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Ascites & its Rational Management

Mar 03 | 1:30 PM

Ascites is the most prevalent consequence of chronic liver failure. A complex chain of pathophysiological processes including portal hypertension and increasing vascular dysfunction leads to the production of ascites in the cirrhotic patient. Ascites development is a hallmark of chronic liver failure's natural history, and it predicts a dismal prognosis with a 50% mortality rate within three years. Complications such as spontaneous bacterial peritonitis, hyponatremia, and increasing renal impairment are common in patients with ascites. The quality of life and survival rates improve when cirrhotic ascites and accompanying consequences are properly managed.Join Dr. Sahay live as he walks us through the rational Mx of ascitis.

[Music] good evening everyone i'm doctor naveed and i welcome you all on behalf of team metrics uh for this evening session on a cyclist and international management uh with our speaker uh dr robinson he's a senior consultant physician internal medicine uh from mumbai uh and uh was a professor at uh km hospital mumbai um he's retired at present he's also professor he's also professor at diy part of medical college and a consultant physician at the polo hospital mumbai so i've been asked to take a topic which is quite common in general practice but not very well understood and we do not know what to do with it okay so this is the case of ascitis everybody gets comes across that right so we talk about why a scientist commonly occurs here if you understand why it occurs then you would know how to manage it what is the rationality behind it you would have seen many in hospitals you would see big ascites and with the needle in the abdomen and the site is being drained so this is the usual practice so what is the rationale behind it how you should be handling it as such a site is a terminal event the physiotic gets the scientists the survival is very low because generally it's not beyond two years so in that period how to handle it in the best way the best most scientific way okay this is one topic which is not very well understood and therefore all the mistakes right so a site is as by definition is collection of free fluid in the peritoneal cavity now what causes it eighty-four percent of cases of ascites is due to cirrhosis of liver okay so very small function is for any other reason okay the other reasons could be infection of the peritoneum like tuberculosis periodontitis in our country or secondaries in the peritoneum okay other causes would be a right heart failure can cause and amongst the cardiac causes of hesitance constrictive pericarditis is the most important right so this so most of the sites that we see is due to cirrhosis of liver so i'll focus on that rest of it is not very difficult to manage and to understand right now cirrhosis [Music] of the liver why does it cause a sinus so there are essentially two abnormalities which occur in cirrhosis of liver one is hepatic dysfunction right and the other one is total hypertension right so in fact i will tell you focusing on portal hypertension why total hypertension develops in cirrhosis and how is a part of the pathogenesis of the situs in cirrhosis so why is cirrhosis is associated with ascitis okay the primary reason okay this could be taken as a point the main reason for getting a situation cirrhosis is renal hypoperfusion very difficult to understand okay is the liver disease but the kidney gets hypoperfused less blood flow to the kidney so renal hypoperfusion is the main cause right now how does it happen why there is renal hypoperfusion okay why you need to understand is your management that is the core action that you take is to improve renal perfusion so why renal perfusion is low okay is because of hypovolemia all cirrhotics have low intravascular volume or there is a state of hypovolemia you see patient is idiomatis so much fluid in the abdomen even middle edema is there in actual the intravascular volume is low so why this happens is the maximum amount of blood volume is pulled in the splanchnic circulation splendid circulation is in the blood vessels of the intestinal artery and pain in cirrhosis there is increased levels of nitric oxide okay so this causes vasodilation in fact it causes vasodilation everywhere right passive dilatation is deep manifestation of cirrhosis of liver palmer erythema spider new y these are all vasodilations so it is thought that it is due to estrogen but apart from that major factors increase nitric oxide so that causes splenic arteriolar vasodilation right so more blood flow into the intestine now the blood blood that is entered into the intestine has to exit through the venous system the intestinal venous system is the portal system the portal vein which enters through the liver all the blood from the gut is drained through the liver total system and in the liver there is cirrhosis fibrosis okay this is obstruction to blood flow so blood large amount of blood goes in the mesenteric arteries planting arteries but cannot exit because of cirrhosis so there is pooling of blood the entire intravascular volume almost is pulled into the abdomen not the entire but major part of it so therefore there is hypovolemia to the renal blood flow the kidney is sensitive to perfusion there is a mechanism given there okay when the hypovolemia occurs intravascular volume falls the kidney compensates now what is the renal compensation one is the activation of renin angiotensin aldosterone system grass okay so that comes into play and number two the sympathetic nerve endings in the liver are sorry in the kidney which senses hypovolemia causes secretion of vasopressin so that's anti-diuretic hormone so free water is absorbed vasoconstriction occurs okay so these two factors activation of renin and utensil elder strong mechanism and the adh okay this has there causes the tendency of blood to increase the volume okay like renin and utensin and strong the aldosterone causes salt and water retention okay so renal hypoperfusion leads to in your mind you can make up is there is hyper aldosteronism secondary hyper eldostrons okay because grass is the end last a of russ is aldosterone so there is increased aldosterone circulation and in a cirrhotic okay the liver is dysfunctional so all endocrine products i mean all hormones are metabolized in the liver so there is decreased hepatic degradation of this increased spironolactone production right so there is a state of secondary hyper aldosterone this causes salt and water retention in the vascular compartment right so just now we said that there is depleted intravascular volume