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1 Abdominal paracentesis Abdominal paracentesis is performed as part of the diagnostic evaluation in all patients with new onset of ascites to help determine the cause It should also be performed to diagnose bacterial peritonitis in all patients admitted to the hospital with cirrhosis and ascites (in whom the prevalence of bacterial peritonitis is 10 30%) and when patients with known ascites develop clinical deterioration (fever, abdominal pain, rapid worsening of renal function, or worsened hepatic encephalopathy) a Inspection Cloudy fluid suggests infection Milky fluid is seen with chylous ascites due to high triglyceride levels Bloody fluid is most commonly attributable to a traumatic paracentesis, but up to 20% of cases of malignant ascites are bloody b Routine studies (1) Cell count A white blood cell count is the most important test Normal ascitic fluid contains < 500 leukocytes/mcL and < 250 polymorphonuclear neutrophils (PMNs)/mcL Any inflammatory condition can cause an elevated ascitic white count A PMN count of > 250/mcL (neutrocytic ascites) with a percentage of > 75% of all white cells is highly suggestive of bacterial peritonitis, either spontaneous primary peritonitis or secondary peritonitis (ie, caused by an intra-abdominal source of infection, such as a perforated viscus or appendicitis) An elevated white count with a predominance of lymphocytes arouses suspicion of tuberculosis or peritoneal carcinomatosis (2) Albumin and total protein The serum-ascites albumin gradient (SAAG) is the best single test for the classification of ascites into portal hypertensive and nonportal hypertensive causes (Table 14 7) Calculated by subtracting the ascitic fluid albumin from the serum albumin, the gradient correlates directly with the portal pressure An SAAG 11 g/dL suggests underlying portal hypertension, while gradients < 11 g/dL implicate nonportal hypertensive causes The accuracy of the SAAG exceeds 95% in classifying ascites It should be recognized, however, that approximately 4% of patients have mixed ascites, ie, underlying cirrhosis with portal hypertension complicated by a second cause for ascites formation (such as malignancy or tuberculosis) Thus, a high SAAG is indicative of portal hypertension but does not exclude concomitant malignancy The ascitic fluid total protein provides some additional clues to the cause An elevated SAAG and a high protein level (> 25 g/dL) are seen in most cases of hepatic congestion secondary to cardiac disease or Budd-Chiari syndrome However, an increased ascitic fluid protein is also found in up to 20% of cases of uncomplicated cirrhosis Two-thirds of patients with malignant ascites have a total protein level > 25 g/dL (3) Culture and Gram stain The best technique consists of the inoculation of aerobic and anaerobic blood culture bottles with 5 10 mL of ascitic fluid at the patient s.



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chronic liver disease include palmar erythema, cutaneous spider angiomas, gynecomastia, and Dupuytren s contracture Asterixis secondary to hepatic encephalopathy may be present Anasarca results from cardiac failure or nephrotic syndrome with hypoalbuminemia Finally, firm lymph nodes in the left supraclavicular region or umbilicus may suggest intra-abdominal malignancy The physical examination is relatively insensitive for detecting ascitic fluid In general, patients must have at least 1500 mL of fluid to be detected reliably by this method Even





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It is understandable that you may want to print a PDF file using code located directly within your web page. The alternative is to make your viewer download of  ...

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javascript ; October 20, 2013; By Sam Deering. Load PDF into iframe and call print . Code snippet to Load PDF into iframe and call print . Also see: 10 JQUERY  ...

PING uses Internet Message Control Protocol (ICMP) packets to query by IP or by name, and works across routers, so it s usually the first tool used to check if a system is reachable Unfortunately, many devices block ICMP packets, so a failed PING doesn t always point to an off line system If PING doesn t work you can try an ARP PING that uses Address Resolution Protocol (ARP) packets instead of ICMP The only downside to ARP is that ARPs do not cross routers, so you can only use it within a broadcast domain Windows does not have ARP PING UNIX and UNIX-like systems use the ARPING utility to perform an ARP PING Here s a sample PING output:

Fever and abdominal pain Peritoneal signs uncommonly encountered on examination Neutrocytic ascites (> 250 white blood cells/mcL) with neutrophilic predominance

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bedside, which increases the sensitivity for detecting bacterial peritonitis to over 85% in patients with neutrocytic ascites (> 250 PMNs/mcL), compared with approximately 50% sensitivity by conventional agar plate or broth cultures c Optional studies Other laboratory tests are of utility in some specific clinical situations Glucose and lactate dehydrogenase (LDH) may be helpful in distinguishing spontaneous from secondary bacterial peritonitis (see below) An elevated amylase may suggest pancreatic ascites or a perforation of the gastrointestinal tract with leakage of pancreatic secretions into the ascitic fluid Perforation of the biliary tree is suspected with an ascitic bilirubin concentration that is greater than the serum bilirubin An elevated ascitic creatinine suggests leakage of urine from the bladder or ureters Ascitic fluid cytologic examination is ordered if peritoneal carcinomatosis is suspected Adenosine deaminase may be useful for the diagnosis of tuberculous peritonitis

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Spontaneous bacterial infection of ascitic fluid occurs in the absence of an apparent intra-abdominal source of infection It is seen with few exceptions in patients with ascites caused by chronic liver disease Translocation of enteric bacteria across the gut wall or mesenteric lymphatics leads to seeding of the ascitic fluid, as may bacteremia from other sites Approximately 20 30% of cirrhotic patients with ascites develop spontaneous peritonitis; however, the incidence is greater than 40% in patients with ascitic fluid total protein < 1 g/dL, probably due to decreased ascitic fluid opsonic activity Virtually all cases of spontaneous bacterial peritonitis are caused by a monomicrobial infection The most common pathogens are enteric gram-negative bacteria (E coli, Klebsiella pneumoniae, Enterococcus species) or gram-positive bacteria (Streptococcus pneumoniae, viridans streptococci) Anaerobic bacteria are not associated with spontaneous bacterial peritonitis

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Print .js - Javascript library for HTML elements, PDF and image files ...
Print .js is a tiny javascript library to help printing from the web. ... Print .js was primarily written to help us print PDF files directly within our apps, ... <button type ="button" onclick="printJS({printable: base64 , type: ' pdf ', base64 : true})"> Print PDF  ...

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