Test: Ascites, Hepatorenal Syndrome & Liver Cancer - NEET PG MCQ

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The test being done is fluid thrill for detection of ascites. The hand of second doctor in picture is to prevent transmission of vibrations by abdominal fat.

For management of Ascites, traditionally spironolactone is given at 100-200 mg/day single dose and furosemide is added at 40-80 mg/day. If ascitic fluid is not mobilized spironolactone can be increased to 400-600 mg/day.

In patient of chronic liver disease, the total hepatocyte mass is lesser and thereby in these patients synthesis of clotting factors is reduced. Since this patient does not have varices the cause of hematemesis in this patient is bleeding diathesis due to liver disease. Bleeding in such patients is treated with FFP in acute situations.
Abnormalities in coagulation in chronic liver diseases

1. Decreased synthesis of clotting factors and impaired clearance of anticoagulants
2. Thrombocytopenia from hypersplenism due to portal hypertension
3. Vitamin K requires biliary excretion for its subsequent absorption thus in patients with chronic cholestatic syndrome vitamin K absorption is frequently diminished

Serum Albumin Ascites Gradient

Refractory ascites can be managed by

• Transjugular intrahepatic peritoneal shunt (TIPS), a radiologically placed portosystemic shunt to decompress the hepatic sinusoids.
• Serial large volume paracentesis (LVP) with albumin
• TIPS is superior to LVP in reducing the reaccumulation of ascites but is associated with an increased frequency of hepatic encephalo-pathy with no difference in mortality rates.
• Diagnostic criteria for refractory ascites
  • Lack of response to maximal doses of diuretic for at least 1 week
  • Diuretic-induced complications in the absence of other precipitating factors
  • Early recurrence of ascites within 4 weeks of fluid mobilization
  • Persistent ascites despite sodium restriction
  • Mean weight loss <0.8 kg over 4 days
  • Urinary sodium excretion less than sodium intake

The child has a serum albumin to globulin ratio (S.A.A.G) of less than 1.1 gm/dl, which indicates a possible diagnosis of nephrotic syndrome.

• Nephrotic syndrome is characterised by high levels of protein in the urine, low levels of protein in the blood, and swelling.
• This condition often leads to fluid retention and can cause symptoms like swelling in the legs and abdomen.
• It is important to conduct further tests to confirm the diagnosis and determine the appropriate treatment.

Ascites in cirrhosis is due to increased transudation from portal vein. The concomitant hypoalbuminemia decreases the oncotic pressure and worsens the ascites, Hyperaldosteronism contributes to resistance to loop diuretics. Therefore, the use of high doses of aldosterone antagonist (spironolactone up to 400 mg/day) is the main therapy to produce a negative sodium balance in cirrhotic patients with ascites.

• Flow from upper abdomen towards the umbilicus point to SVC obstruction
• Flow from lower abdomen towards the umbilicus point to IVC obstruction
• Flow of blood away from the umbilicus points to Portal Hypertension.
• Ascites will always cause a stretched skin with everted umbilicus and bulging flanks
• Pulsatile liver is seen with severe tricuspid regurgitation

• SAAG is calculated by subtracting the ascitic fluid albumin from the serum albumin and does not change with diuresis.
• A SAAG > 1.1 g/dL reflects the presence of portal hypertension and indicates that the ascites is from an increased pressure in the hepatic sinusoids.Possible causes include cirrhosis, cardiac ascites, sinusoidal obstruction syndrome (venoocclusive disease), massive liver metastasis, or hepatic vein thrombosis (Budd-Chiari syndrome).
• A SAAG < 1.1 g/dL indicates that the ascites is not related to portal hypertension as in tuberculous peritonitis, nephrotic syndrome, peritoneal carcinomatosis, or pancreatic ascites.
• White, milky fluid indicates the presence of triglycerides in levels > 200 mg/dL (and often >1000 mg/dL), which is the hallmark of chylous ascites. Chylous ascites results from lymphatic disruption that may occur with trauma, cirrhosis, tumor, tuberculosis, or certain congenital abnormalities.
• Dark brown fluid can reflect a high bilirubin concentration and indicates biliary tract perforation.
• Black fluid may indicate the presence of pancreatic necrosis or metastatic melanoma.

The first line of treatment for ascites primarily involves:

• Salt restriction: Reducing salt intake helps decrease fluid retention.
• Diuretics: These medications promote urine production, helping to eliminate excess fluid.
• Paracentesis: This procedure removes fluid from the abdomen but is not the initial treatment.
• Shunt: Surgical options like shunts are considered later if other treatments fail.

Overall, the most effective initial approach is to restrict salt.

