Approach to Ascites Updated by Daniel Kim, 06/2017

Objectives Become familiar with the different etiologies of ascites Know the indications for paracentesis Understand the diagnostic approach to evaluating ascites

Ascites classification Portal Hypertension Cirrhosis Liver Disease (ie. Alcoholic hepatitis, acute liver failure) Hepatic Veno-occlusive Disease (ie. Budd Chiari) CHF Constrictive Pericarditis Hypoalbuminemia Nephrotic Syndrome Protein-Losing Enteropathy Severe malnutrition Peritoneal Disease Malignant Ascites Infectious Peritonitis (ie. TB, fungal) Peritoneal Dialysis There are many different etiologies of ascites, obviously the most common being related to cirrhosis The easiest way to think about it is by classifying what the underlying pathophysiology is Whether related to: 1) portal hypertension (increased hydrostatic pressures) 2) hypoalbuminemia (decreased oncotic pressures) 3) peritoneal disease (increased diffusing capacity) What are the top 3 most common etiologies??

Ascites classification Portal Hypertension Cirrhosis** Liver Disease (ie. Alcoholic hepatitis, acute liver failure) Hepatic Veno-occlusive Disease (ie. Budd Chiari) CHF** Constrictive Pericarditis Hypoalbuminemia Nephrotic Syndrome Protein-Losing Enteropathy Severe malnutrition Peritoneal Disease Malignant Ascites** Infectious Peritonitis (ie. TB, fungal) Peritoneal Dialysis Most common etiologies 1) Cirrhosis – 81% 2) Malignancy – 10% 3) CHF – 3% All other etiologies are <=2%

Diagnostic evaluation Imaging Ultrasound CT MRI Serology CBC with diff CMP Coags Imaging Helps assess for fluid collection Can aid in evaluating the underlying etiology (ie. Liver nodules, dilated portal veins, malignancy) Serology Again can aid in evaluating the underlying etiology Ie. Abnormal LFTs/coags pointing towards hepatic etiology Ie. Hypoalbuminemia Ie. Leukocytosis with left shift suggesting infection

Paracentesis Indications Basic tests Additional tests Diagnostic New-onset Suspicion for spontaneous or secondary bacterial peritonitis Therapeutic Respiratory compromise Abdominal pain/pressure Basic tests General appearance Cell count & differential Total protein Albumin Additional tests Gram stain/culture, LDH, glucose, amylase, cytology, bilirubin respiratory compromise Related to abdominal distention Abdominal pain/pressure Including abdominal compartment syndrome

Analysis Serum-Ascites Albumin Gradient (SAAG) = (serum albumin) – (ascites albumin) ≥1.1 g/dL  portal HTN <1.1 g/dL  unlikely portal HTN Cell count & differential *best test to assess for infection PMN > 250/mm3 suggests infection Correction for bloody tap WBC correction – subtract 1 WBC for every 750 RBC PMN correction – subtract 1 PMN for every 250 RBC SAAG ≥1.1 g/dL  portal HTN 97% accuracy of being related to portal HTN Can look back at “ascites classification” slide to review etiologies related to portal HTN Cell count & differential If PMN > 250/mm3 – recommend starting empiric Abx (pending gram stain/culture)

Analysis Utilization of Glucose, LDH, Total Protein Helps distinguish cardiac from hepatic etiology Ascitic Fluid Total protein <2.5 g/dL Suggests hepatic etiology Ascitic Fluid Total protein ≥2.5 g/dL Suggests cardiac etiology

Summary Most common causes of ascites Indications for Paracentesis 1. Cirrhosis, 2. Malignancy, 3. CHF Indications for Paracentesis a) diagnostic (1. new onset; 2. r/o SBP) b) therapeutic (if ascites is causing symptoms) Analysis SAAG ≥1.1 g/dL  portal HTN <1.1 g/dL  unlikely portal HTN

This is a useful algorithm from UpToDate *don’t have to go through it – just for people to know that this resource is available on UpToDate.

MKSAP Questions A 68-year-old man is evaluated for new-onset ascites with lower-extremity edema. Symptoms have increased gradually over the past 4 weeks. He has consumed three alcoholic beverages per day for many years. His medical history is notable for coronary artery bypass graft surgery 8 months ago and dyslipidemia. His medications are low-dose aspirin, atorvastatin, and metoprolol. On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 122/84 mm Hg, pulse rate is 64/min, and respiration rate is 16/min; BMI is 28. Cardiac examination reveals an elevated jugular venous pressure, a normal S1 and S2, and no murmurs. Pulmonary examination findings are normal. Abdominal examination reveals hepatomegaly, distention, dullness to percussion over the flanks, and a positive fluid wave. There is 2+ pitting edema of the lower extremities. Laboratory studies reveal a serum albumin level of 3.5 g/dL (35 g/L). Other studies, including serum alanine aminotransferase and aspartate aminotransferase levels, are normal. Paracentesis reveals a total nucleated cell count of 120/µL with 30% polymorphonucleocytes. Ascitic fluid albumin level is 2.3 g/dL (23 g/L) and total protein is 3.5 g/dL (35 g/L). Which of the following is the most likely cause of this patient’s ascites? 1. Alcoholic cirrhosis 2. constrictive pericarditis 3. nonalcoholic cirrhosis 4. TB peritonitis

MKSAP Question SAAG = 3.5 - 2.3 = 1.2 (>1.1) A 68-year-old man is evaluated for new-onset ascites with lower-extremity edema. Symptoms have increased gradually over the past 4 weeks. He has consumed three alcoholic beverages per day for many years. His medical history is notable for coronary artery bypass graft surgery 8 months ago and dyslipidemia. His medications are low-dose aspirin, atorvastatin, and metoprolol. On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 122/84 mm Hg, pulse rate is 64/min, and respiration rate is 16/min; BMI is 28. Cardiac examination reveals an elevated jugular venous pressure, a normal S1 and S2, and no murmurs. Pulmonary examination findings are normal. Abdominal examination reveals hepatomegaly, distention, dullness to percussion over the flanks, and a positive fluid wave. There is 2+ pitting edema of the lower extremities. Laboratory studies reveal a serum albumin level of 3.5 g/dL (35 g/L). Other studies, including serum alanine aminotransferase and aspartate aminotransferase levels, are normal. Paracentesis reveals a total nucleated cell count of 120/µL with 30% polymorphonucleocytes. Ascitic fluid albumin level is 2.3 g/dL (23 g/L) and total protein is 3.5 g/dL (35 g/L). Which of the following is the most likely cause of this patient’s ascites? 1. Alcoholic cirrhosis 2. constrictive pericarditis 3. nonalcoholic cirrhosis 4. TB peritonitis SAAG = 3.5 - 2.3 = 1.2 (>1.1) Ascitic Fluid Total Protein: 3.5 (≥ 2.5) *Both suggest ascites related to portal HTN from cardiac etiology