1. Andrew Maclennan Morning Report July 24, 2009
Evaluation of Ascites
Andrew Maclennan
Morning Report
July 24, 2009

2. Pathophysiology of Ascites
From: Robbins Basic Pathology

3. Causes of Ascites Cause Frequency Cirrhosis 81% Cancer 10%
Heart Failure 3%
Tuberculosis 2%
Dialysis 1%
Pancreatic Disease
Other
Source: UpToDate

4. Rare Causes of Ascites Category Infectious diseases
Amebiasis, Ascariasis, Brucellosis, Chlamydia peritonitis, Complications related to HIV infection, Pelvic inflammatory disease, Pseudomembranous colitis, Salmonellosis, Whipple's disease
Hematologic
Amyloidosis, Castleman's syndrome, Extramedullary hematopoiesis, Hemophagocytic syndrome, Histiocytosis X, Leukemia, Lymphoma, Mastocytosis, Multiple myeloma
Miscellaneous
Abdominal pregnancy, Crohn's disease, Endometriosis, Gaucher's disease, Lymphangioleiomyomatosis, Myxedema, Nephrotic syndrome, lymphatic tear or ureteral injury. Ovarian hyperstimulation

5. Imaging Ultrasound with Dopplers CT / MRI Easily confirms ascites
May see nodularity of cirrhosis
Evaluate patency of vasculature
No radiation, contrast
CT / MRI
Evaluation for malignancy

6. Tests on Ascitic Fluid Routine Optional Unusual
Cell count and differential
Glucose concentration
Tuberculosis smear and culture, adenosine deaminase
Albumin concentration
LDH concentration
Cytology
Total protein concentration
Gram stain
Triglyceride concentration
Culture in blood culture bottles
Amylase concentration
Bilirubin concentration

7. Cell Count, differential and culture
Is ascites infected?
Greater than 250 PMN = SBP
If ascites is bloody ( > 50,000 RBC/mm3), correct by subtracting 1 PMN / 250 RBC
Is ascites bloody?
5% of pts w/ cirrhosis - spontaneous or s/p traumatic tap.
Non-traumatic  associated with malignancy
20% of malignant ascites
10% of peritoneal carcinomatosis

8. Serum to Ascites Albumin Gradient
Is portal hypertension present?
97% accurate
SAAG > 1.1 g/dL  Portal HTN
SAAG < 1.1 g/dL  Other causes
The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):

9. Serum to Ascites Albumin Gradient
SAAG > 1.1 g/dL
SAAG < 1.1 g/dL
Cirrhosis
Peritoneal carcinomatosis
Alcoholic hepatitis
Peritoneal tuberculosis
CHF
Pancreatitis
Massive hepatic metastases
Serositis
Budd Chiari Syndrome
Nephrotic syndrome
Congestive heart failure/constrictive pericarditis

10. Total Protein Exudate ( > 2.5 g/dL) or Transudate?
Supplanted by SAAG
Is there gut perforation? (vs SBP)
Total protein >1 g/dL
Glucose <50 mg/dL (2.8 mmol/L)
LDH greater than serum ULN

11. Glucose and LDH Consistent with infection or malignancy?
Infection and cancer consume glucoselow
LDH is a larger molecule than glucose, enters ascitic fluid with difficulty.
Ascitis/Serum LDH ratio
~ 0.4 in cirrhotic ascites
Approaches 1.0 in SBP
>1.0, usually infection or tumor

12. Other tests Amylase Triglycerides — run on milky fluid.
Uncomplicated cirrhotic ascites
About 40 IU/L. The AF/S ratio is about 0.4
Pancreatic ascites
About 2000 IU/L. The AF/S ratio is about 6
Triglycerides — run on milky fluid.
Chylous ascites - TG > 200 mg/dL, usually 1000 mg/dL
Bilirubin — run on brown ascites.
Biliary perforation – AF Bili > serum Bili

13. Tests for TB Smear – extremely insensitive
Culture – 62-83% when large volumes cultured
Cell count – mononuclear cell predominance
Adenosine deaminase –
Enzyme involved in lymphoid maturation
Falsely low in pts with both cirrhosis and TB

14. Cytology
“almost 100%” with peritoneal carcinomatosis have positive cytology
Malignant ascites from massive hepatic mets, HCC, lymphoma are usually negative
Overall sensitivity for detection of malignancy-related ascites is 58 to 75 %

15. Not helpful
“Some tests of ascitic fluid appear to be useless. These include pH, lactate, and ‘humoral tests of malignancy’ such as fibronectin, cholesterol, and many others”

16. Biopsy Cirrhosis Fatty Liver

17. Causes of Cirrhosis Cause Testing Alcoholic liver disease
History, AST / ALT > 2
Chronic hepatitis C
Hep C Ab, Viral load
Primary biliary cirrhosis
Antimitochondrial antibodies
Primary sclerosing cholangitis
Contrast cholangiography , ANA, Anti smooth muscle Ab, ANCA
Autoimmune hepatitis
Type 1: ANA, ANCA antismooth muscle Ab Type 2: anti-LKM-1
Chronic hepatitis B
Hepatitis B serologies
Hemochromatosis
Ferritin, genetic testing
Wilson’s disease
Ceruloplasmin
Alpha-1-antitrypsin deficiency
Serum AAT
Nonalcoholic fatty liver disease
Hx of DM or metabolic syndrome

18. Malignant Ascites
Definition: abnormal accumulation of fluid in the peritoneal cavity as a consequence of cancer.
Commonly caused by cancers of:
Breast, bronchus, ovary, stomach, pancreas, colon
20% of cases have tumors of unknown primary
Survival poor – usually less than 3 months
Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006)

19. Malignant Ascites: Pathophysiology
Obstruction of lymphatics by tumor
Prevents absorption of fluid and protein
Alteration in vascular permeability
Hormonal mechanisms (VEGF, IL2, TNF alpha)
Decreased circulating blood volume
Activates RAAS leading to Na retention
Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006)

20. Pathophysiology of Malignant Ascites

21. Management of Malignant Ascites
Therapeutic paracentesis
Removing up to 5L appears safe
No good data on role of volume expanders
Diuretics
Equivocal evidence of efficacy
May be helpful for portal HTN
Less/minimally useful when no portal HTN
Drainage Catheters
Peritoneovenous shunts

22. Peritoneovenous Shunt
Contraindications
Protein > 4.5 g/l (occlusion)
Loculated ascites
Coagulopathy
Advanced renal/cardiac disease
GI malignancy
Complications
Infection
Hematogenous spread of mets
DIC
Pulmonary edema
Pulmonary emboli
Denver Shunt
(Similar to LaVeen Shunt)

23. Transjugular intrahepatic portosystemic shunt (TIPS)

24. References
Up to Date
Ascites and renal dysfunction in liver disease, Second edition. Edited by Pere Ginès, Vicente Arroyo, Juan Rodés, and Robert W. Schrier. Malden, Mass., Blackwell, 2005.
The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):
Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006)
Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis, and management. Arch Intern Med. Vol Dec 10/24, 2001.