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Ascites

Aug 24, 20256 min read

IM

DR WAQAR

DEFINITION

Accumulation of more than 25 cc of fluid in the peritoneal cavity is called ascites.

( normally, only about 25 cc fluid in the cavity)

GRADES OF ASCITES

  1. Grade 1: Mild ascites, only detected by ultrasound. Physical exam normal.
  2. Grade 2: Moderate ascites, causing moderate abdominal & flank distension
  3. Grade 3: Large ascites, causing huge abdominal distension ( Grade 2 & 3 can be detected by physical exam)

At least 1.5 L fluid should be present in the abdomen so as to be detected by examination

S/S

Patient’s complaints:

  • No complaints ( if very little fluid)
  • Abdominal distension
  • Respiratory distress

On Examination :

  • Normal ( if very little fluid)
  • Abdominal distension if significant fluid is present
  • Shifting dullness if significant fluid is present
  • Fluid thrill if significant fluid is present
  • Umbilicus may be bulging if significant fluid is present

CLASSIFICATION

Ascites can be divided into 2 main types according to the protein concentration of the fluid

  1. TRANSUDATE: Protein less than 30g/L in the ascitic fluid.
  2. EXUDATE: Protein more than 30 g/L

A better way of classification is the SAAG ratio
( Serum to Ascites Albumin Gradient)

SAAG

  • Serum albumin minus ascitic fluid albumin ( albumin difference)
  • This difference can be more than 1.1g/100cc or less than 1.1g/100cc

So, ASCITES WITH SAAG > 1.1 OR SAAG < 1.1

CAUSES OF ASCITES

SAAG > 1.1

  • Cirrhosis wth/portal HTN
  • Portal HTN due to any other cause
  • Heart failure
  • Budd-Chiari syndrome (hepatic vein obstruction)
  • Spontaneous bacterial peritonitis

SAAG < 1.1

  • Bacterial & fungal peritonitis
  • Tuberculous peritonitis
  • Nephrotic syndrome
  • Pancreatitis
  • Low serum albumin

Some other types of Ascites

  1. Hemorrhagic ascites: due to malignancy

  2. Chylous ascites:

    • Collection of white “milky” fluid
    • Rich in fats/Triglycerides
    • Occurs in lymphomas, TB peritonitis

COMMONEST CAUSE OF ASCITES IS CIRRHOSIS W/ PORTAL HTN Why ascites occurs in cirrhosis

  • Low serum albumin ⇒ low oncotic pressure ⇒ ascites
  • Backpressure in portal vein ⇒ fluid comes ⇒ out

INVESTIGATIONS IN ASCITES

  1. CBC, electrolytes, serum albumin
  2. LFTs
  3. Hepatitis serology
  4. Abd. ultrasound
  5. Paracentesis(ascitic tap):
    • Every new patient with ascites should get a “diagnostic” tap:
    • Take out 10-20 cc fluid
    • Check albumin (to calculate SAAG), neutrophils (to see infection), RBC, Gram stain & culture, cytology (malignant cells), amylase levels (in suspected pancreatic ascites)Z
Complications of paracentesis:
  • Infection * Intestinal perforation

Relative contraindications:

  • Pregnancy
  • Bleeding disorders

MANAGEMENT OF ASCITES

Low salt & water intake | Diuretics | Paracentesis

In very resistant ascites, a procedure called TIPS is sometimes used. (transjugular intrahepatic porto-systemic shunt).

MANAGEMENT OF ASCITES

  1. Low salt & water: < 2 g/d of salt ( less than ½ tea spoon)
  2. Diuretics:

    • Spironolactone ( aldactone): 1st choice. side effects : gynecomastia, hyperkalemia

    • Can add lasix (furosemide) if needed

    • Reduce ascites gradually (0.5 to 1 kg wt. loss daily). Too much wt. loss “suddenly” is not good!