• The hepatorenal syndrome is a form of functional renal failure without renal pathology that occurs in about 10% of patients with advanced cirrhosis or acute liver failure.
• There are disturbances in the arterial renal circulation in patients with HRS; these include an increase in vascular resistance accompanied by a reduction in systemic vascular resistance.
• The reason for renal vasoconstriction is most likely multifactorial. The diagnosis is made usually in the presence of a large amount of ascites in patients who have a stepwise progressive increase in creatinine.
• Type 1 HRS is characterized by a progressive impairment in renal function and a significant reduction in creatinine clearance within 1-2 weeks of presentation. Type 2 HRS is characterized by a reduction in glomerular filtration rate with an elevation of serum creatinine level, but it is fairly stable and is associated with a better outcome than that of Type 1 HRS.
• Patients are managed with midodrine, an alpha-agonist, along with octreotide and intravenous albumin. The best therapy for HRS is liver transplantation.
• In patients with either type 1 or type 2 HRS, the prognosis is poor unless transplant can be achieved.

In Hepatorenal syndrome, which occurs in patients with cirrhosis, the following points are significant:

• Creatinine clearance is typically below 40 ml/min, indicating poor kidney function.
• Urinary sodium levels are often less than 10 mmol/L, showing the kidneys are trying to retain sodium due to low blood volume.
• Urine osmolality is usually higher than plasma osmolality, suggesting that the kidneys are still concentrating urine.
• There is no sustained improvement in renal function even after volume expansion, which confirms the diagnosis.

Among these statements, the one that is incorrect is that urine osmolality is lower than plasma osmolality.

HCC in (he western world is mainly seen with hepatitis C but in developing world is related to chronic liver disease due to various conditions like alcoholic cirrhosis.
In clinical setting of

1. South Asian ethnicity
2. Presence of risk factor alcoholic cirrhosis
3. Presence of portal vein thrombosis malignant infiltration of portal vein radicles is considered. The presence of characteristic CT Scan finding confirms the diagnosis as hepatocellular carcinoma.

Triple-phase CT (including an arterial phase, a portal venous phase, and a late washout phase) has been found to be highly accurate in the diagnosis and characterization of HCC. CT findings are:

1. Hypervascular pattern with arterial enhancement and rapid washout during the portal venous phase. In contrast, regenerative nodules generally appear iso-attenuating or hypo-attenuating when compared to the remaining parenchyma.
2. Visualization of a tumor capsule
3. Demonstration of an internal mosaic resulting from variable attenuation within the tumor, and portal vein branch invasion.

Choice B of metastasis is less likely as it has multiple lesions and large metastasis can outgrow their blood supply leading to central necrosis
Choice C of cholangiocarcinoma will show no changes in liver parenchyma but involvement of biliary tree.
Choice D is ruled out as more common NET arise in duodenum or pancreas.

• Hepatitis B vaccinations can decreases the incidence of hepatitis B and thus hepatocellular carcinoma
• Another vaccine preventable cancer is human papilloma vaccine preventing cervical cancer.

Liver transplantation is first choice for cirrhotic patient with single tumors < 5cm and portal hypertension chemoembolization/TACE is used for unresectable HCC.

• Hepatocellular adenoma (HCA) is rare, benign hepatic neoplasia that is usually identified as a well-defined, solitary lesion. Hepatocellular adenoma occurs predominantly in childbearing women and is related to endogenous or exogenous estrogen levels. High doses and long duration of OC, as well as pregnancy, are associated with a higher incidence of HCA, whereas discontinuation of OC is associated with regression of HCA
• An angiomyolipoma is a very rare hepatic tumor consisting of fat, epithelioid, and smooth muscle cells with thick-walled blood vessels.

• Ultrasound is usually the first investigation that detects the focal mass. It is a simple and noninvasive technique to differentiate solid from cystic lesions and may be sufficient to establish the diagnosis of small hemangiomas or hepatic cysts. However, the diagnostic specificity for solid lesions is low even when improved by the use of color-flow Doppler or contrast US, which may add dynamic information regarding the lesions.
• Triple-phase CT is an excellent modality for characterizing lesions, yielding specific signs in cases of large hemangiomas or FNH, but in many cases, this single modality is not sufficient for establishing the correct diagnosis.
• Magnetic resonance imaging is the best imaging modality in terms of specificity for diagnosing hepatic lesions, particularly when liver-specific contrast agents are utilized

• Cavernous hemangiomas are the most common Beningn Liver Tumour, with an incidence of up to 20% in the general population, depending on the ultrasound studies or autopsy series. This usually small lesion is a congenital hamarlomalous proliferation of vascular endothelial cells and may be multiple in 10% of cases.
• Focal nodular hyperplasia (FNH) is the second most common solid BLT, occurring in up to 3% of the population. FNH is considered to be a nonneoplastic lesion that is caused by a hyperplastic response to a congenital vascular malformation or a disruption in blood supply.

Hepatocellular carcinoma is a type of liver cancer influenced by various risk factors. The following points explain the major risk factors associated with this cancer:

• Hepatitis C infection: This viral infection is a significant risk factor as it can lead to chronic liver disease and cancer.
• Alcoholism: Excessive alcohol consumption damages the liver, increasing the likelihood of cancer development.
• Alfatoxins: These are toxins produced by certain moulds found on crops and can increase cancer risk when consumed.

However, a diet high in animal fat is not directly linked to the risk of developing hepatocellular carcinoma.