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 abdominal distension At least 1.5 L fluid should be present in the abdomen so as to be detected by examination

S/S Patient’s complaints: * No complaints ( if very little fluid) * Abdominal distension * Respiratory distress 2) On Examination : * Normal ( if very little fluid) * Abdominal distension if significant fluid * Shifting dullness is present * Fluid thrill * Umbilicus may be bulging

CLASSIFICATION Ascites can be divided into 2 main groups according to the protein concentration of the fluid TRANSUDATE: Protein less than 30g/L 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 SAAG < 1.1 ( transudate) (exudate) ( less protein) ( more protein)

CAUSES OF ASCITES SAAG > 1.1 ( transudate) SAAG < 1.1 ( exudate) Cirrhosis wth/portal HTN Heart failure Budd-Chiari syndrome (hepatic vein obstruction d) Spontaneous bacterial peritonitis Peritonitis(due to any cause) b) Tuberculous peritonitis c) Cancer peritoneum( 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 albumin low oncotic pressure ascites * Backpressure in portal HTN fluid exudes out

Other Causes of Ascites 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 3) Nephrotic syndrome serum albumin 4) Peritonitis/T.B. peritonitis * Ascites occurs due to leaking of fluid from the inflamed peritoneum. 5) Myxedema

Ascites causes contd. BUDD-CHIARI SYNDROME It is hepatic vein thrombosis, leading to back- pressure, liver congestion & ascites. 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 & Diuretics Paracentesis Water intake In very resistant ascites, a procedure callled TIPS is sometimes used. (transjugular intrahepatic porto-systemic shunt).

MANAGEMENT OF ASCITES We will discuss management of ascites due to cirrhosis. In other causes, treat the cause. Low salt diet: < 2 g/d ( less than ½ tea spoon) Diuretics: * Spironolactone( aldactone): 1st choice. side effects : gynecomastia, hyperkalemia * Can add lasix (furosemide) if needed * Aim is to reduce ascites gradually( 0.5 to 1 kg wt. loss daily). Too much wt. loss “suddenly” is not good! In 95% of cases, ascites can be controlled by 1) & 2)

Wt. Electrolytes Creatinine When any patient is using diuretics, frequently check the following: Wt. Electrolytes Creatinine

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

Complications of Ascites SBP Resp. distress Right sided ( sponta- pleural effusion -neous bact. peritonitis)

COMPLICATIONS OF ASCITES SPONTANEOUS BACTERIAL PERITONITIS (S.B.P.) Patients with portal HTN & ascites, can get a type of peritonitis called spontaneous bacterial peritonitis. 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 : Abdominal pain & tenderness, fever ( these may be very mild) 2) Worsening of ascites or encephalopathy in a cirrhosis patient. 3) Can be asymptomatic Any cirrhosis patient who gets worsening of his ascites or develops encephalopathy 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 stain 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 of Ascites (contd) 2) Right sided pleural effusion 3) Respiratory difficulty So , remember 3 complications of ascites: * SBP * Right sided pleural effusion * Respiratory distress

How to Approach the patient Take a detailed history keeping in view the causes of ascites Ask questions related to hep.B&C, alcohol, drugs, primary biliary cirrhosis etc ( all these cause cirrhosis & cirrhosis causes ascites) Ask about symptoms of CHF Ask about recent pregnancy or oral contraceptive use ( Budd-Chiari syndrome) Any H/O T.B.? Any H/O renal problems?( nephrotic syndr.)

Approach to patient 2) Examine for ascites 3) Examine for CHF, abdominal tenderness for peritonitis, facial edema & pedal edema (nephrotic syndrome) 4) Do appropriate investigations to find the etiology: Cirrhosis : ? * CHF : ? Nephrotic Syndrome: ? Do paracentesis ( to see transudate or exudate)

Approach to Patient 5) If the ascites is causing respiratory distress, do therapeutic paracentesis 6) If no distress, can give medicines & diet management