Ascites of local cause By: Assistant lecturer Waleed Fouad

Definition Ascites describes the condition of pathologic fluid accumulation within the abdominal cavity. Healthy men have little or no intraperitoneal fluid, but women may normally have as much as 20 mL depending on the phase of the menstrual cycle.

Etiology Normal peritoneum Portal hypertension [SAAG] >1.1 g/dL) Hepatic congestion Congestive heart failure Constrictive pericarditis Tricuspid insufficiency Budd-Chiari syndrome Liver disease Cirrhosis Fulminant hepatic failure Alcoholic hepatitis Massive hepatic metastases

Etiology cont. Normal peritoneum Hypoalbuminemia (SAAG <1.1 g/dL) Chylous ascites Pancreatic ascites Bile ascites Urine ascites Nephrotic syndrome Protein-losing enteropathy Miscellaneous conditions (SAAG <1.1 g/dL) Ovarian disease Severe malnutrition with anasarca

Etiology cont. Diseased peritoneum (SAAG <1.1 g/dL) Infections Peritoneal carcinomatosis Primary mesothelioma Pseudomyxoma peritonei Bacterial peritonitis TB peritonitis Hepatocellular carcinoma Fungal peritonitis Malignant conditions Chlamydia peritonitis Alveolar hydatid disease HIV-associated peritonitis Strongyloidiasis CMV

Etiology cont. Eosinophilic peritonitis Whipple's disease Primary lymphatic hypoplasia Endometriosis Familial Mediterranean fever Granulomatous peritonitis Sarcoidosis Rare conditions Vasculitis

Grading of ascites A grading system for ascites has been proposed by the International Ascites Club: An older system that grades ascites from 1+ to 4+ is also used. Grade 1 Mild ascites detectable only by ultrasound Grade 2 Moderate ascites manifested by moderate symmetrical distension of the abdomen Grade 3 Large or gross ascites with marked abdominal distension 1+ is minimal and barely detectable 2+ is moderate 3+ is massive but not tense 4+ is massive and tense

Diagnosis The diagnosis of ascites is established with a combination of a physical examination and an imaging test (usually ultrasonography). Abdominal paracentesis with appropriate ascetic fluid analysis is the most efficient way to confirm the presence of ascites and diagnose its cause. Peritoneoscopy with culture and histology of a biopsied nodule is the most rapid route to the diagnosis.

Tests performed on ascitic fluid Routine tests Optional tests Unusual tests Cell count and differential Albumin concentration Total protein concentration Culture in blood culture bottles Glucose concentration LDH concentration Gram stain Amylase concentration Tuberculosis smear and culture Cytology Triglyceride Bilirubin Adenosine deaminase CEA PH & lactate Cholesterol Fibronectin

Tuberculous Peritonitis Tuberculous peritonitis should be considered in all patients presenting with unexplained lymphocytic ascites with a serum-ascites albumin gradient of <1.1 g/dL. The gold-standard for diagnosis is culture growth of Mycobacterium on ascetic fluid or a peritoneal biopsy.

Tuberculous Peritonitis cont. Other Tests Routine laboratory tests Normocytic normochromic anemia in 50 % Tuberculin skin testing Positive in 70 % of patients Chest x-ray Old tuberculosis in 20 to 30 % US & CT Peritoneal thickening, omental caking and /or ascites with fine mobile septations.

Peritoneal fluid analysis Ascitic leukocyte count 150 to 4000 mm3 + Lymphocytic Pleocytosis > 50% Albumin content Useful in differentiating tuberculous ascites from carcinomatous ascites SAAG <1.1 Sensitivity of 0 to 6 % Direct smear for Ziehl-Neelson stain >3.0 g/dL >1.1 PCR Underlying cirrhosis If ADA Rapid detection

Multiple miliary nodules over the peritoneum with an adhesion band attached to anterior surface of liver capsule.

Malignant ascites It occurs most often with ovarian cancer in about one-third of women at the time of diagnosis. It is also associated with a variety of other primary cancer sites: Stomach, Liver, Uterus, Testis, Breast, Pancreas, Colon, Lymphoma, Mesothelium, Lung, Unknown primary site.

In the presence of malignant cytologic findings without a primary tumor diagnosis, further investigations of male patients may not lead to improved survival, since all primary tumour groups are associated with a uniformly poor prognosis. Female patients may benefit from further investigations, possibly including lapa­ roscopy or even laparotomy, since ovarian cancer is treatable.

Serum tumour markers Peritoneal nodules, omental caking and 1ry tumour site. US & CT CEA - CA125 – α feto protein Peritoneal fluid analysis Albumin content >3.0 g/dL Ascetic WBCs Lymphocytic Pleocytosis > 50% Other tests α1-antitrypsin Cyclic AMP CholesterolFibronectin Glycosaminoglycans SAAG <1.1

Cytology Gold standard Malignancies can produce ascites without shedding many neoplastic cells Diagnostic sensitivity of only 40% to 60%. Immunohistochemical staining can increase the diagnostic sensitivity Laparoscopy Used with caution in patients with malignant ascites High risk for trocar implantation metastasis

Positron Emission Tomography- CT scan shows peritoneal nodule characterized by abnormally high radiotracer uptake. Positron emission tomography (PET) is a nuclear medicine medical imaging technique which produces a three-dimensional image or map of functional processes in the body.

Axial intravenous contrast-enhanced abdominal CT scan shows tiny nodules in the gastrohepatic ligament (short arrows) and in the inferior portion of the falciform ligament (long arrow).

Axial intravenous contrast-enhanced abdominal CT scan shows nodules in the lesser sac (arrows).

Close-up view showing peritoneal implants, as well as abnormal feeding blood vessels. Laparoscopy demonstrated obvious diffuse carcinomatosis, with implants on all peritoneal surfaces.

Chylous ascites Chylous ascites is a milky-appearing peritoneal fluid Abdominal malignancy and cirrhosis Two-thirds of all cases Other etiologies Infections Primary lymphatic Hypo or hyperplasia Filariasis TB Congenital InflammatoryPost-operative yellow-nail syndrome Radiation therapy Sarcoidosis Lymphatic injury or compression Malignancy particularly Lymphoma is a common cause.

CT Can identify pathologic intra abdominal lymph nodes and masses Lymphangiography & lymphoscintigraphy Abnormal retroperitoneal nodes, leakage from dilated lymphatics, fistulization, and patency of the thoracic duct Triglyceride values are typically above 200 mg/dL

PANCREATIC ASCITES Massive accumulation of pancreatic fluid in the peritoneal cavity The most common underlying cause is chronic pancreatitis secondary to alcohol abuse. Following an episode of acute pancreatitis or a traumatic injury to the pancreas. Also has been described with pancreatic pseudocysts.

US & CT Can detect the presence of a pseudocyst Accurately demonstrate the normal pancreatic duct and detect any abnormalities arising from it MRCP ERCP Localize the site of leakage and endoscopic therapy if possible Peritoneal fluid analysis SAAG <1.1 Albumin content >3.0 g/dL Ascitic amylase > 1,000 IU/L Elevated Ascitic WBCs Ascitic/serum amylase ratio is 6.0

Ascites due to more than 1 cause Approximately 5 percent of patients with ascites have more than one cause, such as cirrhosis plus Tuberculous peritonitis, peritoneal carcinomatosis or heart failure. Patients with more than one cause for ascites formation tend to be the most confusing to diagnose because each partial cause may not be severe enough to lead to fluid retention by itself.

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