Ed McDonald
Often
Mismanaged
Possible
Cancer / Infection
Pathogenesis
Treatment
Clinical
Historical
Clinical
Historical
Greek
as·ci·tes
noun ə-ˈsīt-ēz
askitēs, ασκίτης, askos
 Bag or Wine Bag
World J. Surg. Vol. 27, No. 1, January 2003
Date of download:
2/27/2013
Copyright © The American College of Physicians.
All rights reserved.
From: Evidence of Hypertr...
18th dynasty, Amarna period, c1345 BC
Ascites + liver
disease
300 - 250 BC
Ascites + renal
disease
30BC -50AD
“taking a sharp-pointed knife or lancet…
and about three fingers’ breadth distance
from [the navel] we divide…the peritone...
VariousImages
Abdominal
Distension
Edema
Causes Clinical Findings
Diagnostic
Workup
85%
8%
3% 2% 2%
Cirrhosis
Miscellaneous Portal
Hypertension Related
Disorder
Cardiac disease
Peritoneal
Carcinomatosis
Mis...
Hepatic Fibrosis
Common causes =
Alcohol, Hep C, NAFLD
Compensated vs.
decompensated
44% 5 yr mortality after
developing a...
Runyon, B. HEPATOLOGY, Vol. 49, No. 6, 2009
Cirrhosis
Etoh
Hepatitis
Pancreatitis
Nephrotic
Syndrome
TB
Acute Liver
Failur...
Alcohol IV Drug Use Tattoos Transfusions
Piercings
Sexual
Activity
Country of
Origin
Travel
Maximum
Weight
Hx of
Cirrhosis...
Fluid seeking lowest point
in abdomen bulging
flanks
Typically requires 500ml
Bickley & Szilagyi. Bates Guide to physical...
Bickley & Szilagyi. Bates Guide to physical examination and history taking. 2003
Flank dullness = ~ 1500ml
If no dullness <10% chance of ascites
http://depts.washington.edu/hepstudy/mgmt/clindx/ascitesEv...
Comprehensive Chemistry Panel
Complete Blood Count
Urinalysis
BNP
PT/INR
Infectious w/u?
Tumor Markers?
New onset ascites
Fever/Pain/AMS
Coagulopathy = Contraindication
Complications in 1%
Runyon, B. HEPATOLOGY, Vol. 49, No. 6...
 NEJM VIDEO
Thompson et al. N Engl J Med 2006;355:e21.
• Cecum/liver
Right side
Concerns
• Spleen
Left
Concerns
• Inferior Epigastric
...
Smith GS, Barnard GF. Massive volume
paracentesis. 1997 (up to 41 liters)
 30-50cc for diagnostic
paracentesis
 >1L for therapeutic
PMN < 250
• transparent,
yellow
Low protein
• water like
WBC > 5000
• Cloudy
RBC > 20,000
• Red
Typical
Straw Color
Chylou...
Serum albumin – ascites albumin = SAAG
 Accuracy is decreased if…
 serum and ascitic fluid albumin
are not drawn at the same time
serum albumin is < 1.1 g/dL
Renal Failure
Hyponatremia
Increased Mortality
Shorter time to recurrence
Gines et al., Gastroenterology 1996; 111:1002
CIRRHOSIS
Peritoneal Carinomatosis
• Protein production by tumor cells lining
peritoneum
Chylous Ascites
• Lymph node obstruction
TB...
Etoh Abstinence
Sodium restriction (88 mmol/day [2000 mg/day]) and diuretics
(oral spironolactone with or without oral fur...
Serial therapeutic paracentesis
Post paracentesis albumin infusion > than 4-5 L.
For large-volume paracentesis, 6-8g/L of ...
Wong, F. Journal of Gastroenterology and Hepatology 27 (2012) 11–20
Spontaneous
Bacterial
Peritonitis
Hepato-renal
Syndrome
Hepatic
Hydrothorax
Cellulitis
Tense
Ascites
Abdominal
Hernias
 Translocation of intestinal bacteria
into ascitic fluids.
 Defined as a neutrophil count > 250
cells/mm3
 If polymicro...
 Ceftriaxone 2g x 5-7 days
 iv albumin 1.5 g/kg on
day 1 and 1.0 g/kg on day
3
 Prophylaxis
 prior SBP
 gastrointesti...
Figure 7a. Hepatic hydrothorax in a 60-year-old man with liver cirrhosis.
Kim Y K et al. Radiographics 2009;29:825-837
©20...
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
Ascites
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Ascites

