THESIS

 TITLE OF THE THESIS

CLINICAL PROFILE,EVALUATION,DIAGNOSIS AND THERAPEUTIC OUTCOMES IN PATIENTS WITH ASCITES

 NEED FOR STUDY

1)Ascites is a major complication of cirrhosis, occurring in 50% of patients over 10 years of follow up The development of ascites is an important landmark in the natural history of cirrhosis as it is associated with a 50% mortality over two years, and signifies the need to consider liver transplantation as a therapeutic option. The majority (75%) of patients who present with ascites have underlying cirrhosis, with the remainder being due to malignancy (10%), heart failure (3%), tuberculosis (2%), pancreatitis (1%), and other rare causes.(1)

2)Ascites is one of the most common complications of liver cirrhosis along with variceal bleeding and hepatic encephalopathy. It is often the first sign of decompensated cirrhosis with portal hypertension. Patients with compensated cirrhosis progress to decompensated cirrhosis at a rate of 5-7% per year, and about 50% of the cases develop ascites within 10 years after diagnosis of liver cirrhosis. The 1-year and 2-year survival rates of patients with decompensated cirrhosis complicated with ascites are 60% and 45%, respectively, which is significantly lower than the 1-year and 2-year survival rates (95% and 90%) of patients with compensated cirrhosis(2)

3)The diagnosis of ascites is considered in cirrhotic patients given a constellation of clinical and laboratory findings, and ultimately confirmed, with insight into etiology, by imaging and paracentesis procedures. Treatment for ascites is multi-modal including dietary sodium restriction, pharmacologic therapies, diagnostic and therapeutic paracentesis, and in certain cases transjugular intra-hepatic portosystemic shunt. (3)

4)The most unfavorable predictors are hyponatremia, arterial hypotonia, high serum creatinine, low urine sodium level, spontaneous bacterial peritonitis, low total protein concentration in the ascitic fluid (≤ 2 g/dL), and the number of red blood cells in the ascitic fluid of more than 10.000/mm3 (hemorrhagic ascites). Also, the well-known scores, namely Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD), and its modified version MELD-Na, as well as the recently developed Chronic Liver Failure Consortium - Acute-on-Chronic Liver Failure (CLIF-C ACLF) scale, help to suggest a poor outcome for patients with cirrhosis(4)

5) Although in most pediatric patients ascites formation is probably a common manifestation of the general fluid retention, in most adult patients with nephrotic syndrome ascites can be attributed to both hypoalbuminemia and the presence of liver disease or congestive heart failure, with increased hepatic sinusoidal pressure.(5

6) 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 leading to spontaneous bacterial peritonitis.Ascites can make it hard to breathe causing shortness of breath.

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

AIM:

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

Objectives:

• 1.To asses the clinical characteristics  in patients presenting with ascites.

• 2.To asses the various laboratory parameters in patients with ascites such as haemoglobin,serum electrolytes,renal and liver parameters

• 3.To study the outcomes and various complications in patients with ascites

4.To study the predictors of outcome in patients with ascites -CTP score,MELD/Na score,renal failure,serum albumin levels.

STUDY DESIGN

Prospective study,Observational

INCLUSION CRITERIA

1.Patients with age >18years 

2.All Patients with ascites on clinical examination with radiological confirmation

3.Patients of both sexes 

4.Patients who have given the consent

EXCLUSION CRITERIA

1.Patients with Age less than 18 years

2. patients without Ascites on Clinical Examination

3.Patients who haven’t given Consent

SAMPLE SIZE AND DURATION

60 patients

October 2020 – November2023

INVESTIGATIONS REQUIRED

CBP 

• RBS 

• Chest x Ray 

• RFT 

• LFT 

• ECG 

• 2D ECHO 

• CUE 

• USG abdomen 

• Ascitic fluid anaylsis

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)

PATIENT INFORMATION SHEET

English:

https://drive.google.com/file/d/12LLDgFBVfnTxDdNv5K715uSyLYPUEgrY/view?usp=drivesdk

Telugu:

https://drive.google.com/file/d/13Df9wCu9zhjECpPxcHEULSAphv6-tDHl/view?usp=drivesdk

Template of this "patient information sheet" is borrowed from this website:

https://www.ncbi.nlm.nih.gov/books/NBK261334/

And modified accordingly to my thesis topic.

