2. WHAT ISASCITES?
Greek origin (askos)
and means bag or sac
It is the collection of
fluid in the peritoneal
cavity
Syn:-
Hydroperitoneum
Hydraskos or
abdominal dropsy
4. ASCITES
It is pathological collection of fluid in the peritoneal cavity.
In Western countries cirrhosis is the commonest cause (80%) of
ascites. Ascites is the most common complication of cirrhosis. It
is a poor prognostic factor. Portal hypertension, renin angiotensin
aldosterone pathway causing renal sodium retention, increased
hydrostatic pressure in hepatic sinusoids and splanchnic vessels
cause ascites. In metastatic malignancy ascites develops due to
liver secondaries, peritoneal carcinomatosis which secretes protein
rich fluid and lymph. Leakage of pancreatic juice, bile, lymph also
causes specific ascites
5. Clinical Types
Mild — 0 to 150 ml amount required to
demonstrate radiologically
Moderate — 500–2000 ml causes clinical dullness
in flanks.
Severe — > 2000 ml.
6. TWO GRADING SYSTEMS FOR ASCITES
HAVE BEEN USED IN THE LITERATURE.
An old system which grades ascites from 1+
to 4+, depending on the detectability of fluid
on physical examination.
More recently, the International Ascites Club
has proposed a system of grading from 1 to 3.
7. The older system
1+ is minimal and barely detectable.
2+ is moderate.
3+ is massive but not tense.
4+ is massive and tense.
The International Ascites Club grading (2003)
Grade 1: mild ascites detectable only by US.
Grade 2: moderate ascites manifested by
moderate symmetrical abdominal distension.
Grade 3: large or gross ascites with marked
abdominal distension.
26. Signs
Mild:
Puddle sign—Tapping around the umbilicus in knee-elbow position elicits
dullness.
Moderate:
Positive shifting dullness in the abdomen.
Severe:
Positive fluid thrill.
Tanyol sign: Umbilicus is shifted upward in pelvic mass (ovarian
cyst) downwards in ascites.
Hamilton ruler test is also used to differentiate ascites from ovarian
cyst. This Blaxland (Athelstan Blaxland) ruler test shows pulsation
in ovarian cyst not in ascites. A flat ruler is placed on the abdomen
just above the anterior superior iliac spines and pressed firmly backwards. If the
swelling is due to ovarian cyst, transmitted aortic pulsation can be felt across the
ruler.
Smiling horizontal umbilicus.
28. Investigations
* Ultrasound abdomen.
* Ascitic tap—always should be done after emptying
the bladder by placing the needle
below the umbilicus lateral to the
rectus muscle. It may be Diagnostic or
Therapeutic tap. Fluid is sent for
analysis.
29. Ascitic fluid having cells less than 1000/mm3 is clear;
from 1000–5000/mm3 is unclear;
more than 5000/mm3 is turbid/cloudy.
(trauma during tapping) blood will clot.
Lipid in the ascitic fluid is seen in chylous ascites.
In cirrhotic patients, ascitic fluid without SBP contains less
than 500 cells/mm3 with 50% of them are neutrophils. If ascitic
fluid contains more than 250 neutrophils/mm3 it suggests acute
inflammation.
Serum ascites albumin gradient (SAAG) is calculated by
subtracting ascitic fluid albumin level from serum albumin level.
30. If SAAG more than 1.1, it is called as high gradient
which suggests portal hypertension. If SAAG is less than 1.1,
it is called as low gradient which suggests absence of portal
hypertension. SAAG is 98% accurate.
High gradient SAAG is seen in—cirrhosis, alcoholic,
cardiac ascites, multiple liver secondaries, fulminant liver
failure, Budd-Chiari syndrome, portal vein thrombosis.
Low gradient SAAG is seen in—peritoneal secondaries,
peritoneal tuberculosis, pancreatic ascites, biliary ascites,
nephrotic syndrome, lymph leak, connective tissue diseases
causing ascites.
31. Abdominal fluid
Straw coloured fluid
Cirrhosis
Tuberculosis
Hypoproteinaemia
Nephrotic syndrome
Budd-Chiari syndrome (Hepatic vein
thrombosis)
Constrictive pericarditis
Chronic pancreatitis
Ovarian tumour (Meig’s syndrome)
Malignancy
Haemorrhagic fluid
Traumatic tap
Tumour
Acute haemorrhagic pancreatitis
Bleeding disorder
Chylous fluid
Parasitic infestation—filariasis
Tuberculosis
Malignancy of thoracic duct
Trauma to thoracic duct
Thrombosis of subclavian vein
Purulent fluid
Abdominal infections
Penetrating wounds or infections
Pyaemia and septicaemia ,Rupture/perforation of an organ
32. Treatment
The cause is treated.
Therapeutic tap—It should be slow and gradual or
staged tapping. Up to 5 liters can
be tapped in 90 minutes.
