Ascites

Question 1

Most common cause of ascites.

Answer 1

Cirrhosis

Question 2

2 main mechanisms that contribute to the formation of ascites.

Answer 2

1. Cirrhosis: leads to increased sinusoid pressure and fluid leaks into peritoneal cavity.
2. Cirrhosis: leads PH and low arterial blood volume activating the Renin-Ag-Aldosterone system increasing water reabsorption.

Question 3

Why doesn’t a blocked portal vein lead to ascites?

Answer 3

Fluid must proceed into the liver for it to flow out into the peritoneal cavity (unless there is perforation). Blockage will actually decrease portal blood pressure and flow.

Question 4

What test can confirm ascites if it is suspected after physical exam?

Answer 4

Ultrasound of the abdomen

Question 5

Two routine tests that must be performed with every paracentesis.

Answer 5

1. Albumin/Protein: test for cirrhotic ascites

2. PMN culture count: checks for spontaneous bacterial peritonitis (SBP)

Question 6

How is a Serum Ascites Albumin Gradient calculated and how is it interpreted?

Answer 6

SAAG = serum albumin - ascites albumin

SAAG> 1.1 means PH because the increased pressure forces liver proteins into the fluid

SAAG< 1.1 means some other cause (bacterial etc)

Question 7

When performing a culture on the ascites fluid what is important to remember?

Answer 7

Perform at bedside right after the paracentesis.

Question 8

What is uncomplicated ascites?

Answer 8

Ascites that responds to diuretics in the absence of infection or renal dysfunction.

Question 9

What are the 2 treatment regimens for uncomplicated ascites?

Answer 9

1. Salt restriction (sodium) + diuretics (spironolactone and/or furosemide)
2. Large Volume Paracentesis (LVP) if the ascites is causing respiratory or cardiac distress due to mechanical obstruction

Question 10

What is refractory ascites?

Answer 10

Diuretic intractable (dose required would cause too many side effects) 
or
Diuretic resistant (diuretics at maximum dose and no effect)

Question 11

Treatment for refractory ascites in patients that would not be good liver transplant candidates.

Answer 11

Peritoneo-Venous Shunt (PVS): surgical shunt from the peritoneal cavity up to the rt. subclavian vein or right jugular.

Question 12

Treatment for refractory ascites in patients that may be good liver transplant candidates.

Answer 12

1. LVP + albumins (albumins would increase oncotic pressure in the blood vessels and keep fluid out of the peritoneal cavity)
2. TIPS (if step 1 fails)

Question 13

What is spontaneous bacterial peritonitis?

Answer 13

SBP: infected ascitic fluid with absence of infection elsewhere in the body

Question 14

What is diagnostic on lab test for SBP and what is the main causative agent?

Answer 14

Dx: PMNs>250 and/or culture (+)

E. coli is biggest culprit

Question 15

Best treatment for SBP.

Answer 15

Tx: Broad spectrum antibiotics,
Cefotaxime + ampicillin

Quinolones (prophylaxis to prevent recurrence)

Question 16

Drug class to avoid in treating SBP.

Answer 16

Aminoglycosides (gentamycin, clindamycin)

Question 17

What is the main proposed cause of SBP?

Answer 17

Bacterial Translocation: bacterial migrating from the intestinal lumen to mesenteric lymph nodes and the liver allowing entry to ascitic fluid

Question 18

Who should be given prophylactic treatment for SBP and what drug class is used?

Answer 18

Treat anyone with a GI bleed

Use quinolones

Question 19

How is SBP distinguished from secondary bacterial peritonitis?

Answer 19

Secondary bacterial peritonitis is caused by bowel perforation and the peritoneal fluid analysis shows elevated PMNs, multiple organisms on Gram stain and culture, and at least two of the following criteria :

1. Total protein greater than 1 g/dL
2. Lactate dehydrogenase above the upper limit of normal for serum
3. Glucose less than 50 mg/dL

Question 20

Describe the pathogenesis of Hepatorenal syndrome.

Answer 20

Renal failure due to cirrhosis or liver failure.

• vasodilation of the peri-renal arteries surrounding the kidneys
• vasoconstriction of the intra-renal arteries leading to decreased GFR
• histologically the kidneys look fine

Question 21

Treatment for each type of Heaptorenal Syndrome.

Answer 21

Vasoconstrictors: octreotide + midodrine in both types along with albumin

Type 1: fast progressing, need a liver transplant quickly, pts can die within a cpl weeks

Type 2: monitoring and treating the ascites with diuretics, salt intake, LVP can treat the HRS