1. بسم الله الرحمن الرحيم

2. APPROACH TO PATIENT WITH ASCITIES.

3. DEF. OF ASCITIES.
Ascites is defined as the accumulation of free fluid in the peritoneal cavity.

4. TYPES OF ASCITIES. Broadly categorizing ascities can be:.
Ascities is most often caused by liver cirrhosis which accounts for over 75% of patients while the remaining 25 % is due to malignancy (10%), heart failure (3%), pancreatitis (1%), TB (2%), or other rare causes.
Broadly categorizing ascities can be:.
1...Peritoneal ascities.
2...Non peritoneal ascities.

5. Peritoneal Causes of Ascites
Examples
Malignant ascites
Primary peritoneal mesothelioma Secondary peritoneal carcinomatosis
Granulomatous peritonitis
Tuberculous peritonitis Fungal and parasitic infections Sarcoidosis Foreign bodies (cotton ,starch, barium)
Vasculitis
Systemic lupus erythematosus Henoch-Schönlein purpura
Miscellaneous disorders
Eosinophilic gastroenteritis Whipple disease Endometriosis

6. Nonperitoneal Causes of Ascites
Examples
Intrahepatic portal hypertension
Cirrhosis Fulminant hepatic failure Veno-occlusive disease
Extrahepatic portal hypertension
Hepatic vein obstruction
(ie, Budd-Chiari syndrome) Congestive heart failure
Hypoalbuminemia
Nephrotic syndrome Protein-losing enteropathy Malnutrition
Miscellaneous disorders
Myxedema Ovarian tumors Pancreatic & Biliary ascites
Chylous
Secondary to malignancy, trauma

7. PATHOPHYSIOLOGY OF ASCITIES.
FACTORES ASSOCIATED WITH ASCITES IN HEPATIC CIRROSIS
Renal sodium retention
Renal water retention 
Portal hypertension    
Poor liver function      
Ascites in hepatic cirrhosis develops because of a considerable increase of total body sodium,water, and portal hypertension which localises much of that sodium and water to the peritoneal cavity

8. The pathogenesis of ascites formation remains controversial
The pathogenesis of ascites formation remains controversial. “Underfill" theory Ascites occurs as a primary event. Sequestration of fluid into the peritoneal cavity as a result of changes in Starling's forces leads to reduction of the circulatory volume and stimulation of the sympathetic nervous & RAAS that promote renal sodium & water retention.

9. “Overflow theory" Renal Na retention occurs as a primary event
“Overflow theory" Renal Na retention occurs as a primary event. It may be due to increased production of a sodium retaining factor or reduced synthesis of a natriuretic factor by the diseased liver. The circulatory volume is expanded & the retained fluid is preferentially localized to the peritoneal cavity as ascites.

10. “Peripheral Arterial Vasodilation Hypothesis"
The currently accepted theory of ascites formation which include features of both the underfill and overflow theories is the
“Peripheral Arterial Vasodilation Hypothesis"
According to this theory, Portal pressure >12 mm Hg is required for the development of PH which will lead to formation of ascites.
Chronic endotoxemia associated with cirrhosis may stimulate the synthesis and release of a potent endothelin-derived relaxing factor, Nitric oxide,;leading to PH changes.

11. SYPTOMS OF ASCITIES.
 The symptoms of ascites depend largely on the quantity of fluid.
Trace ascites ______ asymptomatic, and fluid is detected only on physical or radiologic examination.
Large amount_______ complain of abdominal fullness, early satiety, abdominal pain, or shortness of breath.
Ascites can give rise to a number of secondary features including :-
umbilical eversion
hernia
pale abdominal striae
scrotal edema
Mechanical effects on the chest.
Pleural effusion .

12. DIAGNOSIS. HISTORY Most cases of ascites are due to liver disease.
Patients with ascites should be asked about risk factors for liver disease like:-
Alcohol use and duration of use-----experience ascities in cyclic fashion.
Chronic viral hepatitis or jaundice
Intravenous drug use
Sexual promiscuity
Transfusions.
Tattoos
Habitation or origination from an area endemic for hepatitis

13. HISTORY
Obesity, hypercholesterolemia, and type 2 diabetes mellitus are recognized causes of nonalcoholic steatohepatitis, which can progress to cirrhosis,leading to ascities.
History of cancer, especially gastrointestinal cancer, are at risk for malignant ascites.
Malignancy-related ascites is frequently painful, whereas cirrhotic ascites is usually painless.
Patients who develop ascites in the setting of known diabetes or nephrotic syndrome may have nephrotic ascites.
Sudden development of ascities in stable cirrhosis,consider HCC.

