Ascites Flashcards
Define ascites
Pathological collection of fluid in the peritoneal cavity
Aetiology of ascites
Non-peritoneal
Portal hypertension:
- Cirrhosis
- Alcoholic liver disease
- Fulminant hepatitis e.g. paracetamol overdose
- Subacute hepatitis
- Liver metastasis
- Cardiac: Congestive heart failure | Constrictive pericarditis
- Budd-Chiari syndrome
Hypo-albuminaemia:
- Nephrotic syndrome
- Protein-losing enteropathy
Miscellaneous: myxoedema, ovarian tumours, pancreatic ascites, surgical trauma
peritoneal
Malignant:
- Peritoneal mesothelioma
- Peritoneal carcinomatosis
- Ovarian cancer
Infectious peritonitis:
- TB
- Chlamydia
- Candida
- Histoplasma
- Cryptococcus
SLE
Clinical features of ascites
Abdominal distension
Abdominal discomfort/pain
Dyspnoea
Reduced mobility
Anorexia and early satiety
Shifting dullness
investigations for ascites
LFTs
U&Es
VBG
FBC: thrombocytopenia suggests portal HTN
Viral serology
Serum albumin
Ascitic tap/paracentesis: cell count and differentials | albumin and total protein concentration | Serum ascites albumin gradient (SAAG) | polymorphonuclear leukocyte (PMN) | LDH
US abdomen: ?cirrhosis or malignancy
CT abdomen: ?splenomegaly (PHTN)
How is ascites graded
Grade 1: mild ascites detectable only by ultrasound
Grade 2: moderate ascites with moderate symmetrical distention of abdomen
Grade 3: large or gross ascites with marked abdominal distention
How is SAAG interpreted
High SAAG (>1.1g/dL) = portal HTN cause
Portal hypertension:
- Cirrhosis
- Alcoholic liver disease
- Fulminant hepatitis e.g. paracetamol overdose
- Subacute hepatitis
- Liver metastasis
- Cardiac: Congestive heart failure | Constrictive pericarditis
- Budd-Chiari syndrome
Low SAAG:
Hypo-albuminaemia:
- Nephrotic syndrome
- Protein-losing enteropathy
Miscellaneous: myxoedema, ovarian tumours, pancreatic ascites, surgical trauma
Malignant:
- Peritoneal mesothelioma
- Peritoneal carcinomatosis
- Ovarian cancer
Infectious peritonitis:
- TB
- Chlamydia
- Candida
- Histoplasma
- Cryptococcus
SLE
How is ascitic PMN interpreted
> 250/mm³ = Spontaneous bacterial peritonitis → urgent abx
250/mm³ with raised LDH/positive gram stain/positive culture = perforative peritonitis → surgical emergency
Management for ascites
- Address underlying cause
- Salt-restricted diet
- Fluid restriction
- Spironolactone ± furosemide if insufficient
- Prophylactic antibiotics e.g. PO ciprofloxacin or norfloxacin (ascitic protein <15g/L)
Conduct regular therapeutic paracentesis for patients with ascites refractory to medical management, whereby the fluid is drained from the abdomen over a few hours.
Refractory → large volume paracentesis, albumin replacement, TIPS
Complications of treatment
Paracentesis
Paracentesis induced circulatory dysfunction → Recurrence of ascites | Hepatorenal syndrome | Dilutional hyponatraemia
Haematoma (1%)
Haemoperitoneum
Severe haemorrhage
Infection
(Contraindicated in DIC)
Complications of ascites
Spontaneous bacterial peritonitis (an infection of previously sterile ascitic fluid without apparent intra-abdominal source of infection)
Encephalopathy
Hepatorenal syndrome