*In 95% of cases, ascites can be controlled by 1) & 2) *

  1. “Therapeutic Paracentesis”
    • It is done if medicines don’t help (resistant ascites) or very big ascites causing respiratory difficulty.
    • Up to 7 L can be removed at one time.
    • Removal of more than 7L can cause problems like hypotension, renal failure, encephalopathy
    • i.v. albumin given at the time of paracentesis can prevent these complications

Complications of Ascites

  1. SPONTANEOUS BACTERIAL PERITONITIS (S.B.P.)
  2. Resp. distress (spontaneous bact. peritonitis)

Other Presentations

RAPID FIRE QUES SDL

  1. More than how much fluid is detectable by examination?

  2. How to detect ascites by physical exam?

  3. How do you classify ascites based on albumin content? Which ratio?

  4. What is the commonest cause of ascites?

  5. Name some causes of ascites with SAAG more than 1.1?

  6. Name some causes with ratio less than 1.1?

  7. Hemorrhagic ascites means?

  8. What is chylous ascites?

  9. What color is chylous ascites?

  10. Which disease causes chylous ascites?

  11. What investigations to do in ascites patient?

  12. After paracentesis, what things to check in the fluid?

  13. Complications of paracentesis?

  14. When not to do paracentesis?

  15. Name 3 basic ways to treat ascites?

  16. Which procedure to do in resistant ascites?

  17. Which diuretic is the best?

  18. Name 2 side effects of this diuretic?

  19. Patient with ascites. Weight is 80kg. Diuretic started. Weight next day was 75kg. Good or bad?

  20. During large volume paracentesis, what complications can happen?

  21. What to give to prevent them?

  22. Name 2 complications of ascites?

  23. What is SBP?

  24. Diagnostic test for SBP?

  25. How does it present?

  26. 2 risk factors for SBP?

  27. Ascitic fluid shows bacteria, neutro. Count 100 cells. Is this SBP?

  28. Ascitic fluid shows no bacteria, neutro count is 300. Is this SBP?

  29. What to give for secondary prophylaxis of SBP?

  30. What is Budd Chiari syndrome?

  31. S/S?

  32. Risk factoirs for BUDD CHIARI?

  33. Treatment of Budd Chiari?

Surgery

  • Collection of excessive, free intraperitoneal fluid

  • Fluid movement: hydrostatic/ colloid pressure balance

  • Clinical assessment:

    • Fluid thrill (large)
    • Shifting dullness (small)

  • Causes:

    • Transudates (Protein <25/L)- low pp, CCF, PH
    • Exudates: TB, peritoneal malignancy, chylous, pancreatic ascites

  • Diff. diagnosis:

    • Int. obst., large ovarian cyst/abd. mass, advance pregnancy

  • Investigations:

    • underlying cause, US, CT

  • TREATMENT:

    • Underlying cause, low Na diet, diuretics, paracentesis, peritoneo-venous shunt (LeVeen)

Therapeutics

Fluid accumulation within peritoneal cavity

Causes:

(cc TB) most important cause is liver cirrhosis

Mechanism of cirrhotic ascites:

A- Classic Starling theory: Hypoalbuminaemia decrease plasma osmotic pressure (ascetic threshold= 3) and due to portal hypertension (act as localizing factor which localizes fluid in the peritoneal cavity rather than peripheral tissues)

B-generalized fluid retention:

  • hyperaldosteronism due to decreased renal blood flow which stimulate RAS also, due to decreased degradation of aldosterone by the liver.
  • Others:

Complications:

1- Spontaneous bacterial peritonitis with:

  • Clinical manifestations:
  • clinical onset of Fever, chill
  • generlaized Abdominal pain
  • Abdominal tenderness
  • Altered mental status

Can be treated by amioglycosides and ampicillin or third. generation cephalosporin or quinolones.

2-Complication due to treatment e.g hepatorenal syndrome if vigorous dieresis.Z

Treatment :

  1. Bed rest to decrease metabolites handled by the liver and to increased renal perfusion.
  2. diet: Na and water restriction.
  3. diuretics:
    • best is I.V albumin. ((rational treatment; due decreased liver function))
    • Spironolactone (maximum rate of ascetic fluid mobilization is 1-2 L / day and if very rapid (dehydration, hepatorenal syndrome and electrolyte imbalance and hepatic encephalopathy)Z

Medical Management of Ascites:

Diuretic therapy: ParacentesisZ have patient void before procedure then needle puncture of abdominal cavity to remove ascitic fluid- temporary

Assessment/Grading of ascites

  • Grade 1 — mild; Detectable only by US

  • Grade 2 — moderate; Moderate symmetrical distension of the abdomen

  • Grade 3 — large or gross asites with marked abdominal distension

    Imaging studies for confirmation of ascites Ultrasound is probably the most cost-effective modality

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