[أبـ البراء ـو]

Tense ascitis ( TTT)

1-Rest in bed.2-Salt restriction ( salt free diet )3-Diuretics:

a) Start with Spironolactone (Aldactone) 100 mg قرص بعد الغداء

And increase gradually up to 4 tablets \day Value : K sparing diuretic, Aldosterone antagonist.

b) Lasix 40 mg daily up to 4 tablets ( 160 mg\d)

N.B.: Diuretics esp. Lasix stopped if there is hyopkalemia or precoma

4-Follow up pt. with fluid chart

(body wtàtarget: decrease B.wt by 1\2 kg \day.)

5-If resistant à Tapping or paracentesis should be done if tense ascitis cause significant discomfort or resp. distress ( Therapeutic purpose of tapping )



6-Tapping:


a-Exclude encephalopathy. b-Palpation of abdomen to avoid injury to any organ during tapping . c-Sterilization of (Macburny's point) or mid way bet. Costal margin & ASIS( most dependant area) ***Sterilization is done in circular manner from in into out by betadine then alcohol. d-introduce canula + IV line.
- Replacement with albumin if tapping > 3L (one bottle contain 10gm)

- Stop if : hypotension , bleeding of tapping ,, disturbed conc. Level.



N.B.:-

• Diagnostic purpose of tapping : if suspicion of malignant ascitis or SBP or new onset ascitis.
• Fluid obtained from tapping : 3 samples for : culture & sensitivity, chemistry, pathological exam.
• Indication of Albumin in CLD Pt.:

- Tapping > 3 L of ascitis fluid. - Infection - Surgery - SBP - Hepatorenal $

SBP ( spontinous bacterial peritonitis ):

Infectious complication of portal HTN related ascitis in absence of cause for peritonitis . most commen org : E-coli….



C\P : Pt with CLD with [ marked deterioration precipitate hepaticencephalopathy],, [ fever, abd.pain , tenderness ] ,, [ silent]



D.D : leucocytosis may be present

Diagnostic paracentesisàcell count [WBC >500\ m3\HPF with out sympt.,,PNL >250 \m3\HPF with symptoms ]



TTT: - Antipyretic.

- Antibioticà3rd generation cephalosporin E.g. : cefotaxime "claforan" 1 gm \ 8 h for 5 days unless there is renal failure ((dose adjustment)) - Anticoma measures ( previousely mentioned ) - Albumin.

Hepatic encephalopathy :-

It's neuropsychiatric complex in pts with acute or chronic LCF or portosystemic shunting(i.e.: disorderd conciousness, abnormal behavior…)

Ask about ppt factors in Ch. Liver disease pts :

-Diuretics

- High dietary prot.

- Haematemsis, melena

- Fever (infection)

- SBP

- Severe vomiting or diarrhea, excess tapping of ascitis.

- Hepatotoxicity ( alcohol ,drugs e.g. : sedative, opiod…)



Management :

1-Vital data ((fever. Haematemsis ))2-Canula à sample for ****bolic profile. ( Na, K, Creat, RBS)3-Ryle &wash to exclude haematemsis.4-Chest x ray à ( chest infection. . Rt sided P.effustion.5-ECG





TTT:

1- To avoid prot. In diet. 2- Eradicate bact. Flora by: - Neomycin 500 mg 2*4*5

– Flagyl 250 mg 1*3*7 - Lactulose 30 ml \8 h. (osmotic purgative ) - Enema \4h

3- Hepamerz"L-Arnithine – L-aspanate (2 amp +200cc glucose 10% \12 h.)

à if creat > 3

4-Aminolesan 500ml\12h (AA infusion

5-TTT of the cause :

E.g. : Haematemsis àDicynon ,konakion, cyclokapron ,zantac…….

Infectionà TTT
SBPà Antipyretic, Antibiotic, Anticoma, Albumin……

أنتهيت بتوفيق من الله
المقالة القادمة تمنا كتير لأنها بتقبلنما كل يوم مش شرط فى الأستقبال
إن شاء الله أكتبها قريب

سبحان الله والحمد لله ولا إله إلا الله
سبحانك اللهم وبحمدك أشهد إلا إله إلا أنت أستغفرك وأتوب إليك