CASE PROFORMA

 History: 

• Abdominal distension: • facial puffiness                                        

• hemetamesis: • Shortness of breath                                    

• malena: • altered bowel habits 

• vomitings: • Abdominal pain 

• jaundice: • cough 

• chest pain • fever 

• palpitations: • evening rise of temperature 

• pedal edema: • Abdominal pain            

• oliguria: • Cough 

• anuria: • Fever/evening rise of temperature 

PERSONAL HISTORY 

1.Alcohol history: 

 2.Smoking history :

3.Appetite :

4.Bladder and bowel habits:

PAST HISTORY: 

• HIV status

 • family history of similar illness 

• Viral hepatitis (HBV; HCV) • Multiple sexual partners                                                    

• Diabetes mellitus • H/o coronary artery disease                                                            

• Hypertension • H/o blood transfusions                                                                    

• Chronic kidney disease     

GENERAL EXAMINATION 

• Pallor:.                                   • Elevated JVP :                     

• Icterus:                                  • Facial puffiness:                                     

• Peripheral edema:                     • Alopecia:                             

• Lymphadenopathy:        • Palmar erythema:    

• Asterixis:.                           • Gynecomastia: 

• Constructional apraxia: • Testicular atrophy:                                                                          

• Axillary hair loss: 

• Waist circumference on presentation:                        

• Spider naevi:                                                                     

CARDIOVASCULAR SYSTEM: 

Heart sounds:

 JVP:

 Added sounds:

GASTROINTESTINAL SYSTEM: 

Inspection: Palpation:

Shape of abdomen organomegaly

Umbilicus liver span

Percussion : Auscultation:

Shifting dullness Bowel sounds 

RESPIRATORY EXAMINATION:

Movements of chest:

Percussion:

Air entry:

Breath sounds:

CENTRAL NERVOUS EXAMINATION :

Higher mental functions:

Motor and sensory system:

Cerebellar functions:

Meningeal signs:

 

INVESTIGATIONS

CBP(complete blood picture):

Random Blood Sugar:

 X-Ray Chest PA view: 

Blood Urea: 

Serum Creatinine:  

Serum Na+: 

Serum K+:

USG Abdomen:

ECG:

Echocardiogram

Liver Function Test 

Total bilirubin

Direct bilirubin

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

CBNAAT(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)

TREATMENT GIVEN

DIURETICS YES/NO

FLUID RESTRICTION YES/NO

SALT RESTRICTION YES/NO

SPECIFIC DRUGS IF GIVEN

THERUPEUTIC PARACENTESIS

OUTCOMES AFTER FOLLOW UP

1.Morbidity: Symptomatically better / same status. 

2. Discharge/LAMA/Reffer to higher center

3.Mortality

4.Asymptomatic

Observations,Results,Discussion 

https://1drv.ms/w/s!Ajc3tZ8oZGcogXtPRhSQ6yKgFPYp

Link to master chart

https://1drv.ms/x/s!Ajc3tZ8oZGcogVnT_K1z7epN5qcb

Patient E logs

https://chandanavishwanatham19.blogspot.com/2022/04/56year-male-with-nephrotic-syndrome.html

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

http://abdulraheem7168.blogspot.com/2021/01/41year-old-male-with-portal.html

https://swathibogari158.blogspot.com/2020/09/chronic-decompensated-liver-disease.html?m=1

https://06akhil.blogspot.com/2021/11/general-medicine-case-4.html?m=1

https://sushma29.blogspot.com/2020/09/ascites-secondary-to-nephrotic-syndrome.html?m=1

https://harikachindam7.blogspot.com/2020/12/55m-with-abdominal-distention-since-15.html?m=1

