Thesis

 Dr.Vishwanatham chandana

Department of general medicine

Diagnostic uncertainties and outcomes in patients with ascites 

Guide:Dr.Y.S.Kanni

HOD:Dr.Rakesh biswas

Co-Guide:

INTRODUCTION:

Ascites is defined as the accumulation of excess fluid in the peritoneal 

cavity. Fluid accumulates when it enters the peritoneal cavity from the 

mesenteries, the peritoneum and hepatic surface at a rate greater than can 

be returned to the circulation via the capillaries and lymphatics.(1)

Common Possible etiologies:(2)

1.Cirrhosis with portal hypertension 

2. Heart Failure :Ascites occurs in patients with increased pressure in the hepatic veins 

and in the veins draining the peritoneum. Ascites usually reflects the long 

standing systemic venous hypertension

3.Chronic kidney disease 

4. Nephrotic syndrome :Another major cause of edema is nephrotic syndrome, the clinical 

hallmarks of which include proteinuria (>3.5 gms/day), hypoalbuminemia, 

hypercholesterolemia and and edema. The degree of edema may range from 

pedal edema to total body anasarca, including ascites and pleural effusions.

5. Peritoneal carcinomatosis 

6. Pancreatitis 

7. Portal vein thrombosis 

8. Budd- Chiari syndrome

9.Tuberculous peritonitis:Results of examination of the peritoneal fluid are also suggestive of 

tuberculous infection if there is an increased concentration of protein 

(>3gms/dl) and lymphocytes. Ziehl-nielsen stained smears ,Cultures of AFB must be done.

9. Others

10. Patients with diagnostic uncertainty

PROBLEM STATEMENT:

Ascites is a common clinical condition encountered by physicians in a day to day practice.It poses a diagnostic and therapeutic challenges to physicians as the causes are various.

If severe, ascites may be painful. The problem may keep the patient from moving around comfortably. Ascites can set the stage for an infection in the abdomen.Ascites can make it hard to breathe.

The study is proposed by me to diagnose and look for the outcomes in patients with ascites after follow up.

Aim

Clinical profile,etiology and outcomes in patients with ascites

Objectives

1.To study the risk factors of ascites.

2.To study the clinical profile of ascites.

3.To study the outcome of these patients and if any causal association between the risk factors and outcome

Study design: prospective ,qualitative, longitudinal study,non experimental

Study period:  November 2020 to November 2022

Place of study: Kamineni institute of medical sciences, Narketpally

Sample size: It is a prospective study of all the patients fulfilling inclusion criteria will be included with a minimal sample size of 50 patients.

Inclusion criteria

1.Patients with age >18years

2.All Patients with ascites

3.Patients of both sexes

4.Patients who have given the consent

Exclusion criteria

1.Patients with age <18years

2.Patients without ascites

3.Patinets who havent given consent

Clinical profile 

Abdominal distension:

hemetamesis:

malena:

vomitings:

jaundice:

chest pain:

palpitations:

pedal edema:

oliguria:

anuria:

facial puffiness:

Shortness of breath

altered bowel habits

Abdominal pain

cough

fever

evening rise of temperature

night sweats

Menstrual history in females:

PERSONAL History:

1.Alcohol history:

Alcohol consumption was classified as per patients' response to questions regarding the frequency of alcohol intake and the effects of alcohol as follows:

(a) None: no history of alcohol intake

(b) Occasional: alcohol intake is not more than two days per week

(c) Frequent: alcohol intake in at least three days per week

(d) Massive: alcohol intake in at least three days per week and history of alcohol intoxication, a need for eye-opener, or history of untoward social consequence of alcohol (like divorce, loss of job, quarrel, etc.)

2.Smoking history

3.Appetite

4.Bladder and bowel habits

PAST HISTORY

Human-immunodeficiency virus (HIV) status

Herbal medicine use

Viral hepatitis (HBV; HCV)

Diabetes mellitus

Hypertension

Chronic kidney disease

family history of similar illness

Multiple sexual partners

Body mass index (BMI)

Blood transfusion

h/o coronary artery disease

GENERAL EXAMINATION:

Pallor:

Icterus:

Peripheral edema:

Lymphadenopathy:

Elevated JVP :

Facial puffiness:

Alopecia:

Palmar erytherma:

Asterexsis:

Constructional apraxia:

Axillary hair loss:

Spider naevi:

Gynecomastia:

Testicular atrophy:

Waist circumference on presentation:

CARDIOVASCULAR SYSTEM:

Heart sounds:

JVP:

Added sounds:

GASTROINTESTINAL SYSTEM:

Shape of abdomen:

Organomegaly:

Liver span:

Shifting dullness:

Fluid thrill:

Bowel sounds:

RESPIRATORY SYSTEM:

Breath sounds:

added sounds:

CNS:

Higher mental functions

Cranial nerves

Motor system

Sensory system

Cerebellar signs

INVESTIGATIONS:

 

HB: 

TC:

DC: 

Random Blood Sugar:

 X-Ray Chest PA view: 

 

 

Blood Urea: 

Serum Creatinine:  

Serum Na+: 

Serum K+:

USG Abdomen:

ECG:

Echocardiogram:

Liver Function Test 

TB 

DB

AST

ALT

ALP

ALBUMIN

A/G

CUE

urine albumin:

urine sugar:

Ascitic fluid analysis:

gross appearance

glucose

protein

albumin

saag

cytology

smear for gram stain

culture and sensitivity when needed

Others (When needed) 

Serum amylase: 

Ascitic fluid amylase: 

24 hours urine protein: 

Adenosine deaminase:

Upper GI endoscopy:

Child pugh score (in selected patient)

Meld score: (in selected patients)

OUTCOMES  AFTER FOLLOW UP

1.Death:

2.Number of hospital admissions and Length of Hospital stay:

3.No hospital admissions, but with some limitations of daily activities:

4.No hospital admissions and Resumed normal daily routine

5.Loss to follow up

References:

1. Bruce A.Runyon; Ascites and spontaneous bacterial peritonitis 

Sleisinger and frodtran gastrointestinal disease pathology, 

diagnosis, management. Fifth edition vol. 2 – 1993. Chapter 88, 

Page 1935. 

 

2. Vicente Arroyo, Pere Gine’s, Ramon Planas Juan Rodes; Oxford 

Text book of clinical hepatology. Chapter 8.1, Page 699.