1. AscitesAscites
Presented byPresented by
ZaYDoon H.AZaYDoon H.A

2. AscitesAscites
• Derived from the Greek wordDerived from the Greek word “askos”,“askos”,
meaning bag or sac.meaning bag or sac.
• Defined as the accumulation of fluid in theDefined as the accumulation of fluid in the
peritoneal cavity.peritoneal cavity.
• It is a common clinical finding, with manyIt is a common clinical finding, with many
extraperitoneal and peritoneal causes ,extraperitoneal and peritoneal causes ,
but most common from liver cirrhosis .but most common from liver cirrhosis .

3. Peritoneal cavityPeritoneal cavity
• It is a potential space between theIt is a potential space between the
parietal peritoneum and visceralparietal peritoneum and visceral
peritoneum, the two membranesperitoneum, the two membranes
separate the organs in the abdominalseparate the organs in the abdominal
cavity from the abdominal wall.cavity from the abdominal wall.
• Derived from the coelomic cavity of theDerived from the coelomic cavity of the
embryo.embryo.
• Largest serosal sac in the body andLargest serosal sac in the body and
secretes approximately 50 ml of fluid persecretes approximately 50 ml of fluid per
day.day.

6. Peritoneal fluidPeritoneal fluid
• It is a normal, lubricating fluid found in theIt is a normal, lubricating fluid found in the
peritoneal cavity.peritoneal cavity.
• The fluid is mostly water with electrolytes,The fluid is mostly water with electrolytes,
antibodies, white blood cells, albumin,antibodies, white blood cells, albumin,
glucose and other biochemicals.glucose and other biochemicals.
• Reduce the friction between theReduce the friction between the
abdominal organs as they move aroundabdominal organs as they move around
during digestion.during digestion.

7. Patient with AscitesPatient with Ascites

8. Etiology of ascitesEtiology of ascites
Most Common causes(90% of cases):Most Common causes(90% of cases):
• Portal HTN secondary to chronic liverPortal HTN secondary to chronic liver
diseases ( cirrhosis)diseases ( cirrhosis)
• Intra-abdominal malignancyIntra-abdominal malignancy
• Congestive Heart FailureCongestive Heart Failure
• Mycobacterium tuberculosisMycobacterium tuberculosis

9. portal hypertensionportal hypertension
• It is a high blood pressure in the portalIt is a high blood pressure in the portal
vein and its tributaries(portal venousvein and its tributaries(portal venous
system).system).
• It is defined as a portal pressure gradientIt is defined as a portal pressure gradient
(the difference in pressure between the(the difference in pressure between the
portal vein and the hepatic veins) of 5 mmportal vein and the hepatic veins) of 5 mm
Hg or greater.Hg or greater.

10. Causes of portal hypertensionCauses of portal hypertension
• Intrahepatic causes:Intrahepatic causes: liver cirrhosis and hepaticliver cirrhosis and hepatic
fibrosis (e.g. due to Wilson's disease,fibrosis (e.g. due to Wilson's disease,
hemochromatosis, or congenital fibrosis).hemochromatosis, or congenital fibrosis).
• Prehepatic causes :Prehepatic causes : portal vein thrombosis orportal vein thrombosis or
congenital atresia.congenital atresia.
• Posthepatic obstructionPosthepatic obstruction occur at any leveloccur at any level
between liver and right heart, including hepaticbetween liver and right heart, including hepatic
vein thrombosis, IVC thrombosis, IVC congenitalvein thrombosis, IVC thrombosis, IVC congenital
malformation, and constrictive pericarditis.malformation, and constrictive pericarditis.