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

https://chandanavishwanatham19.blogspot.com/2021/03/52year-old-male-with-ascites.html

https://drkulkarnimd.blogspot.com/2021/04/46m-with-ascites-and-portal-hypertension.html

https://pravalikachithanuri.blogspot.com/2020/10/45-year-old-male-with-decompensated.html

http://sairaghuver.blogspot.com/2020/10/is-online-e-log-book-to-discuss-our.html

https://apoorvagoli.blogspot.com/2020/12/a-38-year-old-man-with-abdominal.html?m=1

https://chetanakorada.blogspot.com/2021/02/45-year-old-male-with-abdominal.html

https://chandanavishwanatham19.blogspot.com/2021/05/30year-old-male-with-ascites.html

https://manishbolla27.blogspot.com/2020/11/a-52-year-male-with-pedal-edema-sob.html?m=1

https://roshinibala.blogspot.com/2020/11/38-year-old-male-presented-with.html

https://soumyanadella128eloggm.blogspot.com/2021/05/35-yo-female-with-abdominal-distention.html?m=1

https://ratnashivani08.blogspot.com/2021/06/medicine-case-discussion.html?m=1

http://saichennuru.blogspot.com/2021/09/45-year-old-male-patient-with-back-pain.html

https://chandanavishwanatham19.blogspot.com/2021/09/30year-male-with-ascitescirrhosis.html?m=1

https://chandanavishwanatham19.blogspot.com/2021/11/66-year-male-with-ascites.html

https://chandanavishwanatham19.blogspot.com/2021/11/55-year-old-female-with-ascites.html

http://prashanthsharma101.blogspot.com/2021/11/48-years-old-male-with-abdominal.html

http://saisurya100.blogspot.com/2021/11/35-y-f-with-chronic-liver-disease.html

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

https://medcases1.blogspot.com/2021/12/year-old-male-came-to-casuality-with.html

https://rhea9895.blogspot.com/2021/12/47-years-old-male-patient-with-reduced.html?m=1

http://vikyatsarvagna.blogspot.com/2021/12/35-yr-old-male-with-hypoglycemia-and.html

http://meghana140.blogspot.com/2021/12/67-year-old-male-with-recurrent.html

http://muskaanmenghwani.blogspot.com/2022/01/a-55yr-old-male-patientdaily-wage.html

https://caseopinionsbyrollno156.blogspot.com/2022/02/cbble-udhc-similar-cases_25.html

http://jayanth1802.blogspot.com/2021/02/45-year-old-with-seizures-secondary-to.html

https://venumadhav171.blogspot.com/2022/02/co-yellowish-discoloration-of-eyes-and.html?m=1

https://elogformedicalcasebyintern.blogspot.com/2021/12/35-f-with-aki-on-ckd.html

https://chandanavishwanatham19.blogspot.com/2022/03/62year-female-with-yellowish.html

https://chandanavishwanatham19.blogspot.com/2022/04/35year-female-with-heart-failurecrf.html

https://asrithareddy10.blogspot.com/2021/01/is-online-e-log-book-to-discuss-our_11.html?m=1

https://anushachowdaryshivakoti150.blogspot.com/2021/12/30f-rat-poisoning.html?m=1

http://vasavibasa24.blogspot.com/2022/05/chronic-liver-disease-with-portal.html

http://sangeetha-23.blogspot.com/2022/04/63year-old-male-with-shortness-of-breath.html

http://shandilyaakula.blogspot.com/2022/05/54-year-old-male-patient-with.html

http://harshinibeechupally.blogspot.com/2022/05/65-year-old-femalehome-maker-was.html

https://bkavya29.blogspot.com/2022/05/med-case.html

https://12avirnenivaishnavi.blogspot.com/2022/05/52-year-old-male-with-portal-htn.html?m=1

https://meghanaraomuddada.blogspot.com/2022/06/50yr-old-man-with-ascites.html?m=1

http://jyothi97.blogspot.com/2022/06/a-case-of-65-yr-old-female-with-ascitis.html

http://10anusri.blogspot.com/2022/06/case-study.html (https://ratnashivani08.blogspot.com/2021/06/medicine-case-discussion.html?m=1)

https://gayathrirollno22.blogspot.com/2022/06/38yr-old-male-with-pedal-edema-and.html