okay therefore the compensatory mechanism is to increase the intravascular volume by salt and water retention so as we started the first two points to bear in mind in pathogenesis of ascites in cirrhosis number one decreased renal blood flow or hyperperfusion right this leads to secondary hyperaldestronism and the strong is more so this will call salt and water retention in the vascular compartment right now the vascular compartment cannot hold this water and salt that is being retained why the intravascular space cannot hold the water is because there is associated hypoproteinemia hypoalbuminemia in all patients of serotonin cirrhosis okay so there is low plasma osmotic pressure the third factor decreased renewal perfusion number two secondary hyperaldosteronism which is causing salt and water retention in the vascular compartment third is hypoalbuminemia or low plasma osmotic pressure which cannot hold the water okay so there is tendency of water to come out of the vascular compartment now where does it go so it goes out wherever the hydrostatic pressure is maximum in cirrhosis the maximum hydrostatic pressure is in the peritoneal cavity because of total hypertension therefore this water which is being retained in the vascular compartment is precipitated in the abdomen because the total pressure is maximum there in normal human situation the maximum hydrostatic pressure is in the dependent part in the legs right so if there was only hypoproteinemia it would have occurred in the legs would occur in the legs but here the edema is akin in the peritoneal cavity because total hypertension is maximum is even more than the hydrostatic pressure in the legs so therefore there is precipitation of fluid in the peritoneal cavity for this reason okay there might be some edema but the ascites is more remarkable than the fidelity or dependent so these are the factors okay low renal perfusion secondary hyperaldosteronism and low plasma osmotic pressure due to hypoproteinemia right which is precipitating fluid in the abdominal cavity so in cirrhotics this is the pathogenesis apart from there there is some other factors contributing is lymphatic obstruction same because of fibrosis in the liver the lymphatics passing across are also obstructed so there is oozing of lymph into the abdominal cavity okay this was discovered during surgery when operation was abdomen labrotomy was done on the patient of cirrhosis it would be seen that lymph is oozing from the liver all the weeping liver as it is commonly called so lymph drips from the liver in acid this also causes the accumulation of fluid in the abdominal cavity so that's the pathogenesis okay of a scientist in a patient with cirrhosis of liver now this is what leads to the this situation with which the patient comes right so a quick word on how you diagnose the cytos okay very easy okay this is a revision i think this scope is much more here than doing this but then on if you look at the patient of the site there will be abdominal distension with flankfulness the umbilicus would be inverted and transversely but if you type it the palpatory finding suggesting ascites is fluid3 though you need to know the implication of all this you can elicit the sign of fluid through the one and one side you put your on the one lateral aspect the arm and on the second you tap away on the opposite side so you can feel the fluids [Music] that suggests there is sufficient fluid which is connecting fluid on one side with the other so at least in a normal adult 1.5 liters or more fluid kill that cause this sign so we are getting fluid that means one and a half liters of fluid is there in the abdomen okay on percussion the abdomen is tympanic but it will become dull if there is fluid okay so if there is how to distinguish that this is fluid only there may be other reasons for dullness in the abdomen so there you do this sign okay the dullness will have a shape characteristic shape of the horseshoe shape dullness that is said that means the dullness is higher up in the flanks and lower in the midline so therefore it gives a u shape to the doubles so horseshoe shaped unless this would imply that there is at least one liter okay one liter or more fluid will cause this sign okay now if the fluid is even less than that okay they usually will have dullness in the flanks which would shift that's commonly called the shifting telnet so less fluid about 500 ml so it will trickle in either side okay and was caused dunless in the flanks of the abdomen and if you change the position of the patient the fluid will shift and the dullness will shift so shifting turns okay so clinically this is a sign you're very afraid now modern day time too many investigations are there so you can take help of this usg ultrasound not needed okay this is good enough right so once you have detected that there is a situation all right you need to know why it is occurred [Music] i told you 84 is because of cirrhosis of liver so just pick on the other causes right so the fluid in ascites would what is commonly called transgender okay non-inflammatory fluid this other reason to get non-infected inflammatory fluid would be cardiac right heart failure military but the most common okay cause is it one that is rare not so common that is constrictive pericarditis so their patient with a scientist all these signs that i told and you see in the net the jvp is raised so it's raised jvp with ascitis you should think of cardiac condition so two conditions now any other hypoprotein situation where there is low plasma ostomatic pressure can cause edema anywhere also in the abdomen like for any reason patient has no protein in the blood like nephrotic syndrome so that can cause so these are all translative causes right in among executive causes which we are more likely to encounter we get to see quite often okay apart from cirrhosis is you know my intuition that wouldn't cause the chronic fluid in the abdomen okay but one that is chronic inflammation of the electroneum like tuberculosis peritonitis okay so in india apart from cirrhosis the second one most common one would be this tuberculosis right sometimes you get a combination okay alcoholics erotics are very prone to get spontaneous bacterial peritonitis that is another story okay so in that tuberculosis periodontis is also very common in india okay so [Music] level but what is practice is called the sag serum protein serum albumin and acidic albumin gradient okay so a gradient acidic gradient gradient of more than 1.1 gram per deciliter is transmitted [Music] if the gradient serum albumin minus the static albumin is less than 1.1 it is an x-ray okay we work out it is easy but then we have got used to