11. CirrhosisCirrhosis
most common causes of cirrhosis:most common causes of cirrhosis:
• Alcoholic liver disease or alcoholicAlcoholic liver disease or alcoholic
hepatitishepatitis
• viral hepatitis (B or C)viral hepatitis (B or C)
• fatty liver diseasefatty liver disease

14. Other causes of ascitesOther causes of ascites
HypolalbuminemiaHypolalbuminemia
• Nephrotic syndromeNephrotic syndrome
• Protein-losing enteropathyProtein-losing enteropathy
• malnutritionmalnutrition

15. Other causes of ascitesOther causes of ascites
• Bacterial, fungal or parasitic diseaseBacterial, fungal or parasitic disease
• VasculitisVasculitis
• Whipple's DiseaseWhipple's Disease
• Familial Mediterranean feverFamilial Mediterranean fever
• EndometriosisEndometriosis
• Starch peritonitisStarch peritonitis
• Budd-Chiari SyndromeBudd-Chiari Syndrome
• MyxedemaMyxedema
• Ovarian disease (e.g. Meigs' Syndrome)Ovarian disease (e.g. Meigs' Syndrome)
• Pancreatic diseasePancreatic disease
• Chylous AscitesChylous Ascites

16. PathophysiologyPathophysiology
1-1- Increased hydrostatic pressureIncreased hydrostatic pressure
• CirrhosisCirrhosis
• Hepatic vein occlusion (Budd-ChiariHepatic vein occlusion (Budd-Chiari
Syndrome)Syndrome)
• Inferior vena caval obstructionInferior vena caval obstruction
• Constrictive PericarditisConstrictive Pericarditis
• Congestive heart failureCongestive heart failure

17. PathophysiologyPathophysiology
2.2. Decreased colloid osmoticDecreased colloid osmotic
pressurepressure
• End-stage liver disease with poor proteinEnd-stage liver disease with poor protein
synthesissynthesis
• Nephrotic syndromeNephrotic syndrome
• MalnutritionMalnutrition
• Protein-losing enteropathyProtein-losing enteropathy
3.3. Increase permeability of peritonealIncrease permeability of peritoneal
capillariescapillaries
• Tuberculous peritonitisTuberculous peritonitis
• Bacterial peritonitisBacterial peritonitis

18. PathophysiologyPathophysiology
4.4. Leakage of fluid into theLeakage of fluid into the
peritoneal cavityperitoneal cavity
• Bile ascitesBile ascites
• Pancreatic ascitesPancreatic ascites
• Chylous ascitesChylous ascites
• Urine ascitesUrine ascites
5.5. Miscellaneous causesMiscellaneous causes
• MyxedemaMyxedema
• Ovarian disease (Meig’s syndrome)Ovarian disease (Meig’s syndrome)
• Chronic hemodialysisChronic hemodialysis

19. Morbidity and MortalityMorbidity and Mortality
• Ambulatory patients with an episode ofAmbulatory patients with an episode of
cirrhotic ascites have a 3-year mortalitycirrhotic ascites have a 3-year mortality
rate of 50%. The development ofrate of 50%. The development of
refractory ascites carries a poorrefractory ascites carries a poor
prognosis, with a 1-year survival rate ofprognosis, with a 1-year survival rate of
less than 50%.less than 50%.

20. DiagnosisDiagnosis
1-history1-history
Pts should be questioned about:Pts should be questioned about:
• Liver diseasesLiver diseases
• Risk factors for Hepatitis C ( needleRisk factors for Hepatitis C ( needle
sharing, tattoos, cocaine, heroin use andsharing, tattoos, cocaine, heroin use and
emigration from Egypt or Southeastemigration from Egypt or Southeast
Asia)Asia)
• Risk factors for Hepatitis B (needleRisk factors for Hepatitis B (needle
sharing, tattoos, acupuncture, andsharing, tattoos, acupuncture, and
emigration from China, Korea, Taiwan,emigration from China, Korea, Taiwan,
or Southeast Asia).or Southeast Asia).

21. • Pts with obesity, diabetes,Pts with obesity, diabetes,
hyperlipidemia and Nonalcoholichyperlipidemia and Nonalcoholic
steatohepatitis ( NASH ) should be ruledsteatohepatitis ( NASH ) should be ruled
out.out.
• Pts with ascites who lack risk factors forPts with ascites who lack risk factors for
cirrhosis should be questioned aboutcirrhosis should be questioned about
cancer, heart failure, TB, dialysis, andcancer, heart failure, TB, dialysis, and
pancreatitis.pancreatitis.
• Operative injury to the ureter or bladderOperative injury to the ureter or bladder
can lead to leakage of urine intocan lead to leakage of urine into
peritoneal cavity.peritoneal cavity.
• HIV pts may have infections lead toHIV pts may have infections lead to
ascites.ascites.