https://tejasree25.blogspot.com/2022/04/chronic-liver-disease-with-portal.html?m=1

https://ratnashivani08.blogspot.com/2021/06/medicine-case-discussion.html?m=1

https://finalmbbspart2gmpracticals.blogspot.com/2022/06/1701006133-case-presentation.html?m=1

https://caseopinionsbyrollno156.blogspot.com/2022/02/cbble-udhc-similar-cases_25.html

https://rusheethgmunit3.blogspot.com/2020/11/november-21-2020-this-is-online-e-log.html?m=1

http://vinaygoud18.blogspot.com/2022/04/40-yr-old-male-with-yellowish.html

https://93harika.blogspot.com/2021/12/ckd-ward-38yr-old-male.html?m=1

http://jadhavrajkumar.blogspot.com/2022/03/general-medicine_9.html

http://chavvaclassworkdecjan.blogspot.com/2021/06/pancreatitis-in-chronic-alcoholic-with.html?m=1

https://63konakanchihyndavi.blogspot.com/2021/05/case-discussion-on-pancreatitis-with.html?m=1

REFERENCES

1)Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut. 2006 Oct;55 Suppl 6(Suppl 6):vi1-12. doi: 10.1136/gut.2006.099580. PMID: 16966752; PMCID: PMC1860002

2)Korean Association for the Study of the Liver (KASL). KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol. 2018 Sep;24(3):230-277. doi: 10.3350/cmh.2018.1005. Epub 2018 Jul 9. PMID: 29991196; PMCID: PMC6166105.

3)Moore, Christopher M, and David H Van Thiel. “Cirrhotic ascites review: Pathophysiology, diagnosis and management.” World journal of hepatology vol. 5,5 (2013): 251-63. doi:10.4254/wjh.v5.i5.251

4)Garbuzenko, Dmitry Victorovich, and Nikolay Olegovich Arefyev. “Current approaches to the management of patients with cirrhotic ascites.” World journal of gastroenterology vol. 25,28 (2019): 3738-3752. doi:10.3748/wjg.v25.i28.3738

5) Ackerman, Zvi M.D. Ascites in Nephrotic Syndrome: Incidence, Patients' Characteristics, and Complications, Journal of Clinical Gastroenterology: January 1996 - Volume 22 - Issue 1 - p 31-34

Authors perspective:

Ascites itself is very fascinating thing to talk about because the way the fluid accumulates due to varied pathophysiologies is quite interesting.The fluid seeping out into the peritoneal cavity always makes me think ,why?.It feels good as I have come so far,I have dig deeper into these patients histories,clinical findings and got to know a lot about ascites.I came to know how dangerous the habit of alcoholism is.In my study the most common cause of ascites which stands out as a villain is cirrhosis,actually speaking the alcohol addiction.

      Initially my thesis topic was different which I was not very much into.Later one day I saw this patient of age 57years who came with jaundice ,pedal edema and abdominal distension and bleeding gums,ulcers over his lower limbs.He was father of one of the UG students who came to me to explain her about her fathers condition,but I myself don’t know anything back then about ascites.She told me that he is like every other father going to work ,coming home and spending some time with them.He was an RMP as far as I remember and used to do dressings for his leg ulcers on his own.I was a first year pg at that time and I went to see the patient.I was shocked to see him because he is very huge with a big distended abdomen,bleeding ulcers over his legs.

Why?When he is like every other person why is he not looking like every other person?I took his history ,done some clinical examination and he himself attributed everything to his alcohol addiction while I was examining him,he was feeling very guilty for what ever he has done to himself,He knows a lot more about his own health condition that what I know.I reassured him that he will become normal (although at that point of time I don’t know if that was reversible or not).I saw his labs which showed severe anemia,deranged coagulation profile ,We had to transfuse him with FFPs ,PRbCs.For the first time I have done ascitic tap on a patient .I went home and started reviewing about ascites,liver failure ,how to interpret ascitic fluid analysis.I slowly started understing what ascites is ,what are the causes, complications .Later that patient got discharged when he got better ,promising me that he will never touch alcohol. Even after discharge I used call that Ug student to know how he is,to know if he is drinking alcohol again,she said no and he was continuing his work as an RMP,his ulcers also healed later.I changed my thesis topic to ascites at that point of time.

