Ascites
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This document discusses ascites, a pathological accumulation of fluid in the abdominal cavity. It begins with historical references to ascites from ancient Greece and Mesoamerica. The document then covers the causes, clinical findings, diagnostic workup and treatment of ascites. The most common cause is cirrhosis, accounting for around 85% of cases. Diagnostic paracentesis is used to analyze ascitic fluid and determine if it is a transudate or exudate. Treatment involves dietary changes, diuretics, serial paracentesis and sometimes liver transplantation. Complications like spontaneous bacterial peritonitis are also discussed.
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Ascites
- 1. Ed McDonald
- 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. 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. 18th dynasty, Amarna period, c1345 BC
- 7. Ascites + liver disease 300 - 250 BC Ascites + renal disease 30BC -50AD
- 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
- 14. 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.
- 15. 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
- 16. 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
- 17. 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
- 19. Fluid seeking lowest point in abdomen bulging flanks Typically requires 500ml Bickley & Szilagyi. Bates Guide to physical examination and history taking. 2003
- 20. Bickley & Szilagyi. Bates Guide to physical examination and history taking. 2003
- 21. Flank dullness = ~ 1500ml If no dullness <10% chance of ascites http://depts.washington.edu/hepstudy/mgmt/clindx/ascitesEval/discussion.html
- 25. Comprehensive Chemistry Panel Complete Blood Count Urinalysis BNP PT/INR Infectious w/u? Tumor Markers?
- 27. 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
- 28. NEJM VIDEO
- 29. Thompson et al. N Engl J Med 2006;355:e21. • Cecum/liver Right side Concerns • Spleen Left Concerns • Inferior Epigastric vessels Umbilical Concerns
- 30. Smith GS, Barnard GF. Massive volume paracentesis. 1997 (up to 41 liters)
- 31. 30-50cc for diagnostic paracentesis >1L for therapeutic
- 32. PMN < 250 • transparent, yellow Low protein • water like WBC > 5000 • Cloudy RBC > 20,000 • Red Typical Straw Color Chylous Ascites Chylous Ascites
- 34. Serum albumin – ascites albumin = SAAG
- 38. Accuracy is decreased if… serum and ascitic fluid albumin are not drawn at the same time serum albumin is < 1.1 g/dL
- 39. Renal Failure Hyponatremia Increased Mortality Shorter time to recurrence Gines et al., Gastroenterology 1996; 111:1002
- 40. CIRRHOSIS
- 43. Peritoneal Carinomatosis • Protein production by tumor cells lining peritoneum Chylous Ascites • Lymph node obstruction TB • Protein production Pancreatitis • Leakage of biliary/pancreatic juices
- 44. 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
- 45. 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
- 46. Wong, F. Journal of Gastroenterology and Hepatology 27 (2012) 11–20
- 48. 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)
- 49. 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
- 50. 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