22. diagnosisdiagnosis
2-Clinical Features2-Clinical Features
• A- Asymptomatic (fluid <100 - 400ml):A- Asymptomatic (fluid <100 - 400ml):
Mild ascitesMild ascites
• B- symptomatic (fluid >400ml):B- symptomatic (fluid >400ml):
Increased abdominal girth, presence ofIncreased abdominal girth, presence of
abdominal pain or discomfort,abdominal pain or discomfort,
early satiety, pedal edema, weight gainearly satiety, pedal edema, weight gain
and respiratory distress depending on theand respiratory distress depending on the
amount of fluid accumulated in theamount of fluid accumulated in the
abdomen.abdomen.

23. Physical examination findings:Physical examination findings:
• Umbilicus Eversion (often with umbilicalUmbilicus Eversion (often with umbilical
herniation)herniation)
• Tympany at the top of the abdomenTympany at the top of the abdomen
• Fluid waveFluid wave
• Peripheral edemaPeripheral edema
• Shifting dullness (> 500ml fluid)Shifting dullness (> 500ml fluid)
• Bulging flanks (>500ml fluid)Bulging flanks (>500ml fluid)

24. Shifting DullnessShifting Dullness

25. Bulging Flanks and UmbilicalBulging Flanks and Umbilical
HerniaHernia

26. DiagnosisDiagnosis
3-paracentesis3-paracentesis
• It is a diagnostic procedure to establishIt is a diagnostic procedure to establish
the etiology of new-onset ascites or to rulethe etiology of new-onset ascites or to rule
out spontaneous bacterial peritonitis inout spontaneous bacterial peritonitis in
patients with preexisting ascites. Largepatients with preexisting ascites. Large
volume paracentesis is performed involume paracentesis is performed in
hemodynamically stable patients withhemodynamically stable patients with
tense or refractory ascites to alleviatetense or refractory ascites to alleviate
discomfort or respiratory compromise.discomfort or respiratory compromise.
• For diagnostic purposes, a small amountFor diagnostic purposes, a small amount
(20cc) may be enough for adequate(20cc) may be enough for adequate
testing.testing.

28. Ascitic fluid analysisAscitic fluid analysis
Cell count:Cell count:
• A white blood cell count is the mostA white blood cell count is the most
important.important.
• A neutrophil > 250 cells/mm3A neutrophil > 250 cells/mm3 
spontaneous bacterial peritonitisspontaneous bacterial peritonitis
• An elevated lymphocyteAn elevated lymphocyte  tuberculosistuberculosis
or peritoneal carcinomatosisor peritoneal carcinomatosis
• Gram stain and culture:Gram stain and culture:
for bacteria and acid fast bacillifor bacteria and acid fast bacilli

29. • Red cell countRed cell count
> 50.000/microliter> 50.000/microliter hemorrhagic ascites,hemorrhagic ascites,
which usually is due to malignancy,which usually is due to malignancy,
tuberculosis or trauma.tuberculosis or trauma.

30. Serum-Ascites Albumin GradientSerum-Ascites Albumin Gradient
• Best single test for classifying ascites intoBest single test for classifying ascites into
portal hypertensive and non-portalportal hypertensive and non-portal
hypertensive causes.hypertensive causes.
• Calculated by:Calculated by:
Serum albumin – Ascites albumin= SAAGSerum albumin – Ascites albumin= SAAG
SAAG >1.1 g/dL= Portal HTNSAAG >1.1 g/dL= Portal HTN
SAAG < 1.1 g/dL= Non-Portal hypertensiveSAAG < 1.1 g/dL= Non-Portal hypertensive
causecause