   Later I came across many patients of ascites due to different causes.Few of them gave up alcohol,few of them did not , inspite of repeated counselling and also denied joining in deaddiction centres.Some patients had different causes like heart failure,Nephrotic syndrome,Budd chiari syndrome,tubercular ascites and so on.I learnt how to interpret ascitic fluid in various etiologies and how the management of each patient is different.I saw some patients dying in the hospital, some on follow up.I saw how problematic and uncomfortable ascites can be even if the patient is alive .It is difficult for patients to walk,turn around it bed,it always feels like you are carrying something unnecessary in your own body.Also it keeps on refilling after paracentesis -which is just a temporary relief and later everything comes back.That is so disappointing.

   Few patients in my thesis are remembered for life time because of the diagnostic uncertainties,challenges in managing them.45 year female patient who came from long distance who had refractory ascites later diagnosed with chronic Budd chiari syndrome.Even after repeated paracentesis ,it kept on refilling.Unfortunately she has expired at her home town after 3months of discharge.30 years male patient who had all the text book described complications of cirrhosis-He had SBP,encephalopathy,coagulopathy,splenomegaly,varices.He fought with sepsis due to SBP for a long time in our hospital and due to affordable issues he left the hospital.The attenders called me after few days and told me that he has expired.I was depressed to know the fact that alcohol can eat up a human at this young age but sometimes it feels like they have done everything themselves by getting addicted to alcohol.I saw patients who want to get out of this habit but we’re not getting adequate support due to family ,financial reasons.Some patients told me that they don’t have money to pay for deaddiction or to buy medications,but I don’t understand how they get money to buy alcohol.Everything is about priorities.If the patient really wants to get out of this , there are many ways to ,but they just need a little bit of constant support, motivation and not a single rupee.47 year old female patient who was initially labelled as diabetic nephropathy,tubercular lymphadenitis and later diagnosed with a completely different autoimmune problem who later landed up in renal failure and dialysis.

        After the end of my study I came to know that the mortality rate is very high in patients with ascites ,mainly in the portal hypertensive ascites group.There is a increasing need in the society for awareness about harmful effects of alcohol ,there is increasing need for feasible and affordable deaddiction centres by government for poor people, strict rules and punishment  on supply of alcohol to teenagers as this is the vulnerable age group to get addicted, there is also need for awareness of liver transplantation because even if some patients are affordable they don’t know what to do next to proceed for transplantation.I conclude with these important obeserations during my thesis period along with studying the various clinical characteristics,laboratory parameters and outcomes in ascites.

Important/Significant findings in my thesis:

The most common cause of ascites is chronic liver disease, followed by heart failure. Jaundice, pedal Oedema, icterus are found to be significant clinical characteristics and serum albumin was found to be significant predictor of outcome in ascites. Anaemia, Hyperbilirubinemia, Raised SGOT are found to be significantly associated with patients presenting with ascites .Mortality was found to be high in patients with portal hypertension, highest in the initial 2 months of presentation.In hospital mortality was found to be 10% and mortality after 6months was found to be 38.5%

Ascites in patients on Hemodialysis due to chronic renal failure:

Ascites with Hemodialysis cases From my thesis : there is overlap of hypoalbuminemia and Heart failure in some patients, but based on other clinical findings and SAAG, HFpEF is the most common one, not HFrEF. I did not record data on regularity of dialysis, inadequacy of dialysis in these patients, may be that would be an add on if I had done it. But I feel it is always multifactorial in CKD patients because they are prone to malnutrition causing hypoalbuminemia,coronary artery diseases, infections like Tubercular ascites which most of the times is missed because peritoneal biopsies are not being done actively, less life span due to other complications interfering with complete evaluation, dialysis

intervals, regularity, an associated CLD,venoocclusive diseases, Reno cardiac and the SAAG would depend on the dominant cause. During my thesis these are the things that I found to interfere with exact diagnosis of cause of ascites in dialysis patients in a rural medical set up.