Ascites: Difference between revisions
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==Background== | <languages/> | ||
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==Background== <!--T:1--> | |||
<!--T:2--> | |||
[[File:Scheme body cavities-en.png|thumb|Lateral view showing abdominopelvic cavity.]] | |||
*Abnormal buildup of peritoneal fluid | *Abnormal buildup of peritoneal fluid | ||
*Most commonly caused by portal hypertension | |||
*Ascites fluid can become infected (spontaneous bacterial peritonitis), carrying a mortality rate between 30%-90%<ref>Sundaram V, Manne V, Al-Osaimi AM. Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers. Saudi J Gastroenterol. 2014;20(5):279-287. doi:10.4103/1319-3767.141686</ref> | |||
===Causes=== <!--T:3--> | |||
<!--T:4--> | |||
*[[Cirrhosis]] 81%<ref>Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.</ref> | *[[Special:MyLanguage/Cirrhosis|Cirrhosis]] 81%<ref>Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.</ref> | ||
*Malignancy 10% | *Malignancy 10% | ||
*[[Heart failure]] 3% | *[[Special:MyLanguage/Heart failure|Heart failure]] 3% | ||
*[[Tuberculosis]] 2% | *[[Special:MyLanguage/Tuberculosis|Tuberculosis]] 2% | ||
*Other 4% | *Other 4% | ||
==Clinical Features== | |||
[[File:Hepaticfailure.jpg|thumb||Ascites secondary to [[cirrhosis]].]] | ==Clinical Features== <!--T:5--> | ||
*Abdominal distention +/- discomfort | |||
<!--T:6--> | |||
[[File:Hepaticfailure.jpg|thumb||[[Special:MyLanguage/Ascites|Ascites]] secondary to [[Special:MyLanguage/cirrhosis|cirrhosis]].]] | |||
*[[Special:MyLanguage/Abdominal distention|Abdominal distention]] +/- discomfort | |||
*Fluid wave | *Fluid wave | ||
*+/- [[SOB]] if massive amount | *+/- [[Special:MyLanguage/SOB|SOB]] if massive amount | ||
==Differential Diagnosis== | ==Differential Diagnosis== <!--T:7--> | ||
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{{DDX abdominal distention}} | {{DDX abdominal distention}} | ||
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{{Hepatomegaly DDX}} | |||
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==Evaluation== <!--T:8--> | |||
<!--T:9--> | |||
[[File:Auscities.png|thumb|Ascites appearance on ultrasound]] | [[File:Auscities.png|thumb|Ascites appearance on ultrasound]] | ||
[[File:Ascites Alerhand.gif|thumbnail|POCUS showing ascites<ref>http://www.thepocusatlas.com/bowel/</ref>]] | [[File:Ascites Alerhand.gif|thumbnail|POCUS showing ascites<ref>http://www.thepocusatlas.com/bowel/</ref>]] | ||
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]] | [[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]] | ||
''Ascites in females with no other reason for it = gynecologic neoplasm until proven otherwise (ovarian cancer)'' | |||
===Workup=== | ===Workup=== <!--T:10--> | ||
<!--T:11--> | |||
*CBC | *CBC | ||
*Chem 7 | *Chem 7 | ||
*PT/PTT | *PT/PTT | ||
*[[LFTs]] + lipase | *[[Special:MyLanguage/LFTs|LFTs]] + lipase | ||
*[[FAST]] | *[[Special:MyLanguage/FAST|FAST]] | ||
====Ascites Fluid Workup==== <!--T:12--> | |||
<!--T:13--> | |||
*Cell count and differential | *Cell count and differential | ||
*Albumin | *Albumin | ||
*Total protein | *Total protein | ||
*Only if suspicious:<ref name=Runyon2012>Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.</ref> | *Only if suspicious:<ref name=Runyon2012>Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.</ref> | ||
**[[Gram stain]] | **[[Special:MyLanguage/Gram stain|Gram stain]] | ||
**Glucose | **Glucose | ||
**LDH | **LDH | ||
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**Triglyceride | **Triglyceride | ||
==Management== | </translate> | ||
{{Ascites Evaluation}} | |||
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==Management== <!--T:14--> | |||
<!--T:15--> | |||
*Salt restriction | *Salt restriction | ||
**Effective in about 15% of patients | **Effective in about 15% of patients | ||
*[[Diuretics]] | *[[Special:MyLanguage/Diuretics|Diuretics]] | ||