high protein and low protein so that's quite okay right why the confusion occurs this cirrhotics will have low serum protein low serum albumin in a cirrhotic causes confusion okay though it is executive the amount of protein in the acidic fluid which is derived from the plasma will be lesser therefore the fat okay serum acidic albumin gradient right then you look for cells it is hyper cellular more than 250 okay so it is suggesting an infection okay like in tuberculosis right and the predominant cell there would be lymphocytes so lymphocytic predominant hypercellular fluid would suggest tuberculosis but there are other suggestive signs okay like systemic features of tuberculosis so that way you distinguish whether it is translated and come to a conclusion that yes this is a scientist due to cirrhosis of living so how do you manage this so this is what is interesting okay management of the scientist so generally you put a needle and drain the fluid that's called parasymptosis so but if actual management you can think of parasynthesis is contraindicated in cirrhosis causing a situation so in ascites due to cirrhosis you should not do parasympathetic fluid that you draw is diagnostic okay so there is a lot of confusion okay for a long period of time the world over what is the best way of managing the site is in a patient with the barcelona convention there was a convention in barcelona a long time ago that has best elucidated how you should be managing societies it's called barcelona convention step care management step care statement so step gear means you take one step at a time right so in a cirrhotic the first step that the first step that i will be talking of i'm going to tell is for management of scientists but their cirrhosis itself should be managed first right like giving up alcohol okay that is the first step in management of cirrhosis so those steps have been taken now you are focusing only on ascites due to cirrhosis so in that the step care treatment of management of the situation first step is bad rest no big deal better anywhere okay we will take batteries here the bedrest is significant so why bed rest is advised the less more amount of time the patient is on the bed better for the scientists to reduce so why this hap is there because there should be rationality behind it is that taking better improves renal perfusion okay when a person is exercising the big muscles are working so the blood flow is diverted to the exercising muscle so when the patient is taking bed rest this flow is not occurring so the renal perfusion improves so you are just reversing the pathogenesis of a cyclist so you encourage the patient to be on bed for longer periods of time right so that's the first step now second is diet right so what is the diet for ascitis this is low sodium diet because sodium is what is holding fluid in the intravascular compartment which actually is shifting the third space of the peritoneum so low salt diet okay there is no definite way of telling what is low salt diet okay we have data from america american diet more than six gram sodium per day so this has to be reduced below two grams per day it's very difficult to achieve okay this should be in a practical way okay so what we practically do is the management of a scientist when you get the patient is intense and you focus only on that you tell the patient that this is temporary once we achieve your correction then we will gradually put you to normal activities like better you can't ask the patient to be on bread okay so this is first to reduce the anxiety so you almost get salt free diet whatever natural salt is there in the food that only or just to make the food palatable because minimal salt actually it should be minimal salt in the diet okay read sweet things okay so that low salt diet the other one is a good protein diet okay because you have to correct the hypoprotein right so the patient should be taking a high protein diet the fallout of that is if you give to a high protein diet it is said may induce encephalopathy yes one complication of cirrhosis so the protein that is given okay is highest tolerated protein i'm telling you the situation where you're managing in an indoor situation right so you give as much protein as possible and you may use encephalopathy and then reduce the amount just below it so maximum tolerated protein that in 24 hour diet one another way is to improve the protein by using protein of vegetable sources so proteins of vegetable sources have are high in branching amino acids when they get digested right so these branch and amino acid which is formed as digestion of vegetable protein is less likely in fact it is corrective for encephalopathy that is another story okay some other time they will arrange for okay the complications of cirrhosis that we can talk so take home message from here you attended what you learned you have to give don't be afraid of giving high protein diet okay so protein animal protein is the maximum tolerated and large chunk of vegetable source of protein so these two things have to be taken care in the diet okay low salt and high protein diet right and lastly is diuretics lastly that's the end of it okay so diuretic now it is if we talk of diuretic okay so which directive okay a potent diuretic like frucia mine is contraindicated in situs because jerusalemide will further deplete the intravascular volume this is where patient treating physicians make a mistake patient is idiomatous treatment of edema is frusamide treatment of wisdom is not frustrating is treatment for reducing the intravascular volume this should be kept in mind okay these common mistakes we will make so these kind of things it comes to your mind listeners you can jot down and forward to these organizers they will let me know about diuretics so two semi potent loop diuretics are indicated if you want to decrease the intravascular volume here the intravascular volume as such is low so you don't do it if you give trusemite alone or flucemide in large doses it will cause complications of cirrhosis the most important being hepatorenal syndrome will cause renal failure because you further deplete the intravascular volume with less even less flow to the kidneys right so this contraindicated susamide the other complication that it causes is hepatic encephalopathy flucimite itself can give semite will deplete the potassium so you'll cause hypokalemic alkalosis hypokalemia thereby alkalosis and alkalosis okay is the first step in development of encephalopathy hepatic encephalopathy okay as a consequence of cirrhosis so for these two complications okay hypokalemic alkalosis leading to encephalopathy and renal failure due to depletion of the