1. 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

2. 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.