Complications of Cirrhosis: Ascites Cases

Complications of Cirrhosis: Ascites

• Ascites is the accumulation of fluid in the abdominal cavity, a complication of cirrhosis.
• Hepatorenal syndrome, spontaneous bacterial peritonitis (SBP), hepatic hydrothorax, varices, hepatic encephalopathy (HE), and hepatocellular carcinoma (HCC) are also complications of cirrhosis.

Clinical Case #1

• A 63-year-old woman presented with abdominal distention, a 10-pound weight gain, despite maintaining a normal diet.
• She had a history of chronic hepatitis C, contracted 25 years prior from a blood transfusion.
• Abdominal ultrasound showed ascites, cirrhosis, and splenomegaly.
• Ascitic fluid analysis revealed a PMN count of 50/uL and an albumin level of 1.2 g/dL.

Clinical Case #2

• A 55-year-old man with a history of alcoholic cirrhosis had sharp diffuse abdominal pain and fever.
• He was taking spironolactone, Lasix, and nadolol.
• Abdominal ultrasound showed ascites, cirrhosis, varices, and enlarged spleen.
• Ascitic fluid analysis revealed a PMN count of 650/uL and an albumin level of less than 1.0 g/dL.

Ascites Definition

• Ascites is the abnormal accumulation of fluid in the abdominal cavity.
• It is a common complication of liver cirrhosis.
• Healthy men typically have little to no intraperitoneal fluid, while women may have up to 20 ml.

Ascites Pathophysiology

• Increased hydrostatic pressure: Cirrhosis, hepatic vein obstruction (Budd-Chiari syndrome), IVC obstruction, constrictive pericarditis, and congestive heart failure can increase hydrostatic pressure.
• Decreased colloid osmotic pressure: End-stage liver disease, nephrotic syndrome, malnutrition, and protein-losing enteropathy can decrease colloid osmotic pressure.
• Increased permeability of peritoneal capillaries: Tuberculosis, bacterial peritonitis, malignant diseases, bile ascites (bile leaking into the abdomen), pancreatic ascites (pancreatic fluid leaking into the abdomen), chylous ascites (lymphatic fluid leaking into the abdomen), and urine ascites (urine leaking into the abdomen) can increase the permeability.
• Leakage of fluid into the peritoneal cavity: Additional causes of ascites include bile ascites, pancreatic ascites, and chylous ascites.
• Miscellaneous causes: Myxedema, ovarian cysts (Meigs syndrome), and chronic hemodialysis.

Portal Hypertension (SAAG >1.1g/dL)

• Portal hypertension is a significant cause of ascites.
• It can be a result of hepatic congestion (heart failure, constrictive pericarditis, tricuspid insufficiency, Budd-Chiari syndrome, and veno-occlusive disease).
• Liver disease (cirrhosis, alcoholic hepatitis, non-alcoholic steatohepatitis, fulminant hepatic failure, massive hepatic metastases, hepatic fibrosis, and acute fatty liver of pregnancy).
• Portal vein occlusion (hypolalbuminemia and severe malnutrition).

Diseased Peritoneum (SAAG <1.1 g/dL)

• Bacterial peritonitis, tuberculous peritonitis, fungal peritonitis, HIV-associated peritonitis, peritoneal carcinomatosis, primary mesothelioma, pseudomyxoma peritonei, massive hepatic metastases, and hepatocellular carcinoma are causes of ascites. Also, other conditions like familial Mediterranean fever, vasculitis, granulomatous peritonitis, and eosinophilic peritonitis.

Ascites Morbidity and Mortality

• Ambulatory patients with cirrhotic ascites have a 3-year mortality rate of 50%.
• Refractory ascites (ascites that doesn't respond to treatment) carries a poor prognosis.

Ascites History

• Patients should be questioned about risk factors for liver disease, such as needle sharing, tattoos, cocaine/heroin use, and emigration from certain areas, possibly those with a higher risk of Hepatitis B and C infection.

Ascites Clinical Features

• Increased abdominal girth, early satiety, and respiratory distress.
• Presence of abdominal pain or discomfort.
• Pedal edema and weight gain.
• Findings such as a palpable umbilical hernia, tympany at the top of the abdomen, a fluid wave, and peripheral edema.
• Assessment of shifting dullness (> 500ml fluid) and bulging flanks (>500ml fluid).