intravascular volume fusamite alone should not be used therefore what is the diuretic you want to remove you don't need a diuretic what you need is to correct the pathogenesis so in the pathogenesis of a scientist due to cirrhosis the second point was secondary hyper aldosterone and strong level is high so therefore you give of this okay you can think about aldosterone antagonist that is the diuretic of choice okay people believe you use it because it is potassium sparing actually not we use it because it's aldosterone antagonist it doesn't cause much diuresis okay so it can antagonize the effect of aldosterone the hyper aldosterone hyperaldestronism that is the major pathogenesis for cirrhosis and liver so on spiral i'll dwell on this for longer okay alderton that's how it is famous okay spinal electron so it is step carefully okay so now we'll focus on what is step here there is a scientist should not be treated acutely suddenly you could remove the like you do parasynthesis and patient patient feels very happy there are funny who is so relieved okay in fact your hastening is exit from this world if you do that okay so you don't have to remove fluid externally this fluid the kidney should be excreting out you have to shift the fluid from the abdominal cavity into the intravascular compartment okay the shift is like that right so you give strong antagonist now how much is the dose okay elder strong antagonist spironolactone doesn't have much diuretic effect will not cause urination so much okay so it is given in four divided doses and as it is step here you take one step at a time so the minimal aldosterone antagonist is used first so just very easy to remember okay 100 milligrams in a day in four divided doses so it is that's why the tablet of aldectron is 25 milligrams so use 25 milligram four times a day right with salt free diet bedrest high protein diet so now you have to wait so you get three days at a time you wait for three days and then you have to see whether ascites is reducing so this is important what is the target of correction of ascitis in cirrhosis always it is a situation cirrhosis that you are correcting so the target is to cause loss of acidic fluid from the abdomen but how would you know that the fluid from the abdomen is being lost many people do abdominal girth so abdominal girth is not standard you cannot tell how much fluid is being lost so again the barcelona convention has given this recommendation that you achieve a weight loss per on the per day basis patient loses weight right so that indicates the static fluid is being lost so the target is in step care treatment the target is a loss of half a kg per day only 500 milligram per day that means the target is to lose 500 gram grams of fluid okay if there is a scientist alone in citrosis there may be only a site is no edema this is highly possible so if it is only a scientist you try to achieve a weight loss of half a kg if there is a scientist with edema in the legs dependent in demand then the target is you cause a loss of one kg per day right very what is the target of management of scientists in cirrhosis okay conventional management is just to cause a loss of half a kg per day if there is ascites alone if ascites and edema both are there attempt to cause a loss of 1 kg per day that's the target now how to achieve this so we have already talked about bedrest diet and aldosterone antagonist so you start with 25 milligram four times a day so that makes it 100 milligram in a day right now in this the fluid will shift okay from abdominal cavity to the intravascular compartment so you may force the kidney open so once you have achieved an aldosterone level of 100 milligram per day and aldosterone antagonists are hundreds milligram per day then for each 100 milligram of aldosterone antagonist you give one tablet 40 milligram of fructomide once in the morning you can add okay if patient is not opening up weight loss is not occurring so that's the proportion but i always suggest that you don't add fruit semi initially you give 100 milligram in a day for three days if weight loss is not occurring or you want to increase the dose then make it now 50 milligram four times by 25 milligram and you can raise it to 100 milligram four times a day so that makes it total 400 milligram in a day so in steps of three days each you have to increase the dose of spirulin electron from 100 milligram in four divided doses to 400 milligram against four divided doses is it so 100 milligrams in a day 200 milligram four times a day same thing okay in that at any point you want that you're feeling that it is not opening up so you can add through semi okay actually the proportion recommended is for each 100 milligram of spinal electron you can add 40 milligram of right so this should achieve diuresis okay it is actual diuresis you're not removing the fluid by putting a needle in the abdomen and draining outside you're shifting this fluid in the intravascular compartment and the kidney will excrete because the renal perfusion will improve okay so this is the standard management of a situs due to cirrhosis of liver now if you do this step care management okay for three weeks and patient does have does not have a loss of fluid the site is not decreasing despite these efforts these efforts number one pedras diet and diuretic if these three are not inducing diuresis and loss of weight that means loss of hesitis the condition is called refractory ascites okay resistant sites but the term used worldwide is refractory ascites that means the patient will not is not responding so mostly that the patient that you get to see you label them as a refractory scientist without having okay going through this step care treatment right so this is for three weeks you have to put the patient to this regimen okay and patient is likely to lose weight lose weight means lose their situations but then that is not the end of the story if the patient doesn't respond to this then is the management of refractory situs okay so newer there are newer modalities there are older modalities and there is the easiest mentality of managing refractory societies so you should be able to those who are still students okay so label the patient as a refractive scientist so what definition by definition refractive science is that which does not respond to better diet and full dose of spinal lactone for three weeks okay so i'll take i'm going to i'll tell you refractory site is but here little bit newer things so the main drug here is spinal actin okay so when is the spinal actin dose okay to be curtailed the use is restricted so two three things can happen the major one is hyponatremia in case patient begins to