Ascites

Question 1

What can it cause

Answer 1

Discomfort, difficulty breathing, fatigue, nausea, poor apetitie

Question 2

Treatment first line

Answer 2

Diuretics, dietary sodium restriction

Question 3

Refractory ascites treatment

Answer 3

large-volume paracentesis, albumin infusion and insertion of a transjugular intrahepatic portosystemic shunt.

Question 4

What is ascites

Answer 4

fluid accumulation in the peritoneal cavity as a result of splanchnic vasodilation and sodium and water retentio

Question 5

What is hepatic hydrothorax

Answer 5

Large pleura effusion - from fluid passing through defect in diaphragma into pleural space

Question 6

Complications of ascites

Answer 6

SBP
Hyponatremia
Hepatorenal syndrome

Question 7

Features of decompensated liver disease

Answer 7

ascites, encephalopathy and gastrointestinal haemorrhage

Question 8

What is SBP defined by

Answer 8

Ascitic fuid tap with neutrophils .250cells/mm3

Question 9

Treatment of SBP

Answer 9

Early administration of appropriate empirical antibiotics - aware of local resistance
Albumin - esp if renal dysfunction

Question 10

When give prophylaxis in ascites

Answer 10

Protein concentration<15g/L

Question 11

Investigations for SBP

Answer 11

FBC
serum creatinine
ascitic fluid appearance
ascitic fluid absolute neutrophil count (ANC)
SAAG - serum ascites albumin gradient
Lactate dehydrogenase

Question 12

What SAAG indicates portal HOTN as a cause of ascites

Answer 12

> 11g/L

Question 13

Causes of ascites when SAAG >11

Answer 13

Cirrhosis/alcholic liver disease
Acute liver failures Liver metasteases
Cardiac - RHF, constricitve pericarditis
Other -
Budd chiari syndrome, portal vein thrombosis, veno-occlusive disease
Myxoaedma

Question 14

Ascites causes when SAAG <11

Answer 14

Hypoalbuminaemia - nephrotic syndrome, severe malnutirtion - kwashiorkor
Malignancy - peritoneal carcinomatosiss
Infection - tuberculous pertiontitis
Other - pancreatitis, bowel obstruction, biliary, postop lymph leak, serositis in CTD

Question 15

When is fluid restrictio recommended in ascites

Answer 15

<125 mmol/L Na

Question 16

What diuretics used in ascites

Answer 16

Aldosterone antagonist eg spirinolactone
Loop diuretics often added

Question 17

Complucations of therapeutic paracentesis

Answer 17

Circulatory dysfunction if large colume (>5L) eg ascites recurrence, hepatorenal syndrome, dilutional hyponatermia, moraltiy

Question 18

What antibitoic prophylactic offer in ascites when protein <15

Answer 18

Oral cirprofloxacin or norfloxaxin until ascites reolved

Question 19

What reduces risk in large volume paracentesis

Answer 19

Albumin cover - give albumin

Question 20

When is liver trnasplation considered wtih ascites

Answer 20

Grade 2 or 3 ascites

Question 21

First episode of ascites treatment

Answer 21

aldosterone antagonist (i.e., spironolactone 100 mg/day) from
the start of therapy and increased in a stepwise manner every
7 days up to 400 mg/day in the unlikely case of no respons

Question 22

Should people stay on diuretics once ascites resolved

Answer 22

No

Question 23

Which patients needto be monitored on diuretics for ascites

Answer 23

Renal impairment
Hyponatremia
Distubances in serum potassu,

Question 24

CI for diuretics

Answer 24

Severe hyponatremia - <120mmol/L), progressive renal failure, worsening hepatic encephalopathy, or
incapacitating muscle cramps

Question 25

What potassium levels should fursoemide vs aldosterone antagonists be stopped at

Answer 25

Furosemide - ,2mmol/L hypo
Aldosterone antagonist - >6 - hyper