14. EXAMINATION Physical examination findings are variable.
The accuracy of detecting ascites depends on the amount of fluid present and the body habitus of the patient (detecting ascites may be more technically difficult in obese patients).
If ascites is present, typical findings include generalized abdominal distention, flank fullness,shifting dullness,fluid thrill and +puddle sign.

15. SHIFTING DULLNESS METHOD OF EXAMINATION
BEGIN BY PERCUSSING AT THE UMBILICUS AND MOVING TOWARD THE FLANKS. THE TRANSITION FROM AIR TO FLUID CAN BE IDENTIFIED WHEN THE PERCUSSION NOTE CHANGES FROM TYMPANIC TO DULL.
ROLL THE PATIENT ON THEIR SIDE AND PERCUSS AS BEFORE. THE AREA OF TYMPANY WILL SHIFT TOWARDS THE TOP AND THE AREA OF DULLNESS TOWARDS THE BOTTOM.

16. FLUID THRILL METHOD OF EXAMINATION
HAVE THE PATIENT OR ASSISTANT PLACE THEIR HANDS IN THE MIDLINE
TAP ONE FLANK SHARPLY AND USE THE FINGERTIPS OF THE OPPOSITE HAND TO FEEL FOR AN IMPULSE ON THE OPPOSITE FLANK

17. PUDDLE SIGN METHOD OF EXAMINATION
PATIENT IS PRONE FOR 3-5 MINUTES AND THEN RISES TO ALL FOURS
DIAPHRAGM OF THE STETHOSCOPE IS PLACED OVER MOST DEPENDENT AREA OF THE ABDOMEN
BEGIN BY FLICKING A FINGER OVER A LOCALIZED FLANK AREA
MOVE THE STETHOSCOPE OVER THE OPPOSITE FLANK
SUDDEN INCREASE IN INTENSITY IS A POSITIVE SIGN (NO LONGER USED)

18. GRADING OF ASCITIES
Two grading systems for ascites have been used depending upon physical findings. The older system 1+ is minimal and barely detectable. 2+ is moderate. 3+ is massive but not tense. 4+ is massive and tense. The International Ascites Club grading (2003) Grade 1: mild ascites detectable only by USG. Grade 2: moderate ascites manifested by moderate symmetrical abdominal distension. Grade 3: large or gross ascites with marked abdominal distension.

19. INVESTIGATIONS A.DETECTION OF ASCITIES. B.FINDING CAUSE OF ASCITIES.
1.ULTRASONOGRAPHY.
2.DIAGNOSTIC PARACENTESIS.
B.FINDING CAUSE OF ASCITIES.
1.IMAGING.
2.ENDOSCOPY.
3.BIOCHEMICAL PARAMETERS.

20. PERACENTESIS Indications Symptomatic relief in Cirrhotic Ascites
Diagnostic study
Suspected Spontaneous Bacterial Peritonitis
Examine ascitic fluid for other etiology
General
Remove up to 4-6 L ascitic fluid
Salt-poor albumin
Preparation: 25% 50 cc bottle IV
Give 1 bottle for every 1.5L of ascitic fluid removed
Labs
Prior to procedure
Complete Blood Count PT
APPT
If platelets <40,000 then
Transfuse 6 pack of platelets before paracentesis.

21. PARACENTESIS Procedure Preparation
Place Foley and empty bladder before procedure
Patient at 30 degrees head up (reverse Trendelenburg)
Prepare site
Midline at approximately 2 cm below and lateral to Umbilicus
Clean and prep site well as SBP is a risk .
Local 1% Lidocaine anesthetic
Paracentesis
Consider Z-Tracking needle on entry into abdomen
Use vacuum bottle to apply suction
Labs to send in ascitic fluid
Cytology (if malignancy suspected)
Cultures (rule-out SBP)
Serum-to-Ascites Albumin Gradient (SAAG)
Adverse Effects
Hypotension Abdominal wall hematomas.
Hyponatremia Hemoperitoneam.
Bleeding Bowel entry.