develop hyponatremia you have to then balance okay so stop it add salt that kind of balancing needs to be done okay or patient develops hyperkalemia if hyperkalemia is developing dangerous so you have to stop this because spinal electron is potassium sparing okay so there you then you have to increase or add fruct this may correct your hypokalemia hyperkalemia okay and third is painful gynecomastia that can occur okay so if there are those who are preparing for meat okay or dm or pg meat okay so this is spinal electron is a non-selective and restron antagonist okay so it also acts on the receptors for estrogen and androgen okay so that way it causes gynecomastia so painful gynecomastia can restrict the use so that's why we have absolutely known okay it's a newer one this is expensive so not to be used as immediately so that was it okay so you know the side effects of what you're doing now if you have labeled your patient as refractive patient is not responding right so you do what is management of refractive scientists the easiest is paracentesis we remove fluid from the abdominal cavity but oh sorry what swathi what is your question how do we understand the patient is i can't get the full sentence would you address that later yes we take the questions uh later if you want i think it's quite interesting but i can't have the whole thing so you can actually uh go in the comments and see dr swati's asked how do we understand that the patient is getting hyponatremix so some features of hyponatremia okay so these are the earliest feature is disorientation okay patient will get disoriented loss of appetite patient will start vomiting there are features of hyponatremia this occurs if you do a serum electrolyte patient may get convulsions patient will become unconscious at the varying states of hyponatremia so this is that all right okay from clinical features and blood investigation serum sodium levels right so is so the treatment is parasynthesis but just now i said just like for at the beginning i said parasynthesis is contraindicated not advised because what fluid in the abdomen is an effect okay it is not a disease it is the effect of the pathogenic factors that we talked you the pathogenic factors are still intact and you are removing the effect okay so what will happen the shift will be faster and more severe the intravascular volume will get depleted completely okay because the pathogenesis is still there okay so in a patient with stable ascites the abdominal fluid is in equilibrium with the intravascular compartment the shift is between intravascular compartment and the peritoneal cavity right so this if you remove from the peritoneal cavity fluid fluid from the interstellar compartment will shift and the first thing that you will induce is hepato renal syndrome okay so assad is not at the most you can if the patient has difficulty in breathing because the diaphragm cannot move down you can remove one liter at the moment okay beyond that at a time you should not remove but in refractory ascites the barcelona convention says that you can get dr swathi so do you want to take the raise hands now yeah yeah you you are the convener you tell us depends on you we can take it now that's fine yes uh yes doctor may have accepted your request you can turn on your audio video when you get the phone hello hi yes good evening sir can you hear me yeah yeah sometimes during any surgery now we get a scientist so i wanted to know whether we should put drain or not means it is recommended or not since there are two schools of thought that it will lead to loss of proteins yes sometimes during lsca sometimes during mostly in lscs only lscs that school of the you have to do okay so take the risk putting drain rain inside the abdomen some people say that we should not put a drain because of the drain the proteins will get lost from the brain and some people say that we talked about woman who is pregnant okay so also has cirrhosis of liver for some reason couldn't be alcoholic at that age right so then there is no harm in putting the drink the retention of food in the inter-peritoneal cavity okay would cause more problem than removing that so this kind of balancing you have to do right okay okay yeah thank you you're putting drain to remove the uzi from the yes that you have to remove otherwise it will cause more problems yes yeah thank you thank you ma'am [Music] so yes so your it is contraindicated but then barcelona convention has recommended after good many years of studying this that you can remove the large volume parasynthesis can be done okay in fact they say tvp total volume parasynthesis you can remove entire amount of fluid in one go but there is one thing okay if you remove fluid from the abdomen i said so the intravascular fluid will shift into the electronic cavity this should not happen why the fluid is shifting is because of low plasma osmotic pressure okay so when you're draining the peritoneal fluid simultaneously you have to raise the plasma osmotic pressure okay how to raise plasma oscillating pressure low plasma osmotic pressure was because of hypoproteinemia so you give albumin infusion okay so you have to have infused albumin and then parasynthesis now total volume means entire amount of fluid you can remove okay so how much albumin to infuse or what is the problem then it was a very simple thing right so the amount of protein albumin that you infuse okay has a proportion for each liter of a sciatic fluid that you are removing [Music] the albumin replaced is 8 to 10 grams which is quite a large amount of protein for each liter of fluid removed there should be simultaneous infusion of 8 to 10 grams of albumin so then in in that case you can do attempt right so this is that this is the popular treatment there are historical treatments okay and there is some modern treatment right so i'll tell you some modern treatment that okay if you those who are physicians are preparing for exam you can use it okay so what is done is you give splatnik vasoconstrictors okay so that blood flow to the intestine is reduced therefore blood gets diverted like you give alpha one receptor antagonist my daughter is the newer drug that is used or so that is what is actually at the moment being used clonidine many people use okay so clonidine so these two drugs can be used to see now that patient is not responding so additional newer addition is just this right now historically what was done so because this is an ancient disease alcohol is ancient so because ancient disease lot of good thinking has been done okay but they have been met with some hurdles therefore not used anymore one most remarkable was to divert the intraperitoneal fluid acidic