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Ascites

  1. 1. Ed McDonald
  2. 2. Often Mismanaged Possible Cancer / Infection
  3. 3. Pathogenesis Treatment Clinical Historical Clinical Historical
  4. 4. Greek as·ci·tes noun ə-ˈsīt-ēz askitēs, ασκίτης, askos  Bag or Wine Bag World J. Surg. Vol. 27, No. 1, January 2003
  5. 5. Date of download: 2/27/2013 Copyright © The American College of Physicians. All rights reserved. From: Evidence of Hypertrophic Osteoarthropathy in Human Skeletal Remains from Pre-Hispanic Mesoamerica Ann Intern Med. 1994;120(3):238-241. doi:10.7326/0003-4819-120-3-199402010-00010 ~2000 BC Meso-american Figurine With Massive Ascites :
  6. 6. 18th dynasty, Amarna period, c1345 BC
  7. 7. Ascites + liver disease 300 - 250 BC Ascites + renal disease 30BC -50AD
  8. 8. “taking a sharp-pointed knife or lancet… and about three fingers’ breadth distance from [the navel] we divide…the peritoneum [with] the first incision until the instrument comes to an empty space. [Then] we introduce… a copper tube [and] we may evacuate through the tube a small quantity of fluid proportionate to his strength…avoiding, by all means, a sudden evacuation..” Full Latin text of Chapter 12 entitled “Ectropion,” extracted from the Latin Epitome 1551
  9. 9. VariousImages
  10. 10. Abdominal Distension Edema
  11. 11. Causes Clinical Findings Diagnostic Workup
  12. 12. 85% 8% 3% 2% 2% Cirrhosis Miscellaneous Portal Hypertension Related Disorder Cardiac disease Peritoneal Carcinomatosis Miscellaneous Runyon BA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215-20.
  13. 13. Hepatic Fibrosis Common causes = Alcohol, Hep C, NAFLD Compensated vs. decompensated 44% 5 yr mortality after developing ascites Runyon, B. HEPATOLOGY, Vol. 49, No. 6, 2009
  14. 14. Runyon, B. HEPATOLOGY, Vol. 49, No. 6, 2009 Cirrhosis Etoh Hepatitis Pancreatitis Nephrotic Syndrome TB Acute Liver Failure Budd Chiari SOS Cancer Lymphatic Leakage Myxedema
  15. 15. Alcohol IV Drug Use Tattoos Transfusions Piercings Sexual Activity Country of Origin Travel Maximum Weight Hx of Cirrhosis Cancer Pain Heart Failure Fever/Sweats Duration STDs Runyon, B. HEPATOLOGY, Vol. 49, No. 6, 2009
  16. 16. Fluid seeking lowest point in abdomen bulging flanks Typically requires 500ml Bickley & Szilagyi. Bates Guide to physical examination and history taking. 2003
  17. 17. Bickley & Szilagyi. Bates Guide to physical examination and history taking. 2003
  18. 18. Flank dullness = ~ 1500ml If no dullness <10% chance of ascites http://depts.washington.edu/hepstudy/mgmt/clindx/ascitesEval/discussion.html
  19. 19. Comprehensive Chemistry Panel Complete Blood Count Urinalysis BNP PT/INR Infectious w/u? Tumor Markers?
  20. 20. New onset ascites Fever/Pain/AMS Coagulopathy = Contraindication Complications in 1% Runyon, B. HEPATOLOGY, Vol. 49, No. 6, 2009 Int J Nephrol Renovasc Dis. 2011; 4: 29–33 platelets19,000 cells/mm3 INR 8.7
  21. 21.  NEJM VIDEO
  22. 22. Thompson et al. N Engl J Med 2006;355:e21. • Cecum/liver Right side Concerns • Spleen Left Concerns • Inferior Epigastric vessels Umbilical Concerns
  23. 23. Smith GS, Barnard GF. Massive volume paracentesis. 1997 (up to 41 liters)
  24. 24.  30-50cc for diagnostic paracentesis  >1L for therapeutic
  25. 25. PMN < 250 • transparent, yellow Low protein • water like WBC > 5000 • Cloudy RBC > 20,000 • Red Typical Straw Color Chylous Ascites Chylous Ascites
  26. 26. Serum albumin – ascites albumin = SAAG
  27. 27.  Accuracy is decreased if…  serum and ascitic fluid albumin are not drawn at the same time serum albumin is < 1.1 g/dL
  28. 28. Renal Failure Hyponatremia Increased Mortality Shorter time to recurrence Gines et al., Gastroenterology 1996; 111:1002
  29. 29. CIRRHOSIS
  30. 30. Peritoneal Carinomatosis • Protein production by tumor cells lining peritoneum Chylous Ascites • Lymph node obstruction TB • Protein production Pancreatitis • Leakage of biliary/pancreatic juices
  31. 31. Etoh Abstinence Sodium restriction (88 mmol/day [2000 mg/day]) and diuretics (oral spironolactone with or without oral furosemide). Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L. Paracentesis should be performed in patients with tense ascites. Diuretic-sensitive patients be treated with sodium restriction and oral diuretics rather than with serial paracenteses. Liver transplantation should be considered
  32. 32. Serial therapeutic paracentesis Post paracentesis albumin infusion > than 4-5 L. For large-volume paracentesis, 6-8g/L of albumin Referral for liver transplantation TIPS may be considered Peritoneovenous shunt
  33. 33. Wong, F. Journal of Gastroenterology and Hepatology 27 (2012) 11–20
  34. 34. Spontaneous Bacterial Peritonitis Hepato-renal Syndrome Hepatic Hydrothorax Cellulitis Tense Ascites Abdominal Hernias
  35. 35.  Translocation of intestinal bacteria into ascitic fluids.  Defined as a neutrophil count > 250 cells/mm3  If polymicrobial, consider perforation  Subtract 1 neutrophil for every 250 red blood cells (RBCs)
  36. 36.  Ceftriaxone 2g x 5-7 days  iv albumin 1.5 g/kg on day 1 and 1.0 g/kg on day 3  Prophylaxis  prior SBP  gastrointestinal hemorrhage  iv ceftriaxone 1 g daily × 7 d or equivalent  hospitalized patients with ascitic TP < 1.5 g/dL  serum Na < 130 mmol/L  BUN > 25 mg/dL  serum creatinine (Cr) > 1.2 mg/dL  Child-Turcotte-Pugh (CTP) score > 9 and TB > 3 mg/dL,  ciprofloxacin 500 mg daily or oral trimethoprim- sulfamethoxazole double- strength daily
  37. 37. Figure 7a. Hepatic hydrothorax in a 60-year-old man with liver cirrhosis. Kim Y K et al. Radiographics 2009;29:825-837 ©2009 by Radiological Society of North America

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