22. ASCITIC FLUID ANALYSIS
Appearance
Cause
Translucent or yellow or straw coloured.
Normal/sterile ,cirrhosis.
Brown
Hyperbilirubinemia
GB or biliary perforation
Cloudy or turbid
Infection
Pink or blood tinged
Mild Trauma
Grossly bloody
Malignancy
Abdominal trauma
Milky ("chylous")
Lymphatic obstruction.

23. BIOCHEMICAL EVALUATION.
ROUTINE
SOME TIMES USEFUL
RARELY HELPFUL
CELL COUNT
TOTAL PROTEINS PH
DIFFERENTIAL COUNT
GLUCOSE
LACTATE
ALBUMIN
LDH
GRAM STAIN
CULTURES
AMYLASE
TRIGLYCERIDES
CYTOLOGY
BILLIRUBIN
TB SMEAR AND CULTURE

24. ASCITIC FLUID ANALYSIS
If the PMN count is >250 cells/mm3,spontaneous bacterial peritonitis.
Serum-ascites albumin gradient = serum albumin - ascitic fluid albumin
if > 1.1 g/dL portal hypertension is present;
if < 1.1 g/dL portal hypertension is not present (about 97% accurate).
Cytology - only positive in peritoneal carcinomatosis.
Lactate dehydrogenase >225mU/L, glucose <50mg/dL, total protein >1g/dL and multiple organisms on gram stain suggest secondary bacterial peritonitis (ruptured viscus or loculated abscess).
A high level of triglycerides confirms chylous ascites.
An elevated amylase level suggest pancreatitis or gut perforation.
An elevated bilirubin level suggest biliary or gut perforation.

25. TREATMENT
Mild to moderate ascites can be treated as an outpatient, but more severe ascites is treated best in hospital.
Important factors in treating ascites include :
1.Bed rest.
2.Removing precipitating factors,
3.Controlling sodium intake
4.Controlling water intake, and potassium depletion.
5.Promoting sodium excretion with diuretic drugs,
6.Removing ascites by paracentesis,
7. Diverting ascitic fluid into the systemic circulation via a transjugular intrahepatic portal systemic stent (TIPSS) shunt or a Leveen shunt .
None this treatment prolongs life, and prognosis for patients with hepatic cirrhosis and ascites is generally poor, liver transplantation should be considered.

26. MCQs.

27. Q. No 1 MCQs IF SAAG IS >1.1 THEN THE CAUSE WOULD BE ALL EXCEPT:
PORTAL HYPERTENSION
MYXEDEMA
NEPHROTIC SYNDROME
TUBERCULOUS PERITONITIS

28. Q. No 2 MCQs THE MOST EFFICACIOUS TREATMENT FOR REFRACTORY ASCITES IS
MAXIMUM DOSE OF DIEURETICS
THERAPEUTIC PARACENTESIS
TIPS
LEE VEEN SHUNT

29. Q. No 3 MCQs SBP IS MORE LIKELY WHEN WBCS >250/microL
NEUTROPHILS>250/microL
LYMPHOCYTES>500/microL
ALL OF THE ABOVE

30. SCENARIO
54 year old female presented in emergency department with history of abdomional pain and abdominal distension for last 6 days.In past history she was HCV positive for last 3 years.
What physical signs you can suspect in this case ?

31. SCENARIO BP 100/70 mmHg Pulse 90/min Abdomen examination revealed
Distended abdomen with everted umbilicus
Splenomegaly
Shifting dullness is positive
Bowel sounds present
HOW WILL YOU INVESTIGATE THIS CASE ?

32. SCENARIO CP shows pancytopenia PT is 4 seconds prolong LFTS are normal
Serum albumin is 3.2
Ascitic fluid analysis
Albumin 2.0
TLC 350
POLYMORPHS 20%
LYPHOCYTES 80%
WHAT ARE THE DIFFENTIAL DIAGNOSIS?
WHAT IS YOUR LIKELY DIAGNOSIS ?

33. SCENARIO
HOW WILL YOU MANAGE THIS CASE?

34. THANK YOU