Download Ascites

Evaluation of Ascites
Andrew Maclennan
Morning Report
July 24, 2009
Pathophysiology of Ascites
From: Robbins Basic Pathology
Causes of Ascites
Cause
Frequency
Cirrhosis
81%
Cancer
10%
Heart Failure
3%
Tuberculosis
2%
Dialysis
1%
Pancreatic Disease
1%
Other
2%
Source: UpToDate
Rare Causes of Ascites
Category
Infectious diseases
Amebiasis, Ascariasis, Brucellosis,
Chlamydia peritonitis, Complications
related to HIV infection, Pelvic
inflammatory disease,
Pseudomembranous colitis,
Salmonellosis, Whipple's disease
Hematologic
Amyloidosis, Castleman's syndrome,
Extramedullary hematopoiesis,
Hemophagocytic syndrome, Histiocytosis
X, Leukemia, Lymphoma, Mastocytosis,
Multiple myeloma
Miscellaneous
Abdominal pregnancy, Crohn's disease,
Endometriosis, Gaucher's disease,
Lymphangioleiomyomatosis, Myxedema,
Nephrotic syndrome, lymphatic tear or
ureteral injury. Ovarian hyperstimulation
Imaging
• Ultrasound with Dopplers
– Easily confirms ascites
– May see nodularity of cirrhosis
– Evaluate patency of vasculature
– No radiation, contrast
• CT / MRI
– Evaluation for malignancy
Tests on Ascitic Fluid
Routine
Optional
Unusual
Cell count and differential
Glucose concentration
Tuberculosis smear and
culture, adenosine
deaminase
Albumin concentration
LDH concentration
Cytology
Total protein concentration Gram stain
Triglyceride concentration
Culture in blood culture
bottles
Bilirubin concentration
Amylase concentration
Cell Count, differential and culture
• Is ascites infected?
– Greater than 250 PMN = SBP
• If ascites is bloody ( > 50,000 RBC/mm3), correct by
subtracting 1 PMN / 250 RBC
• Is ascites bloody?
– 5% of pts w/ cirrhosis - spontaneous or s/p
traumatic tap.
• Non-traumatic  associated with malignancy
– 20% of malignant ascites
– 10% of peritoneal carcinomatosis
Serum to Ascites Albumin Gradient
• Is portal hypertension present?
• 97% accurate
SAAG > 1.1 g/dL  Portal HTN
SAAG < 1.1 g/dL  Other causes
The serum-ascites albumin gradient is superior to the exudate-transudate concept in
the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon
MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20.
Serum to Ascites Albumin Gradient
SAAG > 1.1 g/dL
SAAG < 1.1 g/dL
Cirrhosis
Peritoneal carcinomatosis
Alcoholic hepatitis
Peritoneal tuberculosis
CHF
Pancreatitis
Massive hepatic metastases
Serositis
Budd Chiari Syndrome
Nephrotic syndrome
Congestive heart failure/constrictive
pericarditis
Total Protein
• Exudate ( > 2.5 g/dL) or Transudate?
– Supplanted by SAAG
• Is there gut perforation? (vs SBP)
– Total protein >1 g/dL
– Glucose <50 mg/dL (2.8 mmol/L)
– LDH greater than serum ULN
Glucose and LDH
• Consistent with infection or malignancy?
– Infection and cancer consume glucoselow
• LDH is a larger molecule than glucose, enters
ascitic fluid with difficulty.
– Ascitis/Serum LDH ratio
• ~ 0.4 in cirrhotic ascites
• Approaches 1.0 in SBP
• >1.0, usually infection or tumor
Other tests
• Amylase
– Uncomplicated cirrhotic ascites
• About 40 IU/L. The AF/S ratio is about 0.4
– Pancreatic ascites
• About 2000 IU/L. The AF/S ratio is about 6
• Triglycerides — run on milky fluid.
– Chylous ascites - TG > 200 mg/dL, usually 1000
mg/dL
• Bilirubin — run on brown ascites.
