Ascites
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.