Ascites

Background

• Abnormal buildup of peritoneal fluid

Clinical Features

• Abdominal distention +/- discomfort
• Fluid wave
• +/- SOB if massive amount

Complications

• SBP
• Hepatorenal syndrome
• Portal/splenic vein thrombosis

Differential Diagnosis

Ascites Diagnosis

The differential diagnosis of ascites is often clarified by the calculation of the serum albumin to ascites gradient (SAAG).^

• High SAAG > 1.1 g/dL – Indicative of portal hypertension
  • Cirrhosis
  • Heart failure
    • Ascites total protein > 2.5 g/dL suggests cardiac ascites
  • Alcoholic hepatitis
  • Budd-Chiari syndrome
  • Portal vein thrombosis

• Low SAAG < 1.1 g/dL
  • Malignancy / peritoneal carcinomatosis
  • Nephrotic syndrome
  • Pancreatitis
  • Peritoneal tuberculosis
  • Serositis
  • Bowel infarction
  • Chylous

^SAAG = (serum albumin in g/dL) − (ascitic albumin in g/dL)

Evaluation

• Ascites in females with no other reason for it = gyn neoplasm until proven otherwise (ovarian cancer)

Workup

POCUS showing ascites

• CBC
• Chem 7
• PT/PTT
• LFTs + lipase
• FAST

SBP Work-Up of Ascitic Fluid via Paracentesis

• Cell count with differential
• Gram stain
• Culture (10cc in blood culture bottle)
• Glucose
• Protein

Consider

• Albumin and SERUM albumin
• LDH and SERUM LDH at same time
• Amylase

Specific circumstances

• TB smear and culture
• Cytology
• TG
• Billirubin

Management

1. Salt restriction
   • Effective in about 15% of patients
2. Diuretics
   • Spironolactone
     • Starting dose = 100mg/day PO (max 400mg/day)
     • 40% of patients will respond
   • Furosemide
     • 40mg/day PO (max 160mg/day)
     • Ratio of 100:40 with spironolactone (reduces risks of potassium prob)
3. Water restriction
4. Paracentesis
5. Consider liver transplantation and shunting

Disposition

• Frequently outpatient, once SBP is ruled out, if a known reason for ascites and sufficiently therapeutically drained

See Also

• Jaundice
• Paracentesis
• SBP