31. SAAGSAAG
SAAG >1.1SAAG >1.1
1.1. Liver DiseaseLiver Disease
2.2. HepaticHepatic
CongestionCongestion
3.3. CHFCHF
4.4. TricuspidTricuspid
InsufficiencyInsufficiency
5.5. Massive HepaticMassive Hepatic
MetastasisMetastasis
SAAG <1.1SAAG <1.1
1.1. PeritonealPeritoneal
carcinomatosiscarcinomatosis
2.2. PeritonealPeritoneal
InfectionInfection
(TB, Fungal,(TB, Fungal,
CMV)CMV)
3.3. NephroticNephrotic
syndromesyndrome
4.4. Pancreatic ascitesPancreatic ascites

32. • Total protein:Total protein:
Helpful in diagnosing spontaneous bacterialHelpful in diagnosing spontaneous bacterial
peritonitisperitonitis
Pts with a value<1 g/dl protein and glucosePts with a value<1 g/dl protein and glucose
of <50mg/dlof <50mg/dl
have high risk of SBPhave high risk of SBP
• Cytology:Cytology:
for malignant cellsfor malignant cells
• Amylase:Amylase:
to exclude pancreatic ascitesto exclude pancreatic ascites

33. ascitic fluidascitic fluid
Appearance:Appearance: The gross appearance of the ascitic fluidThe gross appearance of the ascitic fluid
can be helpful in the differential diagnosis.can be helpful in the differential diagnosis.
Turbid or cloudyTurbid or cloudy:: infected fluid.infected fluid.
MilkyMilky:: Triglyceride concentration of greater than 200mg/dlTriglyceride concentration of greater than 200mg/dl
(often greater than 1000mg/dl), malignancy is usually(often greater than 1000mg/dl), malignancy is usually
MC cause, but cirrhosis may present with chylous fluid.MC cause, but cirrhosis may present with chylous fluid.
Pink or BloodyPink or Bloody:: Pink fluid usually traumatic tap. FranklyPink fluid usually traumatic tap. Frankly
bloody may occur in hepatocellular carcinoma, or otherbloody may occur in hepatocellular carcinoma, or other
malignancy related ascites.malignancy related ascites.
BrownBrown:: Deeply jaundiced pts may present with brownDeeply jaundiced pts may present with brown
ascitic fluid, which may represent gallbladder rupture orascitic fluid, which may represent gallbladder rupture or
perforated duodenal ulcer.perforated duodenal ulcer.

34. diagnosisdiagnosis
4-Imaging Studies4-Imaging Studies
A-A- Chest and Plain Abdominal FilmsChest and Plain Abdominal Films
• Elevation of the diaphram (usually withElevation of the diaphram (usually with
>500 ml of fluid)>500 ml of fluid)
• Abdominal hazinessAbdominal haziness
• Bulging FlanksBulging Flanks
• Poor definition of intra abdominal organsPoor definition of intra abdominal organs
--

35. • Medial displacement of the cecum andMedial displacement of the cecum and
ascending colon.ascending colon.
• Hellmer's sign: the lateral liver angle isHellmer's sign: the lateral liver angle is
displaced medially from thedisplaced medially from the
thoracoabdominal wall in a patient with athoracoabdominal wall in a patient with a
large extraperitoneal fluid collectionlarge extraperitoneal fluid collection
extending into the flank (Pathologicextending into the flank (Pathologic
processes in both the intra- andprocesses in both the intra- and
extraperitoneal spaces).extraperitoneal spaces).

36. bilateral pleural effusions in abilateral pleural effusions in a
patient with ascitespatient with ascites

37. loss of anyloss of any
definition ofdefinition of
the edge of thethe edge of the
spleen or liverspleen or liver
andand
displacementdisplacement
of the bowelof the bowel
loops out ofloops out of
the pelvis andthe pelvis and
bulging flanksbulging flanks

38. Pelvic AscitesPelvic Ascites

39. Imaging StudiesImaging Studies
B-B- CT scanCT scan
• Well visualizedWell visualized
• Fluid may be visualized in the:Fluid may be visualized in the:
• Right perihepatic spaceRight perihepatic space
• Posterior subhepatic space (MorisonPosterior subhepatic space (Morison
pouch)pouch)
• Pouch of DouglasPouch of Douglas

40. Large ascitesLarge ascites
displacing bowel posteriorlydisplacing bowel posteriorly

41. Perihepatic ascitesPerihepatic ascites

42. [CT] Small amount of ascitic
fluid in the pouch of Douglas
and surrounding the adjacent
small bowel loops

43. Abdominal CT, showing Morison'sAbdominal CT, showing Morison's
pouch as the dark margin surroundingpouch as the dark margin surrounding
the right kidney (at lower left corner ofthe right kidney (at lower left corner of
image).image).

