Ascites Flashcards

1
Q

Define ascites

A

Pathological collection of fluid in the peritoneal cavity

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2
Q

Aetiology of ascites

A

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

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3
Q

Clinical features of ascites

A

Abdominal distension
Abdominal discomfort/pain
Dyspnoea
Reduced mobility
Anorexia and early satiety
Shifting dullness

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4
Q

investigations for ascites

A

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)

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5
Q

How is ascites graded

A

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

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6
Q

How is SAAG interpreted

A

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

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7
Q

How is ascitic PMN interpreted

A

> 250/mm³ = Spontaneous bacterial peritonitis → urgent abx
250/mm³ with raised LDH/positive gram stain/positive culture = perforative peritonitis → surgical emergency

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8
Q

Management for ascites

A
  1. Address underlying cause
  2. Salt-restricted diet
  3. Fluid restriction
  4. Spironolactone ± furosemide if insufficient
  5. 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

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9
Q

Complications of treatment

A

Paracentesis
Paracentesis induced circulatory dysfunction → Recurrence of ascites | Hepatorenal syndrome | Dilutional hyponatraemia
Haematoma (1%)
Haemoperitoneum
Severe haemorrhage
Infection

(Contraindicated in DIC)

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10
Q

Complications of ascites

A

Spontaneous bacterial peritonitis (an infection of previously sterile ascitic fluid without apparent intra-abdominal source of infection)
Encephalopathy
Hepatorenal syndrome

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