Cirrhosis with ascites-consider pt for liver transplant Evaluation of Ascites C.L.I.P.S. How Common 60,000 cases in 100,000 persons with cirrhosis Causes Cirrhosis 81% Heart failure 10% Cancer-3%PE How do they usually present (history)? Abdominal distention, edema, weight gain Spontaneous bacterial peritonitis fever/chill, abd pain altered mental status renal failure, acidosis Physical exam findings Percussion-shifting dullness or fluid wave abdominal pain USN- Anechoic fluid collection with in the abdomen, bowel looks like “palm trees swaying in the wind.” Paracentesis Indications-DX- New onset ascites, r/p spontaneous bacterial peritonitis (SBP) Tx respiratory compromise, refractory cirrhotic ascites Contraindications-uncooperative pt, acute abdomen, infected abdominal wall. Relative contraindications- bowel distension, multiple prior abd surgeries, pregnancy . INR above 3 (above 2 if on warfarin ) PTT 1.5 above normal Plt below 30K Always USN guided-Make sure pt has an empty bladder Find pocket with USN. 2 cm below umbilicus , semi recumbent, or 3-4 cm towards umbilicus from left anterior superior iliac spine. Avoid epigastric artery. Z-track. Cirrhosis with ascites-consider pt for liver transplant Updated 1/18 Stromberg

Evaluation of Ascites C.L.I.P.S. Laboratory CBC with diff Protein, Alb LDH, Glucose Culture and Gram stain- Inoculate culture bottles at bedside. Results Serum to ascites albumin Gradient (SAAG) SAAG Greater or equal to 1.1 indicates portal HTN SAAG less than 1.1 indicates portal HTN not the cause of ascites. Ascitic fluid protein above 2.5 CHF, Myxedema, Budd-Chiari Ascitic fluid protein below 2.5 Cirrhosis or alcoholic hepatitis Cell count above 250 PMN/mm=SBP Albumin If remove more than 5 liters infuse albumin 8 gm per liter removed. Pre-existing renal insufficiency ( Cr cl below 50) Hepatorenal SBP Albumin1.5 gm/kg day on and 1 gm/kg day 3 5 days of third generation cephalosporin then life long prophylaxis Stop PPI Fluid restriction in not needed in most patients with ascites unless [Na] below 125.