This is lecture notes for 5th sem MBBS students. Introduction to ascites. Includes causes , pathophysiology and approach to a patient with ascites

1. Hepatology lectures for
5th Sem;MBBS
Pratap Sagar Tiwari
MBBS,MD (Medicine),DM (Hepatology)

2. Summary
? Predisposing
conditions
Etiologies
Liver Fibrosis/cirrhosis
Portal Hypertension
Varices
Splenomegaly
Ascites
Normal Liver

3. PORTAL HYPERTENSION
Ascites
1
2
3
Causes
4 Management
Approach

4. DEFINITION: ASCITES
H/o VH
VH prevention measures
for pts with a known
H/o VH
Secondary Prophylaxis
• Ascites is the pathological accumulation of fluid within
the peritoneal cavity.
The peritoneal cavity normally contains approximately 50–75 mls of
fluid that serves to lubricate the tissues that line the abdominal wall
and viscera.1,2
1. Rumack C, Wilson S, Charboneau J, et al. Diagnostic ultrasound, 4th ed St Louis, MO: Mosby,
2011.
2. Hanbidge A, Lynch D, Wilson S. US of the peritoneum. Radiographics 2003; 23: 663–685.
Pleural fluid: 10-20 ml
Pericardial fluid: 15-50 ml

5. CAUSES OF ASCITES
Causes of ascites can be categorized on basis of several aspects like
• etiology (infection, malignancy),
• pathophysiology (portal hypertension-related, non-PHTN related),
• organ/system specific (cirrhotic, cardiac, renal )
• others (exudative vs transudative: (protein < 25 g/L) )
However the common causes of ascites are;

6. CAUSES OF ASCITES
Common Causes Less Common causes
Cirrhosis -84 % • Massive hepatic metastasis
Cardiac causes • Infection (tuberculosis, chlamydia
infection)
Peritoneal carcinomatosis • Pancreatitis
• Primary peritoneal malignancies-
mesothelioma and sarcoma
• Abdominal malignancies- gastric or colonic
adenocarcinoma
• Metastatic disease from breast or lung
carcinoma
• Melanoma
• Renal disease

7. RARE CAUSES OF ASCITES
Rare Causes
• Hypothyroidism
• Familial mediterranean fever
• Collagen vascular disease
• Amyloidosis
• Fitz-hugh-Curtis syndrome
• Protein-loosing enteropathy, malnutrition
• Trauma (Bile ascites, urine ascites), Chylous ascites

8. PATHOPHYSIOLOGY
Portal hypertension-related Non-portal hypertension related
Exudation
Lymphatic
obstruction
Hypoalbuminemia
Transudation
PATHOPHYSIOLOGY

9. PATHOPHYSIOLOGY
Normally;
• The peritoneum behaves like a
semipermeable membrane that enables the
continuous exchange of water and solutes
between the peritoneal cavity and the
intraperitoneal blood and lymph vessels.
PATHOPHYSIOLOGY

10. PATHOPHYSIOLOGY
Non-portal hypertension related
Exudation
Lymphatic
obstruction
Hypoalbuminemia
Any causes leading to
hypoalbuminema
Protein-loosing enteropathy
Malnutrition
Nephrotic syndrome
• Albumin comprises 75-80% of normal plasma colloid oncotic pressure and 50% of
protein content.
• When plasma proteins, especially albumin, no longer sustain sufficient colloid
osmotic pressure to counterbalance hydrostatic pressure, edema/ascites
develops.
PATHOPHYSIOLOGY

11. PATHOPHYSIOLOGY IN ASCITES: due to Portal HTN

12. APPROACH
✓ Small amounts of ascites are asymptomatic, but with larger accumulations of fluid (>
1 L) there is abdominal distension, fullness in the flanks, shifting dullness on
percussion and, when the ascites is marked, a fluid thrill/fluid wave.
✓ Other features include eversion of the umbilicus, herniae, abdominal striae,
divarication of the recti and scrotal oedema.
✓ Dilated superficial abdominal veins may be seen if the ascites is due to portal
hypertension.
HISTORY EXAMINATION INVESTIGATION

13. Approach to Ascites
History
Examination
Investigation
• Bowel obstruction, severe constipation and ileus- inability to
pass stool and flatus together with nausea/ vomiting
• Weight loss, night sweats and anorexia
• ↑ eructation or flatus- aerophagia or ↑ intestinal production
of gas
• Symptoms of other medical conditions- heart failure and tb
• Question about risk factors like excessive alcohol use, iv drug
abuse, chronic viral infection and jaundice
APPROACH TO ASCITES