fluid into the vascular compartment there is a shunt leaving levine had designed this shunt that fluid from one compartment will move to the other this shunt was placed in the peritoneal cavity and the other one in the subclavian right subclavian vein okay so whenever the inter-abdominal pressure would rise like patient coughs okay or moves the interrupt abdominal pressure rises the small amount of fluid from the peritoneal cavity this acidic fluid will spot into the supplement so through the day small amounts of fluid will shift okay this fluid is isotonic to the plasma right so it will be excreted in the urine but what was the what problem occurred because these erotics are very prone to get spontaneous bacterial parabolitis so infection was the major part okay this would lead infection and this body senses it as foreign protein because of the infection so their disseminated intravascular coagulation would occur a lot so this has been given up okay because total volume para synthesis and availability of albumin for intravenous infusion is available okay so therefore this is not being used now now last addition to this okay is management is and many people say this is better mean the standard treatment of bedrest diet and diuretic is still on on top of that you would reduce the portal pressure using a shunt because very popular tips trans jugular intra-hepatic photo system extension so it is passed through the jugular vein into the liver and the stent is open okay so it causes the total pressure to fall right but only drawback with this okay is that maintenance encephalopathy you are directing total blood directly into the circulation so the requirement is that the liver function should be very good okay if liver function is compromised doing putting a shunt would cause hepatic flopped so these three are the options okay okay what of option we can most commonly use in actions of tips but tips should have become more popular than okay because it is it occurs in serotonin in any social strata because the trip should have been more popular than what it is right so it's still paracentesis you can do but simultaneous infusion now when you're doing this okay it is not a permanent solution okay after some time the effect of paracentesis will go the serum albumin would metabolize and then again the process will start so once cirrhosis has led to a situation it is a remission and recurrence this will keep happening okay the permanent solution to that is only one what is permanent solution to cirrhosis of liver as such or any chronic liver disease liver transplant so it doesn't end okay without talking about liver transplants okay again um in our country we are still patchily we are doing like in advanced countries there is a registry okay you get into the queue and the queue can change depending upon how important is your requirement okay so all these things are matters of future for the moment okay cirrhosis causing a situation this is the best that you can do so many new things you would have heard right so that's has to be implemented now after having this learn this what betters me is still in bigger any kind of hospital small big government okay corporate the it looks like nobody has a idea of how to handle this okay everybody's parasynthesis doing parasites so you need to know about it right rest of it excited for any other reason the management is just treatment of the underlying cause suppose you find that this is peritonitis causing a cycle it's just anti-tuberculosis drug right it's due to heart failure management of heart failure you don't have to manage a situation it's just minor heart failure it will become all right if it is hyper protein like dr swati was asking okay pregnant woman getting a site is okay likely hyper protein those kind of things are more likely to be there okay so underlying cause that's why you don't have to be afraid of that fluid that fluid is not going to harm right so that can be treated so that's it okay constrictive pericarditis that's it very cardio to me management of constricted pericardium correct right so maximum the site is my the most common cause for a site is this roses and this is the standard treatment for it of course it entails correction of cirrhosis plus we talked about one effect there are other complications of cirrhosis will be there so that has to be treated with ascites in cirrhosis the complication is spontaneous bacterial parasites so that has to be kept in mind and as i said in india in such countries vegetable is still there cirrhosis of liver ascites is commonly associated with the spontaneous bacterial tuberculospheric matters not that has to be kept in mind all right so i think that should be enough is it okay okay it is an amazing lecture and a lot of concepts were clear we started with the basics and very well navigated throughout the whole topic uh coming up to the management touched upon the ancient management which was nice and then came to the recent management and then where india still needs to get ahead like with the something like a registry organ transplant right registry so albumin infusion can be done only during parasynthesis only or it can be done in routine as there is a hypoalbunemia that's very good so i was telling you about sir uh or if what sir what will be the dose of albumin in routine the routine there is no fixed dose okay what you want to achieve that is it okay and those i said one liter because there is a target you are removing one liter of fluid so by studies it has been found that when you remove so much fluid an 8 gram infusion will prevent shift from intravascular compartment but what she's saying has a point in fact in early period okay in my career i had done this study okay as a medical student pg okay infusing so she's talking of albumin in my time albumin was not available like that so i would do a whole blood transfusion okay in in the those times you could do whole blood transfusion and it's not so restrictive so don't related donor patients and relatives are used to make them donate blood and transfusion so that would raise the intra vascular osmotic pressure very nice question in fact so if you give albumin okay without doing parasynthesis that too would be able to okay correct this but then because you are infusing albumin so you can take advantage of that and remove some fluid ffp okay you can give ffv full plasma you can give that's right that's right there are many things we will be wasting plotting factors and all so nowadays you you don't use whole blood look at the blood products because depending on where you are staying in this city okay so like in when my city mumbai here you you won't get whole blood now