Ascites: Difference between revisions
Ostermayer (talk | contribs) (Marked this version for translation) |
|||
| (43 intermediate revisions by 9 users not shown) | |||
| Line 1: | Line 1: | ||
<languages/> | |||
<translate> | |||
==Clinical Features== | ==Background== <!--T:1--> | ||
<!--T:2--> | |||
[[File:Scheme body cavities-en.png|thumb|Lateral view showing abdominopelvic cavity.]] | |||
*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--> | |||
*[[Special:MyLanguage/Cirrhosis|Cirrhosis]] 81%<ref>Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.</ref> | |||
*Malignancy 10% | |||
*[[Special:MyLanguage/Heart failure|Heart failure]] 3% | |||
*[[Special:MyLanguage/Tuberculosis|Tuberculosis]] 2% | |||
*Other 4% | |||
==Clinical Features== <!--T:5--> | |||
<!--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 | ||
*+/- [[Special:MyLanguage/SOB|SOB]] if massive amount | |||
==Diagnosis== | ==Differential Diagnosis== <!--T:7--> | ||
===Workup=== | |||
</translate> | |||
{{DDX abdominal distention}} | |||
<translate> | |||
</translate> | |||
{{Hepatomegaly DDX}} | |||
<translate> | |||
==Evaluation== <!--T:8--> | |||
<!--T:9--> | |||
[[File:Auscities.png|thumb|Ascites appearance on ultrasound]] | |||
[[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]] | |||
''Ascites in females with no other reason for it = gynecologic neoplasm until proven otherwise (ovarian cancer)'' | |||
===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]] | ||
*[[Paracentesis]] | |||
====Ascites Fluid Workup==== <!--T:12--> | |||
<!--T:13--> | |||
*Cell count and differential | |||
*Albumin | |||
*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> | |||
**[[Special:MyLanguage/Gram stain|Gram stain]] | |||
**Glucose | |||
**LDH | |||
**Amylase | |||
**AFB smear and culture | |||
**Cytology | |||
**Triglyceride | |||
</translate> | |||
{{Ascites Evaluation}} | |||
<translate> | |||
==Management== <!--T:14--> | |||
<!--T:15--> | |||
*Salt restriction | |||
**Effective in about 15% of patients | |||
*[[Special:MyLanguage/Diuretics|Diuretics]] | |||
**[[Special:MyLanguage/Spironolactone|Spironolactone]] | |||
***Starting dose = 100mg/day PO (max 400mg/day) | |||
***40% of patients will respond | |||
**[[Special:MyLanguage/Furosemide|Furosemide]] | |||
***40mg/day PO (max 160mg/day) | |||
***Ratio of 100:40 with spironolactone (reduces risks of potassium prob) | |||
*Water restriction | |||
*[[Special:MyLanguage/Paracentesis|Paracentesis]] | |||
*Consider liver transplantation and shunting | |||
==Disposition== <!--T:16--> | |||
<!--T:17--> | |||
*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/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Symptoms]] | |||
</translate> | |||
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.