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Group 7 Dimaun, Joy Sandoval, Noel Santos, Marjorie Soliman, Lea
GROUP 7 ² PERITONEAL FLUID (one case only) Nanay Celia, a 46 year old fish vendor, underwent paracentesis after being confined for an enlarged stomach and a pleural effusion. Blood is drawn, and a peritoneal fluid specimen is obtained and sent to the laboratory for analysis. BLOOD CHEMISTRY RESULTS: Total protein: 6.5 g/dL Lactate dehydrogenase (LD) 300 U/L FBS: 82 mg/dL LFT (ALT, AST, GGT, ALP) normal PERITONEAL FLUID RESULTS: A. Physical exam: a. Color ² yellow b. Clarity ² clear c. Clots present ² no B. Microscopic exam: d. Leukocyte count: 8 cells/uL C. Chemical exam: i. Total protein ii. LD iii. Glucose 2.9 g/dL 125 U/L 67 mg/dL (Reference range: 6.0 to 8.3 g/dL) (Reference range: 275 to 645 U/L) (Referente range: 70 to 110 mg/dL)
D. Gram stain: no organisms seen E. Cytology exam: no malignant cells seen 1. Calculate the fluid-to-serum total protein ratio. 2. Calculate the fluid-to-serum lactate dehydrogenase ratio. 3. Classify this peritoneal fluid specimen as a transudate or exudate and state two physiologic mechanisms that can cause this type of effusion. 4. What is the possible diagnosis of the patient? Explain.
1. Serum Total protein: Peritoneal fluid Total protein: Formula: fluid protein/serum protein Solution: 1.9 g/dl / 6.5 g/dl = 0.45 ratio
6.5 g/dL 2.9 g/dL
2. Serum Lactate dehydrogenase (LD): Peritoneal fluid LD: Formula: fluid LD/Serum LD Solution: 125 U/L / 300 U/L = 0.42 ratio
300 U/L 125 U/L
3. The peritoneal fluid obtained from the patient is a transudate fluid. Transudate fluids are usually clear, serum-like, has fewer cell count, lower total protein and LD ratio and a higher glucose. Likewise, the fluid obtained from the patient. Transudates are results of increased pressure in the portal vein or decreasing colloid oncotic pressure in blood vessels. Vasoconstriction and fluid retention produce an increased hydrostatic pressure in the capillaries. An imbalance between the pressure within blood vessels (which drives fluid out of the blood vessel) and the amount of protein in blood (which keeps fluid in the blood vessel) can result in accumulation of transudate fluid.
4. Transudative fluids result from changes in blood flow, and are typically seen in persons with cirrhosis, congestive heart failure, and a few other conditions that disrupt normal hemodynamics. We first considered cirrhosis as the possible diagnosis of the patient but the problem is it does not explain the pleural effusion. That is why our final diagnosis is heart failure which includes ascites (swelling of the abdomen) and pleural effusion as its major signs and symptoms. Heart Failure Heart Failure is a condition in which a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's needs. Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life. In our case it is biventricular failure due to pleural effusion but mostly a right-sided failure due to ascites. Biventricular failure Dullness of the lung fields to finger percussion and reduced breath sounds at the bases of the lung may suggest the development of a pleural effusion (fluid collection in between the lung and the chest wall). Though it can occur in isolated left- or right-sided heart failure, it is more
common in biventricular failure because pleural veins drain both into the systemic and pulmonary venous system. When unilateral, effusions are often right-sided, presumably because of the larger surface area of the right lung. Right-sided failure Backward failure of the right ventricle leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body. This causes swelling under the skin (termed peripheral edema or anasarca) and usually affects the dependent parts of the body first (causing foot and ankle swelling in people who are standing up, and sacral edema in people who are predominantly lying down). Nocturia (frequent nighttime urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night. In progressively severe cases, ascites (fluid accumulation in the abdominal cavity causing swelling) and hepatomegaly (enlargement of the liver) may develop. Significant liver congestion may result in impaired liver function, and jaundice and even coagulopathy (problems of decreased blood clotting) may occur.