44. Imaging StudiesImaging Studies
C-C- UltrasoundUltrasound
• Easiest and most sensitive technique forEasiest and most sensitive technique for
detection of ascitic fluid.detection of ascitic fluid.
• Volume as small as 5-10ml can be seen.Volume as small as 5-10ml can be seen.

45. ..
Morison's pouchMorison's pouch
with abnormalwith abnormal
fluid collectionfluid collection
(red arrows)(red arrows)
between thebetween the
liver and rightliver and right
kidneykidney

48. Management of AscitesManagement of Ascites
The goal is to prevent Na loading and increaseThe goal is to prevent Na loading and increase
renal excretion of Na and H2O and produce arenal excretion of Na and H2O and produce a
net re-absorption of fluid from the ascites backnet re-absorption of fluid from the ascites back
into the circulating volume.into the circulating volume.
• Dietary Na restrictionDietary Na restriction
Diet of 2g sodium per dayDiet of 2g sodium per day
• Fluid Restriction:Fluid Restriction:
Only done when serum Na is <128mmol/LOnly done when serum Na is <128mmol/L
• Check LabsCheck Labs
Ck serum electrolytes and creatinine everyCk serum electrolytes and creatinine every
other day.other day.
Weigh the patient and measure urinaryWeigh the patient and measure urinary
output daily.output daily.

49. Management of AscitesManagement of Ascites
Diuretic therapy:Diuretic therapy:
• Spironolactone: diuretic of choiceSpironolactone: diuretic of choice
(25-200mg PO daily or bid)(25-200mg PO daily or bid)
• Lasix: (20-80 mg/d PO/IV/IM)Lasix: (20-80 mg/d PO/IV/IM)
• Zaroxolyn: (works on Edema of CHF)Zaroxolyn: (works on Edema of CHF)
(5-20 mg/dose PO q24hr)(5-20 mg/dose PO q24hr)
• Mannitol: (0.5-2 g/kg IV over 30-60 min,Mannitol: (0.5-2 g/kg IV over 30-60 min,
repeat q6-8hrs)repeat q6-8hrs)
• Amilioride: 5-20 mg/d POAmilioride: 5-20 mg/d PO

50. Management of AscitesManagement of Ascites
Large Volume ParacentesisLarge Volume Paracentesis
• To relieve symptomatic tense ascites andTo relieve symptomatic tense ascites and
peripheral edema.peripheral edema.
• Up to 20L can be removed over 4-6hr.Up to 20L can be removed over 4-6hr.
• Removal of 5L or more of ascitic fluidRemoval of 5L or more of ascitic fluid
during a single session.during a single session.

51. Paracentesis Contraindications:Paracentesis Contraindications:
• Acute abdomen (absolute)Acute abdomen (absolute)
• Severe bowel distentionSevere bowel distention
• Previous abdominal surgery (if necessary performPrevious abdominal surgery (if necessary perform
open procedure)open procedure)
• Pregnancy (if necessary perform after first trimesterPregnancy (if necessary perform after first trimester
using an open technique above the umbilicus)using an open technique above the umbilicus)
• Distended bladder that cannot be relieved by foleyDistended bladder that cannot be relieved by foley
cathedercatheder
• Infection at site of insertion (cellulitis or abscess)Infection at site of insertion (cellulitis or abscess)
• Thrombocytopenia (relative)Thrombocytopenia (relative)
• Coagulopathy (relative)Coagulopathy (relative)