14. Approach to Ascites
History
Examination
Investigation
Clues for Cardiac disease
• Elevated JVP
• Kussmaul’s sign
• Pericardial knock
• Murmur of TR
APPROACH TO ASCITES

15. Approach to Ascites
History
Examination
Investigation
Clues for Chronic liver disease
• Pt is sarcopenic with distended abdomen
• Peripheral signs of CLD
Jaundice ,Parotid swelling, Gynaecomastia in males,
Breast atrophy in females, Loss of axillary hairs,
Spider naevi, Caput medusae, Testicular atrophy,
palmar erythema, Dupytrens contracture,
Leuconychia
APPROACH TO ASCITES

16. Approach to Ascites
History
Examination
Investigation
Abdomen Examination
• Inspection: generalized distention (localized incase
of loculated ascites or mass), bulging flanks,
distended superficial veins, everted umbilicus and
umbilical nodule may be seen in malignancy
• Grey-Turner's or Cullen's sign can be present in case
of Acute Pancreatitis
APPROACH TO ASCITES

17. Approach to Ascites
History
Examination
Investigation
Abdomen Examination
• Palpation: tenderness, guarding( peritonitis)
,enlarged liver or splenomegaly
• Percussion: Shifting dullness, fluid thrill
APPROACH TO ASCITES

18. INSPECTION
• Asymptomatic
• Abdominal distension
• fullness in the flanks
Shifting dullness on percussion, a fluid thrill/fluid wave.
• Eversion of the umbilicus
• Hernia
• Abdominal striae
• Divarication of the recti
• Scrotal oedema
Other features include
*Dilated superficial abdominal veins may be seen if the ascites is due to portal hypertension.
PERCUSSION
SUMMARY

19. Approach to Ascites
History
Examination
Investigation
Imaging, eg USG
Ascites fluid
Evaluation
Others; like ECHO

20. ➢IMAGING: ULTRASOUND & CT SCAN

21. ASCITES FLUID EVALUATION
• Appearance
• SAAG ?
• Exudative ascites ? SBP ?
• Others
Why SAAG ?
The presence of a gradient ≥1.1g/dL indicates that the pt has PHTN-related ascites with
96% accuracy.
A SAAG <1.1g/dL indicates that the pt does not have PHTN-related ascites, and another
cause of the ascites should be sought.

22. SAAG (SERUM ASCITES ALBUMIN GRADIENT)

23. OTHERS; ASCITES EVALUATION
➢Pancreatic ascites: Ascitic amylase > 1000 mg/dl
➢Cytology
➢Tuberculous peritonitis:
• lymphocytosis and ADA> 40 U/L
• Ascitic fluid AFB smear: sensitivity 0-3 %
• Ascitic fluid culture: sensitivity 35-50 %
• Elevated ADA: sensitivity >90% (cutoff value 35-40 U/L)
Laparatomy or Laparascopy with biopsy- gold standard if cause is uncertain

24. OTHERS; LABORATORY EVALUATION
➢Serum amylase and lipase- to rule out pancreatitis
➢24 hr. urinary protein- nephrotic syndrome
➢Malabsorption and increased small intestinal bacterial overgrowth- detection of
hydrogen and methane gas in expired breath
➢ECHO
➢Hepatic venous pressure gradient
➢Liver biopsy

25. SPONTANOUS BACTERIAL PERITONITIS
Definition: an infection of initially sterile ascitic fluid without a detectable intra-
abdominal surgically treatable source of infection.
The presence of infection is documented by
- positive ascitic fluid bacterial culture (essentially monomicrobial) &
- an elevated ascitic fluid absolute PMN count (>250 cells/mm3)
Note; Absolute PMN count = total white blood cell count X % of PMN

26. SECONDARY BACTERIAL PERITONITIS

27. TREATMENT
Note: The ascites that recurs at least on three occasions within a 12-month period despite dietary sodium restriction and
adequate diuretic dosage is defined as recidivant ascites.
➢ Ascites is uncomplicated when it is not infected, refractory or a/with HRS.

28. TREATMENT
➢ Sodium and water restriction
➢ Diuretics
➢ Paracentesis
➢ TIPSS
➢ Liver Transplantation
➢ OTHERS;