**[[Spironolactone]] | **[[Special:MyLanguage/Spironolactone|Spironolactone]] | ||
***Starting dose = 100mg/day PO (max 400mg/day) | ***Starting dose = 100mg/day PO (max 400mg/day) | ||
***40% of patients will respond | ***40% of patients will respond | ||
**[[Furosemide]] | **[[Special:MyLanguage/Furosemide|Furosemide]] | ||
***40mg/day PO (max 160mg/day) | ***40mg/day PO (max 160mg/day) | ||
***Ratio of 100:40 with spironolactone (reduces risks of potassium prob) | ***Ratio of 100:40 with spironolactone (reduces risks of potassium prob) | ||
*Water restriction | *Water restriction | ||
*[[Paracentesis]] | *[[Special:MyLanguage/Paracentesis|Paracentesis]] | ||
*Consider liver transplantation and shunting | *Consider liver transplantation and shunting | ||
==Complications== | ==Disposition== <!--T:16--> | ||
*[[SBP]] | |||
*[[Hepatorenal syndrome]] | <!--T:17--> | ||
*[[Pleural effusion]] | *Frequently outpatient, once [[Special:MyLanguage/SBP|SBP]] is ruled out, if a known reason for ascites and sufficiently therapeutically drained | ||
==Complications== <!--T:18--> | |||
<!--T:19--> | |||
*[[Special:MyLanguage/SBP|SBP]] | |||
*[[Special:MyLanguage/Hepatorenal syndrome|Hepatorenal syndrome]] | |||
*[[Special:MyLanguage/Pleural effusion|Pleural effusion]] | |||
==See Also== <!--T:20--> | |||
<!--T:21--> | |||
*[[Special:MyLanguage/Jaundice|Jaundice]] | |||
*[[Special:MyLanguage/Paracentesis|Paracentesis]] | |||
*[[Special:MyLanguage/SBP|SBP]] | |||
*[[Special:MyLanguage/Cirrhosis|Cirrhosis]] | |||
*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]] | |||
== | ==References== <!--T:22--> | ||
<!--T:23--> | |||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Symptoms]] | [[Category:Symptoms]] | ||
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Latest revision as of 20:35, 6 January 2026
Background
- Abnormal buildup of peritoneal fluid
- Most commonly caused by portal hypertension
- Ascites fluid can become infected (spontaneous bacterial peritonitis), carrying a mortality rate between 30%-90%[1]
Causes
- Cirrhosis 81%[2]
- Malignancy 10%
- Heart failure 3%
- Tuberculosis 2%
- Other 4%
Clinical Features
- Abdominal distention +/- discomfort
- Fluid wave
- +/- SOB if massive amount
Differential Diagnosis
Abdominal distention
- Obesity
- Intestinal obstruction
- Pregnancy
- Ascites
- Cirrhosis
- Malignancy
- Heart failure
- Tuberculosis
- Spontaneous bacterial peritonitis
- Peritoneal dialysis-associated peritonitis
- Distended bladder / Acute urinary retention
- Constipation / fecal impaction
- Large tumor(s) (e.g. ovarian, lymphoma)
- Organomegaly
Hepatic Dysfunction
Infectious
- Hepatitis
- Malaria
- HIV (present in 50% of AIDS patients)[3]
- EBV
- Babesiosis, leptospirosis
- Typhoid
- Hepatic abscess, amebiasis
Neoplastic
Metabolic
Biliary
- Biliary cirrhosis
Drugs
- Alcoholic cirrhosis
- Alcoholic hepatitis
- Hepatotoxic drugs
Miscellaneous
- Other causes of cirrhosis
- Autoimmune hepatitis
- Veno-occlusive disease
- CHF (right heart failure)
Evaluation
POCUS showing ascites[4]
Ascites in females with no other reason for it = gynecologic neoplasm until proven otherwise (ovarian cancer)
Workup
Ascites Fluid Workup
- Cell count and differential
- Albumin
- Total protein
- Only if suspicious:[5]
- Gram stain
- Glucose
- LDH
- Amylase
- AFB smear and culture
- Cytology
- Triglyceride
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[6]
- Cirrhosis
- Heart failure
- Ascites total protein > 2.5 g/dL suggests cardiac ascites[7]
- 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)
Management
- Salt restriction
- Effective in about 15% of patients
- 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)
- Spironolactone
- Water restriction
- Paracentesis
- Consider liver transplantation and shunting
Disposition
- Frequently outpatient, once SBP is ruled out, if a known reason for ascites and sufficiently therapeutically drained
Complications
See Also
References
- ↑ Sundaram V, Manne V, Al-Osaimi AM. Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers. Saudi J Gastroenterol. 2014;20(5):279-287. doi:10.4103/1319-3767.141686
- ↑ Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.
- ↑ Tintanelli's
- ↑ http://www.thepocusatlas.com/bowel/
- ↑ Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
- ↑ Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
- ↑ Runyon BA. Cardiac ascites: a characterization. J Clin Gastro. 1998; 10(4): 410-412.