Male, 59 years old, emergency colostomy for diverticulitis w/ perforation 2 years ago. 6 months ago, colostomy takedown was attempted, but an ileostomy needed to be placed d/t stricture and difficulty with the surgical stapler. (Trying to be concise; don’t think this history is really relevant.)
Now he is 14 weeks post ileostomy takedown with biomesh placement for peristomal hernia. No complications to speak of during or after this surgery except for a number of additional hernias (not unexpected). He’s put on nearly 40 pounds since then while having little appetite, and has a belly like Tweedledee.
Cardiologist (chronic a-fib for 30+ years) says he’s got abdominal edema, but when asked if it was ascites, said no, not ascites, just excess fluid in the tissues from the trauma of the surgery. Prescribed Lasix 20mg PO daily, with 20mg additional PRN if no urination 1 hour after the first pill. He lost 10 pounds last week - the first week of Lasix, which was promising. But he can’t seem to lose more than that. The weight is now going back up to the new baseline daily (then down 2 pounds or so with the Lasix). The abdomen is still huge, firm, and very rounded, with very tight skin. While the patient has been obese since childhood, his arms, legs and chest are actually fairly slim ATM, and it looks as if he’d be of normal BMI now if this belly would go down.
Lungs have some coarse crackles bilaterally and there’s a productive cough with clear/white sputum, which is normal for this COPD patient who smokes 4-5 cigarettes a day. No pedal edema. Liver and kidney labs are coming back WNL, thank goodness!
So I know nothing about this condition, and was wondering what, if anything, we can do, besides taking the Lasix as prescribed. All my googling of “abdominal edema” and the like is bringing up ascites information.
Has he had a CMP and liver panel? IANAD, but something has to be causing the third-spacing of fluids, and it seems to me that there has to be an osmotic cause to be driving water out of his cells and/or blood into the extracellular compartment. Unless I’m wrong. Which very well may be the case.
Oh also and duh, I’m assuming they have ruled out some kind of ileus as the cause of the abdominal distension.
I’ll suggest he ask at his visit on Tuesday. He gets blood taken frequently for INRs, and docs often add lab orders without warning him, so multiple things get tested and we’re not always told the results. If they haven’t been, I’ll suggest we request it, because I think you’re right.
I know the liver was being watched fairly closely for quite some time after his surgery, because it was a bit wobbly just after the surgery, but it did eventually get its act together. I don’t recall when the last one was done.
One would think. However, we’re talking about the VA, where they have a bizarre combination of brilliant old grizzled hands and clueless baby doctors. Sometimes the obvious does get overlooked. In this case, though, I think it’s safe to assume…the belly’s been huge for months, there have been no signs of infection or symptoms of blockage. He’s stooling normal stools with a normal, regular pattern.
ETA: It’s driving me crazy that I can’t go to these appointments due to my work schedule. Control freak? Moi?
No, don’t run away! I’m sorry. I’m still learning how to be a nurse, and so I use way too much jargon still. I’ll get over it as I get better at my work.
Um…he had surgery on his belly, and he’s healing pretty well from that. But now his belly’s all bloated and swollen with water. The medicine they gave him makes him piss out extra water. It worked really well for a week, but now it’s kind of stalled out. He’s still all bloated, though. Anything I can do to help him get rid of this extra water? (And the unspoken question: why is this happening?)
Sometimes it can be useful to ask for an actual copy of the lab results (assuming you haven’t done that already) instead of just hearing that they are “normal.” Sometimes they only look at one element of the panel and ignore others.
Some other thoughts I had last night: you said kidney panel was normal, but are they just looking at creatinine and gfr? He might have nephrotic syndrome (which I guess also technically causes ascites, but this is a kidney pathology and not a liver pathology). I think a urine dip with protein can help rule that out, but not sure.
Also CHF can possibly cause this picture? You said that he already had some CHF symptomatology, right? Is it possible the stress from the surgery is causing some severe venous pooling of fluid?
Oh, also do you have any recent abdominal CTs?
Good luck!
I’d want to see an actual abdominal echo or CT to verify there’s no ascites and that it’s local abdominal tissue edema, frankly. On exam I’d look for a fluid wave. What’s his liver scratch test like? What’s the albumin and total protein? Is he orthostatic? What’s his total fluid I & O situation? Total caloric intake? Is he ambulatory? Does he have an S3 or S4 gallop?
Meanwhile, one could add a touch of spironolactone and see what happens.
Thank you thank you thank you. I don’t have the answers to all of those questions*, but at least now I know what questions to ask. I’m going to rearrange my schedule so I can go to one of his appointments.
If it were you, which doctor would you take these questions to: PCP (General Practitioner, I think), Cardiologist who gave you the Lasix, the Surgical team or just the first dang one you have an appointment with?
*Not symptomatically orthostatic, but I’ll check his numbers this afternoon, can’t get him to do I&Os, caloric intake fair to good, but don’t have numbers, yes ambulatory, I don’t hear a gallop, but IANACardiologist nor do I have a lot of experience w/ heart sounds, and that afib confuses my ears.
When you say the VA, what do you mean, exactly? Does he get all of his care through the VA, some of his care through the VA and some from community providers, or what?
I’d get this gentleman hooked up with a My Health e-Vet account. This will give you access to all of the lab results for tests performed through the VA system, regardless of whichever VA facility the tests were done. Unfortunately, it doesn’t appear to include imaging studies, but any of his VA providers can give a copy of those reports, as well as other studies done that aren’t available through the online system. This will also facilitate care given by community doctors, who will be able to see the results of tests that the VA does, which will help avoid duplication of tests.
Yes, all his care is currently through the VA. Oh, HEY! Lookee there! They’ve finally upgraded his account. Only took 'em a year.
Hmmm…whole lotta nothing but INRs since February. I am suddenly less assuaged that his liver and kidneys are okay. :dubious: Ok, now I know for sure what I need to pester them for. Thank you!
