Ascites PDF

ASCITES Complications of Cirrhosis Ascites - Hepatorenal Syndrome - Spontaneous Bacterial Peritonitis (SBP) - Hepatic Hydrothorax Varices Hepatic Encephalopathy (НЕ) Hepatocellular Carcinoma (HCC) ***************************************************************...

ASCITES Complications of Cirrhosis Ascites - Hepatorenal Syndrome - Spontaneous Bacterial Peritonitis (SBP) - Hepatic Hydrothorax Varices Hepatic Encephalopathy (НЕ) Hepatocellular Carcinoma (HCC) *************************************************************** ASCITES -Definition - Pathophysiology - Etiology -Morbidity and Mortality - History -Clinical features P/E finding -Diagnosis -Stages -Management Clinical Case #1 A 63 year old woman has a 3 month history of abdominal distention a 10lb weight gain despite maintaining her normal diet. She denies abdominal discomfort or change in bowel habits. The patient has chronic hepatitis C contracted from a blood transfusion received 25 yrs ago. Abdominal ultrasound a moderate amount of ascites, morphologic features of cirrhosis without focal hepatic lesions, and splenomegaly. Paracentesis is done, the ascitic fluid PMN is 50/uL and the albumin is 1.2 g/dL. 1 Clinical Case Question - Which of the following is the most appropriate treatment at this time? A.Ciprofloxacin B.Spironolactone C.Peritoneovenous shunt D.TIPS E.Large-volume paracentesis Clinical Case # 2 A 55 year old man has a 3-day history of sharp diffuse abdominal pain and fever. The patient has alcoholic cirrhosis that was documented by liver bx 2 yrs ago. Current meds are spironolactone 200mg, Lasix 80mg, and nadolol 20mg. On PE: T=102.0 The abdomen is distended, tender to palpation, and there is a reducable umbilical hernia. Abdominal US shows a large amount of ascites, cirrhosis without focal hepatic lesions, varices and enlarged spleen. Paracentesis is done, the ascitic fluid PMN count is 650/uL and the albumin is less than 1.0 g/dL Clinical Case Question -Which of the following is the most appropriate treatment at this time? A.Large-volume paracentesis B.Increase in diuretic dosage C.Intravenous cefotaxime D.TIPS E.Surgical reduction of hernia *************************************************************** Ascites Definition: Derived from the Greek word “askos”, meaning bag or sac A Condition of pathologic fluid accumulation within the abdominal cavity which is a common complication in liver cirrhosis Healthy men: have little or no intraperitoneal fluid Healthy women: may have as much as 20ml of intraperitoneal fluid, depending on phase of menstrual cycle 2 Ascites Analysis The three main causes of ascites, cirrhosis, right-sided heart failure and peritoneal pathology (malignancy or tuberculosis), can be easily distinguished by combining the results of both the SAAG and ascites total protein content Pathophysiology 1. Increased hydrostatic pressure - Cirrhosis -Hepatic vein occlusion (Budd-Chiari syndrome -IVC obstruction -Constrictive Pericarditis -Congestive heart failure 2. Decreased colloid osmotic pressure -End-stage liver disease with poor protein synthesis -Nephrotic syndrome with protein loss -Malnutrition -Protein-losing enteropathy 3. Increase permeability of peritoneal capillaries -Tuberculous peritonitis -Bacterial peritonitis -Malignant disease of the peritoneum 4. Leakage of fluid into the peritoneal cavity -Bile ascites -Pancreatic ascites -Chylous ascites -Urine ascites 5. Miscellaneous causes -Myxedema -Ovarian dz (Meig’s syndrome) -Chronic hemodialysis 3 Etiology Portal hypertension (SAAG > 1.1g/dL) 1. Hepatic Congestion -Congestive Heart Failure -Constrictive Pericarditis -Tricuspid Insufficiency -Budd-Chiari Syndrome -Veno-occlusive disease 2. Liver Disease -Cirrhosis -Alcoholic Hepatitis -Non Alcoholic Steato-Hepatitis -Fulminant Hepatic failure -Massive Hepatic metastases -Hepatic Fibrosis -Acute fatty liver of pregnancy 3. Portal vein occlusion Hypolalbuminemia (SAAG < 1.1 g/dL) -Nephrotic syndrome -Protein-losing enteropathy -Severe malnutrition with anasarca Miscellaneous conditions (SAAG< 1.1 g/dL) Chylous ascites Pancreatic ascites Bile ascites Nephrogenic ascites Urine ascites Ovarian disease 4 ► Diseased Peritoneum (SAAG 500ml fluid) - Bulging flanks (>500ml fluid) Shifting Dullness 6  Ascites Bulging Flanks and Umbilical Hernia Diagnosis Lab Studies ►A diagnostic aspiration of 10-20mL of fluid should be obtained and the following should be performed: Cell count: - a white blood cell count is the most important - a neutrophil count above 250 cells/mm3 is indicative of and underlying spontaneous bacterial peritonitis - an elevated lymphocyte count arouses suspicion of tuberculosis or peritoneal carcinomatosis Gram stain and culture: for bacteria and acid fast bacilli SAAG Serum-Ascites Albumin Gradient ► Best single test for classifying ascites into portal hypertensive and non-portal hypertensive causes ► Calculated by: ► Subtracting the ascitic fluid albumin from the serum albumin SAAG >1.1 g/dL= Portal HTN SAAG < 1.1 g/dL= Non-Portal hypertensive cause 7 SAAG >1.1 SAAG