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ASCITES Part 1

management of ascites

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PRATAPSAGAR TIWARI
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3 views

ASCITES Part 1

management of ascites

Uploaded by

PRATAPSAGAR TIWARI
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Hepatology lectures for

th
5 Sem;MBBS
Pratap Sagar Tiwari
MBBS,MD (Medicine),DM (Hepatology)
Summary
Normal Liver ? Predisposing
conditions
Etiologies

Liver Fibrosis/cirrhosis

Portal Hypertension

Ascites Splenomegaly Varices


PORTAL HYPERTENSION

1 Ascites

2 Causes

3 Approach

4 Management
DEFINITION: ASCITES

• Ascites is the pathological accumulation of fluid within


the peritoneal cavity.
H/o VH
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.
VH prevention measures
2. Hanbidge A, Lynch D, Wilson S. US of the peritoneum. Radiographics 2003; 23: 663–685. for pts with a known
H/o VH

Secondary Prophylaxis
Pleural fluid: 10-20 ml
Pericardial fluid: 15-50 ml
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;


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- • Renal disease
mesothelioma and sarcoma
• Abdominal malignancies- gastric or colonic
adenocarcinoma
• Metastatic disease from breast or lung
carcinoma
• Melanoma
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
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY

Portal hypertension-related Non-portal hypertension related

Transudation Exudation

Lymphatic
obstruction

Hypoalbuminemia
PATHOPHYSIOLOGY
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
PATHOPHYSIOLOGY
• 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.
Non-portal hypertension related
Any causes leading to
hypoalbuminema Exudation

Protein-loosing enteropathy Lymphatic


obstruction
Malnutrition
Hypoalbuminemia
Nephrotic syndrome
PATHOPHYSIOLOGY IN ASCITES: due to Portal HTN
APPROACH
HISTORY EXAMINATION INVESTIGATION

✓ 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.
APPROACH
ApproachTO ASCITES
to Ascites
History • Bowel obstruction, severe constipation and ileus- inability to
pass stool and flatus together with nausea/ vomiting
Examination • Weight loss, night sweats and anorexia
• ↑ eructation or flatus- aerophagia or ↑ intestinal production
Investigation 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
ApproachTO ASCITES
to Ascites
History Clues for Cardiac disease
Examination • Elevated JVP
• Kussmaul’s sign
Investigation • Pericardial knock
• Murmur of TR
APPROACH
ApproachTO ASCITES
to Ascites
History

Examination Clues for Chronic liver disease


• Pt is sarcopenic with distended abdomen
Investigation • 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
ApproachTO ASCITES
to Ascites
History
Examination
Abdomen Examination
Investigation • 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
ApproachTO ASCITES
to Ascites
History
Examination Abdomen Examination
• Palpation: tenderness, guarding( peritonitis)
Investigation ,enlarged liver or splenomegaly
• Percussion: Shifting dullness, fluid thrill
SUMMARY
Other features include
INSPECTION
• Eversion of the umbilicus
• Asymptomatic
• Hernia
• Abdominal distension • Abdominal striae
• fullness in the flanks • Divarication of the recti
• Scrotal oedema

*Dilated superficial abdominal veins may be seen if the ascites is due to portal hypertension.

PERCUSSION Shifting dullness on percussion, a fluid thrill/fluid wave.


Approach to Ascites

History

Examination

Investigation
Imaging, eg USG
Ascites fluid
Evaluation
Others; like ECHO
➢IMAGING: ULTRASOUND & CT SCAN
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.
SAAG (SERUM ASCITES ALBUMIN GRADIENT)
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


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
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
SECONDARY BACTERIAL PERITONITIS
TREATMENT

➢ Ascites is uncomplicated when it is not infected, refractory or a/with HRS.

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.
TREATMENT

➢ Sodium and water restriction


➢ Diuretics
➢ Paracentesis
➢ TIPSS
➢ Liver Transplantation
➢ OTHERS;

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