Pathophysiology Heart failure is caused by any condition which reduces the efficiency of the myocardium, or heart muscle, through damage or overloading. As such, it can be caused by as diverse an array of conditions as myocardial infarction (in which the heart muscle is starved of oxygen and dies), hypertension (which increases the force of contraction needed to pump blood) and amyloidosis (in which protein is deposited in the heart muscle, causing it to stiffen). Over time these increases in workload will produce changes to the heart itself:
Paracentesis Paracentesis is a procedure in which excess fluid in the abdomen is sampled by aspiration through a needle. The fluid may be called ascites fluid, abdominal fluid, or peritoneal fluid. Paracentesis is commonly performed to identify the cause of newly diagnosed ascites (excess fluid in the abdominal cavity); to diagnose changes in the condition of a patient already known to have ascites; and to relieve pressure from severe distention due to increased fluid in the abdomen. A sample of the fluid withdrawn from the abdominal cavity is nearly always sent for laboratory analysis to determine the presence or absence of infection, and/or to learn more about the cause of ascites if necessary. Ascites forms for a variety of reasons, including infection, diseases of various organs, and conditions which result in abnormal blood flow. The most common cause in the United States is alcoholic cirrhosis. y Paracentesis is the removal of peritoneal fluid from the abdominal cavity with a needle, tubing, and a container that may have a vacuum. The patient is positioned lying down with the head of the bed raised. A local anesthetic is applied and then the doctor inserts the needle into the abdominal cavity and the sample is removed. It is performed to drain excess peritoneal fluid ² to relieve pressure in the abdomen. The volume of fluid removed may be large ² sometimes as much as four liters (1 gallon) or more. This may need to be repeated periodically with some diseases.
Heart failure Heart failure is almost always a chronic, long-term condition, although it can sometimes develop suddenly. The condition may affect the right side, the left side, or both sides of the heart.
Right-sided heart failure means the right ventricle of the heart loses its pumping function. Left-sided heart failure means the heart's ability to pump blood forward from the left side of the heart is decreased. The left side of the heart normally receives blood rich in oxygen from the lungs and pumps it to the remainder of the body.
Heart failure is often classified as either systolic or diastolic.
Systolic heart failure means that your heart muscle cannot pump, or eject, the blood out of the heart very well. Diastolic heart failure means that your heart's pumping chamber does not fill up with blood.
Peritoneal Fluid or Ascites Peritoneal fluid is a liquid that acts as a lubricant in the abdominal cavity. It is found in small quantities between the layers of the peritoneum. Peritoneal fluid is produced by mesothelial
cells in the membranes and acts to moisten the outside of the organs and to reduce the friction of organ movement during digestion. Treatment The condition that causes ascites will be treated, if possible. Treatment may include:
y y y y
Diuretics or ´water pills,µ to help remove the fluid; usually, spironolactone (Aldactone) is used at first, and then furosemide (Lasix) will be added Antibiotics, if an infection develops Limiting salt in the diet (no more than 1,500 mg/day of sodium) Avoiding drinking alcohol
Procedures used for ascites that do not respond to medical treatment include:
Placing a tube into the area to remove large volumes of fluid (called a large volume paracentesis) Transjugular intrahepatic portosystemic shunt (TIPS), which helps reroute blood around the liver
As patients develop end-stage liver disease, and the ascites no longer respond to treatment, liver transplantation becomes necessary.
References: http://www.surgical-tutor.org.uk/default-home.htm?system/abdomen/ascites.htm~right http://en.wikipedia.org/wiki/Transudate http://en.wikipedia.org/wiki/Heart_failure http://www.nlm.nih.gov/medlineplus/ency/article/000286.htm http://www.enotes.com/nursing-encyclopedia/paracentesis http://en.wikipedia.org/wiki/Ascites http://symptoms.wrongdiagnosis.com/cosymptoms/abdominal-swelling/pleural-effusion-descsall.htm Questions: 1. Peritoneal fluid is collected by? a. Pleurocentesis b. Paracentesis c. Pericentesis d. Thoracentesis 2. Formed as ultrafiltrates of plasma, with no additional material contributed by the mesothelial cells that line the membrane? a. Serous fluid b. Pleural fluid c. Pericardial fluid
d. Nota 3. Usual volume of serous fluid to be collected? a. 100 ml b. 200 ml c. 1 L d. 2 L 4. Which of the following causes effusions? a. Congestive heart failure b. Hepatic cirrhosis c. Infection and inflammation d. AOTA 5. Usual cause of Ascites? a. Liver disease b. Lung disorder c. Kidney problem d. NOTA 6. Process in which individual molecules flow through a hole without collisions between molecules? a. Effusion b. Diffusion c. Fusion d. NOTA 7. A fluid that provides lubrication and free movement? a. Serous fluid b. Lubricant c. Water d. NOTA 8. Formation of serous fluid is controlled by? a. Permeability of the capillaries in the parietal membrane b. Hydrostatic pressure in the capillaries c. Oncotic pressure d. AOTA 9. It is the double layer of tissue A. Ascites B. peritoneum. C. peritoneal 10. It helps to lubricate your abdominal organs so they can move around inside. e. A. peritoneal fluid f. B. Ascites fluid g. C. Amniotic fluid
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