52. Paracentesis Complications:Paracentesis Complications:
• Bladder perforationBladder perforation
• Small or large bowel perforationSmall or large bowel perforation
• Stomach perforationStomach perforation
• Laceration of major vessels ( mesenteric, iliac,Laceration of major vessels ( mesenteric, iliac,
aorta)aorta)
• Laceration of catheter or guide wire and loss inLaceration of catheter or guide wire and loss in
peritoneal cavity (requires laparotomy)peritoneal cavity (requires laparotomy)
• Abdominal wall hematomaAbdominal wall hematoma
• Incisional herniaIncisional hernia
• Wound infectionWound infection
• Wound dehiscenceWound dehiscence

53. Management of AscitesManagement of Ascites
Transjugular IntrahepaticTransjugular Intrahepatic
Portasystemic Shunt:Portasystemic Shunt:
The TIPS procedure is an interventionalThe TIPS procedure is an interventional
radiologic technique that reduces portalradiologic technique that reduces portal
pressure and may be the most effectivepressure and may be the most effective
treatment fortreatment for diuretic resistantdiuretic resistant
ascites.ascites.
Risks:
• Hepatic Encephalopathy (30% of pts)
• Thrombosis and shunt stenosis.

54. TIPS ProcedureTIPS Procedure
• side to side portacaval shunt, usually placed throughside to side portacaval shunt, usually placed through
the right internal jugular vein. A needle is placedthe right internal jugular vein. A needle is placed
through the IJV into the hepatic vein.through the IJV into the hepatic vein.

55. toneovenous shunt:toneovenous shunt: • Developed to returnDeveloped to return
ascitic fluid from theascitic fluid from the
peritoneal cavity directlyperitoneal cavity directly
to the systemicto the systemic
circulation.circulation.
• Consists of an intra-Consists of an intra-
abdominal tubeabdominal tube
connected through aconnected through a
valve to silicone tube thatvalve to silicone tube that
transverses thetransverses the
subcutaneous tissue upsubcutaneous tissue up
to the neck and entersto the neck and enters
one of the jugular veins.one of the jugular veins.
• This leads to diuresisThis leads to diuresis
and mobilization ofand mobilization of
ascites.ascites.
::

56. Risks ofRisks of Peritoneovenous shunt:Peritoneovenous shunt:
• DICDIC
• InfectionInfection
• Variceal bleedingVariceal bleeding
• Small bowel obstructionSmall bowel obstruction
• Shunt occlusionShunt occlusion
• DeathDeath
Due to these risk this procedure is rarelyDue to these risk this procedure is rarely
used.used.
Peritoneovenous shunts are therapeutic butPeritoneovenous shunts are therapeutic but
do not improve survival rates in patientsdo not improve survival rates in patients
with cirrhosis and ascites.with cirrhosis and ascites.

57. Management of AscitesManagement of Ascites
liver transplantation:liver transplantation:
• Tx of choiceTx of choice
• Corrects portal hypertensionCorrects portal hypertension
• Changes the natural course of progressiveChanges the natural course of progressive
liver failure due to cirrhosisliver failure due to cirrhosis
• Not all pts are candidates for transplant,Not all pts are candidates for transplant,
and those who are may wait for years for aand those who are may wait for years for a
donordonor
• Many die from complications of ascitesMany die from complications of ascites
while waiting for transplant donorwhile waiting for transplant donor

58. Complications from AscitesComplications from Ascites
1.1. Refractory Ascites:Refractory Ascites:
• Fluid overload that is unresponsive toFluid overload that is unresponsive to
Na-restricted diet and high dose anti-Na-restricted diet and high dose anti-
diuretic treatment.diuretic treatment.
• Usually in the setting of chronic or acuteUsually in the setting of chronic or acute
liver diseases with associated portalliver diseases with associated portal
hypertension.hypertension.