it's a blood product so there you can but if there is nothing as i told you uh dr karthik i'm sorry i thought who had asked is to raise the intravascular osmotic pressure so it is very nice some we are thinking like that okay that means the message has gone across so you can do it this in your hospital when you are managing patients don't be afraid of okay you can use just straight albumin without doing parasynthesis okay so you can use erase this plasma osmotic pressure so that way the fluid will decrease definitely it's not a curable condition so these these things are helpful so correct yes uh so we have a question by dr ashok agarwal who asked how to manage a scientist in ckd who are dialysis dependent and that is very important okay that there you manage the ckd first right and raise this what you can do is raise the intravascular abdomen osmotic pressure try to do that right in fact more you by doing an acidic tab you may use a acute renal failure on the ckd okay so that risk is there so that is too many abnormalities but then you're a physician you have to try which way okay there is no straight guideline in ckd how you would do okay um so we have dr raj kumar who's asked what about synthetic plasma extenders yes have you used them okay i've used them that's very good again okay so synthetic now that you have albumin available so you need not do the second best cousin of albumin would be synthetic okay plasma expanders yes that that helps in fact okay we have done by as i told you in my md i did this experiment so it was always constrained with finances because the plasma expanders so you arrange plasmax and i have done that so that helps in fact okay that will raise the plasma osmotic pressure reduce the situs which is like giving high protein diet to the patient that's correct thank you sir uh so what is the dose of ffp these i do not know okay i don't know like this okay then you can you'll have to do a trial and see these are the scopes of what studies you can do [Music] yes i think you've answered most of it if there are any questions that we have probably missed or something um there's dr nishan who's asked for glucose diet recommendation [Music] what is the ionotropic of choice this one let's try this what what is the question what is it what is the ionotope of choice with hypotension hypotension so this is this uh hypertension due to what um dr vishal if you can probably uh rephrase the question or you can come up on stage so i'll answer this nishant dr nishant i'll answer you also hypotension you have to first find out what the what is the cause of the hypotension okay if it is hypovolemic hypovolemic hypotension that's causing shock your treatment is of the hypovolemia okay if it is cardiogenic shock then in that case of the different thing cardiogenic shock because of lesser force of contraction of the ventricle okay then there you use dopamine dopamine okay or you can use intra aortic pump devices diabetic burn balloon counter pulsation mechanism says that what is that one stimulants and yeah so yeah let me answer this okay this is commonly people do any patient of a scientist called liver stimulants and gut sterilizer so guts sterilize it one at a time because the gut for a sterilization gut sterilizer is given for hepatic encephalopathy okay so the question is valid a patient would not be only having a scientist and cirrhosis the patient may have some degrees of hepatic encephalopathy okay if there is hepatic encephalopathy then you have to there is a role for god sterilizers that is that so next time you keep complications of cirrhosis i will speak all this so gut have got macros and simultaneously there is regeneration that is called cirrhosis okay so there is no rule actually refractive mean the rifaximin is used as a gut sterilizer dolphin in zero adh antagonism okay so there's no this is in if it is ai if if the hyponatremia is a inappropriate ads secretion only then there is a role of acting doctor so talk acting is for hyponatremia due to excessive function okay there could be one number one signal in pathogenesis i said but there is increased secretion of [Music] adh okay in the pathogenesis probably that's why he has asked the question okay so you do not need to treat the adh that is getting secreted you have to treat what is causing adh secretion so you just need to improve renal perfusion okay so that that right increased renal perfusion the secretion of vasopressin or adh will decrease how to medically treat yes defined by energy medically treated tuberculosis like you treat tuberculosis anywhere okay okay same okay probably what it means is there is hepatic discompensation so this may okay so the mechanism by which anti-tuberculosis drugs cause hepatic hepatitis and the mechanism with which alcohol causes hepatitis are different right so you can use safely but you have to have a baseline sjot sgpt before you start the treatment like in any patient in fact okay doctor barity so you can if you're diagnosed this this is a good one so tuberculosis peritonitis okay you can use the full dose of okay in the same way like you do for pulmonary tuberculosis or any but you must have a baseline suta gpt level an increase of three times three to five times it should hold back or change the drugs okay hepatosafe antiquatress drug you can use but not initially you can use all the fam facing included parasynomite included [Music] iv fluids do not have a role in ascites so um can we start prophylactic antibiotics to prevent sbp spontaneous bacterial productivity yes it is this one is a good one so as i told you okay you have to have another session this was only a scientist you had given me okay but then that will take long okay but then because the question has been raised say yes okay you give profile you don't give primary prophylaxis for spontaneous bacterial carotinitis okay so if patient develops spontaneous bacterial peritonitis that means he is prone to get it again and again right so therefore once you have treated spontaneous bacterial periodontitis all patients should be on lifelong prophylaxis for spontaneous bacteria the drug used drug of choice used is fluoroquinolone at the moment okay so prophylactic fluoroquinolone once spontaneous bacterial matrix is developed again role of types in scientists caused by ashok mean by enzyme okay so this is as i said this is not only one disorder it is composite management of cirrhosis so in that people use protein and law okay as the primary performance just now we're talking primary prophylaxis for varicella bleed okay so this causes vasoconstriction the role of propeller non-selective beta blocker is that it causes splintering vessel constriction