Ascites - Diagnostic Approach and Differential Diagnosis
The most common causes: cirrhosis, malignancy and heart failure. Approx 5% of patients w/ ascites have more than one cause (e.g. cirrhosis + TB, peritonitis, peritoneal carcinomatosis, HF, etc.).
Physical Exam:
1) Most relevant findings: Fluid wave (LR 5.3), peripheral edema (LR 3.8) / absence of edema (LR 0.17), shifting dullness (LR 2.1) - fluid wave/shifting dullness detect > 1 litre of ascites.
2) Other findings: bulging flanks, flank dullness, puddle sign, auscultatory percussion, abdominal wall hernias (umbilical, inguinal, incisional).
3) Signs of underlying disease: Cirrhosis, Malignancy, Heart Failure
Labs + Ascitic Fluid Analysis:
1) General appearance: Uncomplicated ascites: clear, pale straw-colored yellow, infection: hazy, cloudy or bloody fluid; hemorrhagic: frank blood; chylous: milky fluid; brown: elevated bilirubin
2) Routine tests: Cell count and differential, albumin and total protein concentration
3) Optional tests: Culture in blood culture bottles (infection, bowel perforation), glucose concentration (malignancy, infection, bowel perforation), LDH (malignancy, infection, bowel perforation), gram stain (suspected bowel perforation), amylase concentration (pancreatic ascites or bowel perforation), TB smear/culture/ADA (TB peritonitis), cytology/CEA antigen (malignancy), triglyceride (chylous ascites), bilirubin
concentration (bowel or biliary perforation), Serum pro-brain natriuretic peptide (heart failure)
Dr. Jorge Cortés @Jcortesizaguirr
#Ascites #workup #Differential #Diagnosis #hepatology
Benign Prostatic Hyperplasia: Pathogenesis and Clinical Findings
Hormonal alterations (result of aging process)
-> Incr testosterone to DHT conversion via 5-alpha-reductase -> DHT binds to AR within prostate cells, especially in transitional zone
-> Incr aromatization of androgens to estrogens via enzyme P450 aromatase -> Estrogen binds to ERs in the prostate -> altered gene expression
-> Initiation of ER and AR -dependent production & secretion of peptide growth factors (IGF-1, EGF, FGF-related proteins)
Inflammation & immune dysregulation -> Bacterial infection, diet, hormones, urine reflux, autoimmune response, or combination -> Incr proliferation of immunocompetent cells (lymphocytes, macrophages, granulocytes) -> Prostate Inflammation: Incr tissue injury and activation of inflammatory cytokines (IL-2, IL-15, IL-17) -> Chronic process of tissue remodeling activates hyper-proliferative programs via Incr growth factors and Decr apoptosis -> Stromal proliferation, transdifferentiation, and extracellular matrix production -> Bladder outlet obstruction due to mass effect (static component)
- Postmicturition: Dribbling, incomplete emptying
- Voiding Symptoms: Hesitancy, weak steam, intermittency, straining
- Storage Symptoms: Urgency, nocturia, incontinence, frequency
Chronic retention of urine & inability to completely empty the bladder -> Hydronephrosis, Acute or chronic renal injury, Hematuria, Urinary retention, UTIs & bladder stones
#BPH #Benign #Prostatic #Hyperplasia #Prostate #Pathophysiology #Urology #Signs #Symptoms #Diagnosis
Types of Renal Calculi
Calcium oxalate
- Interstitial apatite plaque, Low urine volume, Increased urinary calcium excretion, Increased urinary oxalate (dietary)
- Idiopathic hypercalciuria, Hypercalcemia, Renal tubular acidosis (type 1)
Calcium phosphate
- Inner medullary collecting duct plaque, Low urine volume, Increased urinary calcium excretion
- Idiopathic hypercalciuria, Hypercalcemia
Calcium carbonate
- Hypercalciuria, Hypercarbonaturia
- Ingestion of calcium carbonate as calcium supplement (>2000 mg/day)
Cystine
- Cystinuria, Defective transport of cysteine and di-basic amino acids in kidney and intestine, Low urinary citrate
- Autosomal recessive genetic disease (incidence 1/10,000)
Struvite
- Magnesium, ammonium and phosphate: alkaline urine
- Infection with ammonia-producing organisms: Proteus, Pseudomonas, Klebsiella, Staphylococcus and Mycoplasma infections, High dietary magnesium
Uric acid
- Hyperuricemia
- Hyperuricemia, Renal tubular acidosis (types 1 and 2)
Drugs
- Acyclovir, indinavir, atazanavir, triamterene
- Antiviral treatment for herpes virus or HIV/AIDS, diuretics to treat heart failure
#Calculi #Types #Renal #stones #differential #diagnosis #causes #calculus
Algorithm and Differential Diagnosis of Macroscopic Hematuria
Important Historical Elements:
- Painless: suggests malignancy
- Painful: suggests calculi/infection
- Urinalysis: presence of dysmorphic RBC’s, RBC/WBC casts, proteinuria suggest intrinsic renal disease
- Timing: early (distal urethra), throughout (upper urinary tract), terminal (bladder neck, prostatic) #Diagnosis #EM #IM #Urology #Hematuria #Macroscopic #Differential #Algorithm #Ddxof
