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ASCITES
By
Dr WAQAR
MBBS, MRCP
Asst. Professor
Maarefa College
DEFINITION
• Accumulation of more than 25 cc of fluid in
the peritoneal cavity is called ascites.
( normally, only about 25 cc fluid in the cavity)
GRADES OF ASCITES
1) Grade 1 : Mild ascites, only detected by
ultrasound. Physical exam normal.
2) Grade 2: Moderate ascites, causing moderate
abdominal & flank distension
3) Grade 3: Large ascites, causing huge marked
distension
At least 1500 cc fluid should be present in the
abdomen so as to be detected by examination
S/S
1) Asymptomatic: No abdominal distension if
there is little fluid. It is only detected by
imaging
2) Patient may complain of abdominal distension &
heaviness, respiratory distress ( huge ascites)
3) Abdominal distension
4) Shifting dullness
when significant fluid
5) Fluid thrill
is present
6) Umbilicus may be bulging
CLASSIFICATION
Ascites can be divided into 2 main groups
according to the protein concentration of the
fluid
1) TRANSUDATE: Protein less than 30g/L
2) EXUDATE: Protein more than 30 g/L
A better, more recent way of classification is the
SAAG ratio( Serum to Ascites Albumin Gradient)
WHAT IS SAAG?
• Serum albumin minus ascitic fluid albumin
( albumin difference)
If the gradient is more than 1.1g/100ml it is
transudate
If gradient is less than 1.1, it is exudate.
So,
ASCITES
SAAG > 1.1
( transudate)
( less protein)
SAAG < 1.1
(exudate)
( more protein)
CAUSES OF ASCITES
SAAG > 1.1 ( transudate)
a) Cirrhosis wth/portal HTN
b) Heart failure
c) Budd-Chiari syndrome
(hepatic vein obstruction)
d) Severe starvation
( kwashiorkor)
SAAG < 1.1 ( exudate)
a) Peritonitis(due to any
cause)
b) Tuberculous peritonitis
c) Cancer( mets. & also
primary carcinoma)
d) Nephrotic syndrome
e) Pancreatitis
ASCITES
ASCITES DUE TO KWASHIORKOR
COMMONEST CAUSE OF ASCITES IS
CIRRHOSIS WITH PORTAL HTN
Why ascites occurs in cirrhosis
* Low serum oncotic pressure
* Backpressure in portal HTN
fluid exudes
out
Other Causes of Ascites
1) CHF: Ascites occurs due to backpressure & passive
congestion of liver. There is also salt & water
retention in the body.
2) Starvation
ascites is due to low serum
3) Nephrotic syndrome
albumin
4) Peritonitis/T.B. peritonitis
* Ascites occurs due to exudation of fluid from
the inflamed peritoneum.
* In TB peritonitis, bacteria usually come from the lung
focus & seed the peritoneum. Treatment is with anti TB
drugs for 6 months.
Ascites causes contd.
BUDD-CHIARI SYNDROME
It is hepatic vein thrombosis, leading to back- pressure, liver congestion & ascites.
a) Etiology: * Hypercoagulation disorders
* Pregnancy
* Oral contraceptives
b) S/S : * ascites * Pain in right upper quadrant
* hepatomegaly * Jaundice
c) Treatment: * anticoagulation wth heparin &
then warfarin * Angioplasty * Stent
INVESTIGATIONS IN
ASCITES
1) Ultrasound
2) Paracentesis(ascitic tap): Every new patient
should get a “diagnostic” tap:
* Take out 10-20 cc fluid
* Check albumin( to calculate SAAG),
neutrophils (to see infection), RBC, Gram stain &
culture, cytology(malignant cells), amylase levels
(in suspected pancreatic ascites)
Complications of paracentesis:
* Infection * Intestinal perforation
MANAGEMENT OF ASCITES
Low salt diet
Diuretics
Paracentesis
MANAGEMENT OF
ASCITES
• We will discuss management of ascites due to cirrhosis.
In other causes, treat the cause.
1) Low salt diet: < 2 g/d ( less than ½ tea spoon)
2) Diuretics:
* Spironolactone( aldactone): 1st choice.
S/E : gynecomastia, hyperkalemia
* Can add lasix (furosemide) if needed
* Aim is to reduce ascites gradually( 0.5 to 1 kg wt. loss
daily
In 95% of cases, ascites can be controlled by 1) & 2)
When using diuretics, routinely check the
electrolytes, creatinine and wt. of the
patients
Management contd.
3) “Therapeutic Paracentesis”
* It is done if medicines don’t help or very tense
ascites causing respiratory difficulty.
* Upto 7 L can be removed at one time.
* Removal of more than 7L can cause
problems like circulatory collapse &
encephalopathy
* i.v. albumin given at the time of paracentesis
can prevent these complications
Therapeutic Paracentesis
Management contd.
4) T.I.P.S. : ( transjugular intrahepatic portosystemic shunt.)
It is a surgery, done to connect the portal system
directly to the systemic circulation.
Used rarely in very resistant ascites.
No need to know the details ! ( Thank
God)
COMPLICATIONS OF ASCITES
SPONTANEOUS BACTERIAL PERITONITIS
(S.B.P.)
It is a bacterial infection of the peritoneum &
ascitic fluid, occurring in “portal HTN related”
ascites.
RISK FACTORS:
* Very low ascitic fluid protein
* Previous episode of SBP
* H/O esophageal varices hemorrhage
SBP contd.
Which Bacteria? : * E.Coli *Klebsiella
* Pneumococci
S/S :
1) Abdominal pain & tenderness, fever ( these
may be very mild)
2) Worsening of ascites or encephalopathy
3) Asymptomatic
Any cirrhosis patient who gets worsening of his
clinical condition
rule out SBP by
paracentesis
SBP contd.
DIAGNOSIS: Do paracentesis
* Neutrophil count in ascitic fluid: more than
250cells/uL
* Send fluid for Gram stain & culture: But Gram
satin can be negative, so don’t depend on it.
Please remember the neutrophil count ! It is
diagnostic even if Gram stain is negative. If the
neutrophils are less than 250/ul, it is not called
S.B.P. even if bacteria are present in Gram Stain.
SBP contd.
Treatment: i.v. antibiotics( 3rd generation cepha-losporins like ceftazidime) or i.v. ciprofloxacin
After the first episode of SBP, patients should
take lifelong antibiotic, either Ciprofloxacin or
norfloxacin, for secondary prophylaxis.
Complications (contd)
2) Right sided pleural effusion
3) Respiratory difficulty