because it reduces blood flow through the intestine okay so that can be used right your answer is your question is valid in this way okay it's not to do with the scientist but it will reduce the portal pressure so propranolol can be used primarily as well as secondary to reduce the total pressure okay but last thing to add okay carbon is all you can you can okay newer one okay so being non-selective it can be used right but the studies at the moment has shown that use simultaneous use of proton law it prevents the complication but is associated with lesser survival so today current day medicine is called evidence based medicine all these trials are showing that survival is lesser when you are using bit of non-selective development but then if it is for drawing the portal pressure for whatever you you think patient here as a prophylaxis for meta message means variation bleed is indicated you can use but not for only for a scientist because associated with decreased i survival so you've covered most of the questions if there are any uh questions that we've missed we'll uh send them out to sir and um mother desi jesse what is his joint in practice uh in practice patients keep asking about place of alternative medicine what are your views on it alternative medicine uh alternative uh medicine yeah in um in the in uh so he is question is in practice patients keep asking about place of alternative medicines already i'm totally incompetent to answer that but strong views this is my personal view you need not follow okay your mind should be always open okay but in my career what i have seen there is nothing okay as yet alternative medicines are too primitive at the moment okay that's my personal looking that kind of thing may be working okay you never know you can't close your mind but as much as i know there isn't anything there's no alternative mention for this um glucose diet not did not recommend because that doesn't do anything in cirrhosis what is causing cirrhosis is the alcohol so that has to be correct [Music] like i said okay sometimes there is nothing you can give lead 52 you should not know whether it causes there is no no rational use so in our this is problem with our medicine okay we have to have okay reasons how it acts why it acts any side effects those things so as such need to do you don't have any rational use as you don't have data data means there is you should have what is pharmacologically what it is how can it so see liver this is as a liver protection cirrhosis occurred because liver is has a high regenerative capacity it is as such an organ which protects itself that's why you call liver you live by the problem okay so if liver gets damaged there is region only organ that regenerates okay so cirrhosis occurs because of this otherwise it would have been hepatic fibrosis like lung fibrosis this is not hepatic fibrosis in alcoholic alcoholism it is process how cirrhosis is different from fibrosis is that there is simultaneous degeneration and fibrosis of hepatocyte simultaneously there is regeneration of healthy hepatocytes so this degeneration and regeneration that disrupts the hepatic architecture which is important okay so therefore patient who has got cirrhosis will live for long okay then people have cirrhosis nothing happens because regenerative capacity that's why the compensated cirrhosis how cirrhosis is compensated because of the regenerative capacity but then it hampers in harms in other way that it disrupts the hepatic architecture there isn't any hepatic dysfunction but disruption of the hepatic architecture will cause total hypertension okay so major complication of cirrhosis is okay fertility is because of fatal hypertension hepatic dysfunction comes in very late right yeah so this was asking you can give albumin weekly so that i'll do and see how they help okay you have understood that pathogenesis and how this act so you can how much cirrhosis is reversible okay so that is one field okay reversible cirrhosis is not reversible it is it will stop at that level because because of the regenerative capacity if the ideological agent has stopped like alcohol the person stops alcohol alcohol is a direct toxin to the liver so if that stops okay so then the liver will start degenerating at that level okay so some fibrosis is there the regenerative capacity is good so there's not much harm okay but it can't be reversed one trial is being done is to give anti-fibrotic drugs like purchasing in cirrhosis and see whether fibrosis can be reversed the idea is to reverse the portal hypertension that way again it is not a reversible condition but progression can stop that is good enough yes we did we did we talked about this albumin infusion always before a sciatic tapping okay you have to give in the right proportion we have already talked of one eight grams per liter of fluid removed before doing the static tapping i think he came in late yes uh yes i think you've covered most of it and most of the questions that i see uh sir is already covered uh in his session so uh you can actually watch the replay of the entire session which will be available in the replay section in a couple of days so if you've missed any parts so joined in late uh you can always have a look at the recording of this session and um um yes i i would uh i don't i see questions coming in but that is what that was okay okay the ada level for abdominal okay so for and tuberculosis this is a vital question okay ada so id would also depend upon the serum protein level the best guide there is you may can make use of ada level is the singularity of the abdominal fluid okay it should be hypercellular and predominant cell should be lymphocytes that would suggest okay at least more than 250 cells and predominantly lymphocytes ada you can make use of as a help in as in any other condition right that's it yes sir i think yeah we've covered most of the questions if we've missed any questions we will uh we will get them answered at some other time from sir but uh thank you so much sir for coming in once again onto netflix and we will definitely keep the third talk with you like you said on complications of cirrhosis we will arrange that for some time very soon and thank you everyone for coming in

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dr. Ravindra Nath Sahay

Dr. Ravindra Nath Sahay

Professor of Internal Medicine at GSMC & KEMH (Retired) | Professor at DY Patil Medical College | Consultant Physician, Apollo Hopital, Navi Mumbai

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dr. Ravindra Nath Sahay

Dr. Ravindra Nath Sahay

Professor of Internal Medicine at GSMC & KEMH...

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