitivity and specificity of SAAG in diagnosis of etiology of ascites

https://www.researchgate.net/publication/287848663_Diagnostic_sensitivity_and_specificity_of_serum_ascites_albumin_gradient_SAAG_in_patients_with_ascites

The sensitivity and specificity of SAAG were 100% and 87.8% respectively.

5) Journal club questions on Ascites theme 

a) Please identify the study design and outcomes in the article linked here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6644216/ as well as the thesis linked here https://chandanavishwanatham19.blogspot.com/2021/03/of-thesis-clinical-profileevaluationdia.html

Study Design - Institution-based cross-sectional study.

The study was conducted from November 1, 2018, to March 30, 2019.At University of Gondar Hospital

Objectives

-Primary Objective

To assess the causes of ascites, its complications, and factors associated with it among medical patients in University of Gondar Hospital.

-Specific Objectives

To identify common causes of ascites.

To describe complications of ascites.

P- All adults aged greater than or equal to 18 years who have ascites.

Outcome - 

A total of 52 patients participated in the study 

38/52 take alcohol occasionally

11/52 take alcohol frequently and massively 

24/ 52 patients - CLD is the major cause of ascites 

Next m/c heart failure 

Then tuberculosis ,schistosomiasis 

CKD 

Thesis presentation - https://chandanavishwanatham19.blogspot.com/2021/03/of-thesis-clinical-profileevaluationdia.html

To study the clinical profile,evaluation,diagnosis and therapeutic outcomes in patients with ascites

Objectives:

• 1.To study the clinical profile of ascites.

• 2.To study the evaluation and diagnosis in patients with ascites

• 3.To study the therapeutic outcomes in patients with ascites

STUDY DESIGN

Prospective study, Qualitative, Non Experimental

OUTCOMES AFTER FOLLOW UP

1. Asymptomatic / Symptomatically better / same status. 

2. Physical limitations Yes/No

3.Social limitations Yes/No

4. Discharge/LAMA/Reffer to higher center

5.Mortality

6.Loss to follow up

b) Please download the CASP diagnostic study checklist here https://casp-uk.net/casp-tools-checklists/ to evaluate the paper here https://www.hindawi.com/journals/ijh/2019/8546010/ and share your learning points on critical appraisal of the paper. 

Aim - To study the diagnostic utility of serum ascites lipid gradients and serum ascites protein gradients in pathophysiological differentiation of ascites. 

Settings and Design- prospective, descriptive, hospital-based, cross-sectional study. 

Methods and Material. The study was conducted on patients with ascites who were admitted to General Medicine Department, Kasturba Hospital, Manipal. The study included 60 patients with ascites of different etiologies (liver cirrhosis, tubercular peritonitis, and malignant ascites).

Ability of SAAG to differentiate Malignant ascites from other etiologies like Tb peritonitis is major problem ,so they utilized Serum ascites Lipid and protein gradients 

Learning points - 

1- Although SAAG has been widely used to classify the etiologies of ascites ,but wouldn’t be able to distinguish malignancy and tubercular peritonitis 

2- SAPG - Best screening test in differentiation of cirhhotic with non cirrhosis ascites when compared to SAAG , but have poor specificity and high sensitivity in differentiating between malignant and non malignant ascites 

3- For the differentiation of low SAAG - HDL cholesterol levels on ascitic fluid can be valuable

4- Lipid gradients are not better indicators for differentiation when compared to SAAG ,but HDL cholesterols levels help in distinguishing between malignancy and tubercular peritonitis . Though HDL lipoproteins are slightly larger than the albumin and gamma globulins, they are not increased in peritoneal inflammation.

Check list - diagnostic study 

c) Please evaluate this randomized controlled trial on different techniques at ascitic tap here: https://pubmed.ncbi.nlm.nih.gov/28233752/ also after downloading the randomized controlled trial CASP checklist here https://casp-uk.net/casp-tools-checklists/

Full text couldn’t be downloaded 

AIM- The aim of this study is to investigate large volume therapeutic paracentesis using either a z-tract or axial (coxial) technique in a randomized controlled trial.

Method - Randomised single blinded study 

Comparaing two techniques of Z tract and modified angular - coaxial needle insertion technique for large volume paracentesis .

Result - out of 61 paracentesis - 

30 to z tract and 31 to coaxial insertion technique 

-Equal rate of post procedural leakage of ascites 

-procedural difficulty and Pain were significantly increased in patients underwent Z technique 

Conclusion: When compared to the z-tract technique, the coaxial insertion technique is superior during large volume paracentesis in cirrhosis patients.

Checklist -