Ascites Diagnosis: Lab Studies

• Diagnostic aspiration of 10-20 mL of fluid to determine cell count, Gram stain and culture (for bacteria and acid-fast bacilli), serum-ascites albumin gradient (SAAG).
• A white blood cell count (WBC), specifically the neutrophil count (>250 cells/mm3) is crucial for spontaneous bacterial peritonitis. Elevated lymphocyte count may suggest tuberculosis or peritoneal carcinomatosis.
• SAAG > 1.1 g/dL suggests portal hypertension; <1.1 g/dL indicates a non-portal hypertensive cause.

Ascites SAAG and Diagnosis

• Total protein and glucose can help diagnose spontaneous bacterial peritonitis (SBP).
• Cytology (cell examination) can identify malignant cells.
• Amylase can rule out pancreatic ascites.
• Ascites appearance (turbid, cloudy, milky, pink/bloody, or brown) can support differential diagnosis.
• Turbid/cloudy: infection; milky: high triglycerides; pink/bloody: trauma/cancer; brown: bilirubin/jaundice.

Ascites Imaging and Staging

• CT scan for visualization of fluid in various spaces (right perihepatic space, posterior subhepatic space, pouch of Douglas).
• Ultrasound can detect small amounts of fluid, typically in the Morison pouch.
• Ascites staging (mild, moderate, severe) based on examination findings aids treatment decisions.

Ascites Management

• Prevent Na loading and increase renal excretion of Na and H2O. Restrict sodium intake (2 g/day dietary sodium), restrict fluid intake (if serum sodium is < 128 mmol/L), and check electrolytes and creatinine periodically.
• Diuretic therapy: Spironolactone is the first choice, followed potentially by lasix, or other diuretics.
• Large-volume paracentesis for symptomatic tense ascites. Removal of 5L or more may be done over a 4-6-hour period, with additional Albumin supplementation if needed.

Paracentesis

• Contraindications: Acute abdomen, severe bowel distention, previous abdominal surgeries, pregnancy (if necessary, planned after 1st trimester), distended bladder, and infections or cellulitis at the insertion site.
• Complications from paracentesis: bladder or bowel perforation, laceration of major vessels, abdominal wall hematomas, wound infection, and hernias.
• Transjugular Intrahepatic Portosystemic Shunt (TIPS) is an interventional radiologic technique used for resistant ascites.

Hepatic Encephalopathy (HE)

• A syndrome of brain dysfunction associated with liver failure.
• Characterized by fluctuating neurologic signs, asterixis ("flapping tremor"), EEG changes, and alterations in consciousness.
• Can range from mild symptoms (confusion) to coma/death.

Hepatic Encephalopathy Grades

• Grade 0: Minimal changes
• Grade 1: Trivial lack of awareness
• Grade 2: Lethargy, obvious asterixis, inappropriate behavior
• Grade 3: Somnolent, unable to perform tasks
• Grade 4: Coma

Hepatorenal Syndrome (HRS)

• A complication of liver cirrhosis, characterized by kidney dysfunction.
• Usually, progressive decline in kidney function.
• Diagnosis by exclusion, and typically occurs when the GFR drops significantly (<40ml/min) within days or weeks.
• Type 1: rapid decline, often precipitated by infections (commonly SBP)
• Type 2: gradually declining, often due to diuretic-resistant ascites

Prevention of Acute Renal Injury in Cirrhotics

• Avoid aminoglycosides, NSAIDs, IV contrast, and hydrate frequently. Closely monitor kidney function in patients with ascites and instruct patients on diuretic, lactulose, and antibiotic use.
• Acute renal failure can happen due to advanced liver diseases such as cirrhosis, severe alcoholic hepatitis, and fulminant hepatic failure.
• HRS incidence is 10% in hospitalized cirrhotic patients; 8-20% per year for patients with decompensated cirrhosis.

Ascites Treatments

• Orthotopic liver transplantation (of choice) is considered when serial paracenteses, TIPS (transjugular intrahepatic portosystemic shunt) and peritoneovenous shunts don't solve refractory ascites problems.

Differential Diagnosis of Ascites

• Intracranial lesions, drugs/alcohol intoxication, toxic encephalopathy (alcohol, drugs), metabolic encephalopathy, infections, hyperammonemia, and post-seizure encephalopathy.

This quiz explores complications associated with cirrhosis, particularly focusing on ascites. Through clinical cases, you will analyze symptoms, diagnostics, and specific conditions related to cirrhosis. Test your knowledge on the consequences of chronic liver disease and its management options.