59. Treatment of Refractory Ascites:Treatment of Refractory Ascites:
Liver transplantation is treatment of choice.Liver transplantation is treatment of choice.
If unsuitable, treatment with:If unsuitable, treatment with:
• Serial paracentesisSerial paracentesis
• TIPSTIPS
• Peritoneovenous shuntPeritoneovenous shunt

60. Complications of AscitesComplications of Ascites
2.2. Hepatorenal syndrome:Hepatorenal syndrome:
Life-threatening medical condition that consists ofLife-threatening medical condition that consists of
rapid deterioration in kidney function in individualsrapid deterioration in kidney function in individuals
with cirrhosis or fulminant liver failure. HRS iswith cirrhosis or fulminant liver failure. HRS is
usually fatal unless a liver transplant is performed,usually fatal unless a liver transplant is performed,
although various treatments, such as dialysis, canalthough various treatments, such as dialysis, can
prevent advancement of the condition. It is aprevent advancement of the condition. It is a
common complication of cirrhosis, occurring incommon complication of cirrhosis, occurring in
18% of cirrhotics within one year of their18% of cirrhotics within one year of their
diagnosis, and in 39% of cirrhotics within fivediagnosis, and in 39% of cirrhotics within five
years of their diagnosis.years of their diagnosis.

62. Type 1 HRS:Type 1 HRS:
• Doubling of initial serum creatinine levelDoubling of initial serum creatinine level
to >205mg/dl or a 50% cause decreasingto >205mg/dl or a 50% cause decreasing
in 24-hour creatinine clearance toin 24-hour creatinine clearance to
<20ml/min in < 2 weeks.<20ml/min in < 2 weeks.
• Mortality is >90% without liverMortality is >90% without liver
transplantation.transplantation.

63. Type 2 HRS:Type 2 HRS:
• RF has a slower progressive course.RF has a slower progressive course.
• Occur in the setting of chronic or acute liverOccur in the setting of chronic or acute liver
disease with portal hypertension.disease with portal hypertension.
• Low GFR (with creatinine >1.5mg/dl)Low GFR (with creatinine >1.5mg/dl)
• No evidence of shock, bacterial infection, orNo evidence of shock, bacterial infection, or
treatment with nephrotoxic agents + absence oftreatment with nephrotoxic agents + absence of
GI fluid losses or renal fluid losses.GI fluid losses or renal fluid losses.
• No improvement in renal function followingNo improvement in renal function following
diuretic withdrawal.diuretic withdrawal.
• Proteinuria <500mg/dl and no US evidence ofProteinuria <500mg/dl and no US evidence of
renal disease or obstructive uropathy.renal disease or obstructive uropathy.

64. Treatment of hepatorenal syndrome:Treatment of hepatorenal syndrome:
• SupportiveSupportive
• Liver transplantation: Tx of Choice.Liver transplantation: Tx of Choice.
• It corrects both liver and kidney disease.It corrects both liver and kidney disease.
• Is associated with up to 60% survival rateIs associated with up to 60% survival rate
in 3 years.in 3 years.
• Shortage of donor organs leads to a highShortage of donor organs leads to a high
rate of death in these patients.rate of death in these patients.

65. Complications of AscitesComplications of Ascites
3-3- Spontaneous Bacterial PeritonitsSpontaneous Bacterial Peritonits
• 20% of patients with cirrhotic ascites20% of patients with cirrhotic ascites
• Diagnosed with neutrophil count ofDiagnosed with neutrophil count of
>250/mm3>250/mm3
• Gram – neg organisms in 60% of casesGram – neg organisms in 60% of cases
(E.coli and Klebsiella pneumoniae )(E.coli and Klebsiella pneumoniae )
• Gram + organisms 25% of casesGram + organisms 25% of cases
(Strep species )(Strep species )

66. • Symptoms:Symptoms: Abdominal pain, fever,Abdominal pain, fever,
development of hepatic encephalopathy,development of hepatic encephalopathy,
diarrhea, hypothermia and shock.diarrhea, hypothermia and shock.
• Ascitic Protein level<1 g/dlAscitic Protein level<1 g/dl is a risk foris a risk for
Spontaneous Bacterial Peritonits.Spontaneous Bacterial Peritonits.
• Treatment:Treatment: Cefotaxime sodiumCefotaxime sodium

67. ReferencesReferences
• ScincedirectScincedirect
• UptodateUptodate
• eMedicine HealtheMedicine Health
• MedicineNet.comMedicineNet.com
• Family Practice Notebook.comFamily Practice Notebook.com

68. Thank youThank you