– Biliary perforation – AF Bili > serum Bili
Tests for TB
• Smear – extremely insensitive
• Culture – 62-83% when large volumes
cultured
• Cell count – mononuclear cell predominance
• Adenosine deaminase –
– Enzyme involved in lymphoid maturation
– Falsely low in pts with both cirrhosis and TB
Cytology
• “almost 100%” with peritoneal
carcinomatosis have positive cytology
• Malignant ascites from massive hepatic mets,
HCC, lymphoma are usually negative
• Overall sensitivity for detection of malignancyrelated ascites is 58 to 75 %
Not helpful
• “Some tests of ascitic fluid appear to be
useless. These include pH, lactate, and
‘humoral tests of malignancy’ such as
fibronectin, cholesterol, and many others”
Biopsy
Cirrhosis
Fatty Liver
http://library.med.utah.edu/WebPath/LIVEHTML/LIVERIDX.html#2
Causes of Cirrhosis
Cause
Testing
Alcoholic liver disease
History, AST / ALT > 2
Chronic hepatitis C
Hep C Ab, Viral load
Primary biliary cirrhosis
Antimitochondrial antibodies
Primary sclerosing cholangitis
Contrast cholangiography , ANA, Anti
smooth muscle Ab, ANCA
Autoimmune hepatitis
Type 1: ANA, ANCA antismooth muscle Ab
Type 2: anti-LKM-1
Chronic hepatitis B
Hepatitis B serologies
Hemochromatosis
Ferritin, genetic testing
Wilson’s disease
Ceruloplasmin
Alpha-1-antitrypsin deficiency
Serum AAT
Nonalcoholic fatty liver disease
Hx of DM or metabolic syndrome
Malignant Ascites
• Definition: abnormal accumulation of fluid in
the peritoneal cavity as a consequence of
cancer.
• Commonly caused by cancers of:
– Breast, bronchus, ovary, stomach, pancreas, colon
• 20% of cases have tumors of unknown
primary
• Survival poor – usually less than 3 months
Becker, G. Malignant ascites: Systematic review and guideline for treatment.
European Journal of Cancer 42 (2006) 589 - 597
Malignant Ascites: Pathophysiology
• Obstruction of lymphatics by tumor
– Prevents absorption of fluid and protein
• Alteration in vascular permeability
– Hormonal mechanisms (VEGF, IL2, TNF alpha)
• Decreased circulating blood volume
– Activates RAAS leading to Na retention
Becker, G. Malignant ascites: Systematic review and guideline for treatment.
European Journal of Cancer 42 (2006) 589 - 597
Pathophysiology of Malignant Ascites
http://www.fresenius.de/internet/fag/com/faginpub.nsf/Content/Pressemappe+ASCO+2007
Management of Malignant Ascites
• Therapeutic paracentesis
– Removing up to 5L appears safe
– No good data on role of volume expanders
• Diuretics
– Equivocal evidence of efficacy
– May be helpful for portal HTN
– Less/minimally useful when no portal HTN
• Drainage Catheters
• Peritoneovenous shunts
Peritoneovenous Shunt
Contraindications
•Protein > 4.5 g/l (occlusion)
•Loculated ascites
•Coagulopathy
•Advanced renal/cardiac disease
•GI malignancy
Complications
Denver Shunt
(Similar to LaVeen Shunt)
•Infection
•Hematogenous spread of mets
•DIC
•Pulmonary edema
•Pulmonary emboli
Transjugular intrahepatic
portosystemic shunt (TIPS)
References
1.
2.
3.
4.
5.
•
Up to Date
Ascites and renal dysfunction in liver disease, Second edition. Edited by Pere
Ginès, Vicente Arroyo, Juan Rodés, and Robert W. Schrier. Malden, Mass.,
Blackwell, 2005.
The serum-ascites albumin gradient is superior to the exudate-transudate
concept in the differential diagnosis of ascites. Runyon BA; Montano AA;
Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug
1;117(3):215-20.
Becker, G. Malignant ascites: Systematic review and guideline for treatment.
European Journal of Cancer 42 (2006) 589 - 597
Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis, and
management. Arch Intern Med. Vol 161. Dec 10/24, 2001.