Pathological accumulation of fluid within peritoneal cavity.

1. ASCITES
DR. YAGNIK CHHOTALA
ASSISTANT PROFESSOR, MEDICINE

2. DEFINITION
• Pathologic accumulation of fluid within the peritoneal cavity.
• It is the most common complication of cirrhosis.
• Most common cause of ascites: Cirrhosis

3. PATHOPHYSIOLOGY IN CIRRHOSIS
1. Portal hypertension with portal pressure >12 mmHg  translation of fluid into
the peritoneal space in excess capacity of the lymphatic system to remove fluid.
2. Progressive peripheral vasodilationreduction in pressure measured at carotid
and renal baroreceptorsactivation of sodium retaining neurohormonal
mechanisms (Renin Angiotensin Aldosterone System, Sympathetic Nervous
System, ADH)sodium and water retention

4. CLINICAL FEATURES
• Symptoms: abdominal distention, shortness of breath
• Signs: shifting dullness, fluid thrill

5. DIAGNOSIS: DIAGNOSTIC PARACENTESIS
1. Cell count in ascitic fluid: In uncomplicated (uninfected) cirrhotic ascites, WBC
count <500 mm3 and Polymorphonuclear neutrophil (PMN) count <250 mm3. PMN
>= 250 mm3 suggests a bacterial infection.
2. SAAG (Serum-Ascites Albumin Gradient):
• >=1.1gm%: cirrhosis, alcoholic, Budd-Chiari syndrome, portal vein thrombosis
• >=1.1gm% with ascitic total protein level >2.5 gm%: cardiac ascites
• <1.1gm%: peritoneal carcinomatosis, biliary or pancreatic leaks, nephrotic syndrome,
tuberculosis peritonitis.
All hospitalized patients with cirrhosis and ascites should under go a diagnostic
paracentesis.

6. TREATMENT
1. Dietary Sodium restriction: <2gm per day
2. Spironolactone + Furosemide (100:40 ratio once daily): maximum 400:160.
Diuretics should be discontinued in patients who develop hepatic
encephalopathy, S.Na <120mEq/l, AKI.
3. Large volume paracentesis: performed in tense ascites or in patients refractory
to diuretics. IV albumin 6-8g per litre of fluid removed should be administered
to prevent circulatory failure.
4. TIPS Placement and Liver transplantation in refractory ascites