Ascites
Background
- Abnormal buildup of peritoneal fluid
Causes
- Cirrhosis 81%[1]
- Malignancy 10%
- Heart failure 3%
- Tuberculosis 2%
- Other 4%
Clinical Features
- Abdominal distention +/- discomfort
- Fluid wave
- +/- SOB if massive amount
Differential Diagnosis
Abdominal distention
- Obesity
- Intestinal obstruction
- Pregnancy
- Ascites
- Cirrhosis
- Malignancy
- Heart failure
- Tuberculosis
- Spontaneous bacterial peritonitis
- Peritoneal dialysis-associated peritonitis
- Distended bladder / Acute urinary retention
- Constipation / fecal impaction
- Large tumor(s) (e.g. ovarian, lymphoma)
- Organomegaly
Evaluation
Ascites appearance on ultrasound
POCUS showing ascites[2]
Liver cirrhosis with ascites on CT
- Ascites in females with no other reason for it = gyn neoplasm until proven otherwise (ovarian cancer)
Workup
- CBC
- Chem 7
- PT/PTT
- LFTs + lipase
- FAST
Ascites Fluid Workup
- Cell count and differential
- Albumin
- Total protein
- Only if suspicious:[3]
- Gram stain
- Glucose
- LDH
- Amylase
- AFB smear and culture
- Cytology
- Triglyceride
Ascites Diagnosis
- High SAAG > 1.1 g/dL – Indicative of portal hypertension[4]
- Cirrhosis
- Heart failure
- Ascites total protein > 2.5 g/dL suggests cardiac ascites[5]
- Alcoholic hepatitis
- Budd-Chiari syndrome
- Portal vein thrombosis
- Low SAAG < 1.1 g/dL
- Malignancy / peritoneal carcinomatosis
- Nephrotic syndrome
- Pancreatitis
- Peritoneal tuberculosis
- Serositis
- Bowel infarction
- Chylous
Management
- Salt restriction
- Effective in about 15% of patients
- Diuretics
- Spironolactone
- Starting dose = 100mg/day PO (max 400mg/day)
- 40% of patients will respond
- Furosemide
- 40mg/day PO (max 160mg/day)
- Ratio of 100:40 with spironolactone (reduces risks of potassium prob)
- Spironolactone
- Water restriction
- Paracentesis
- Consider liver transplantation and shunting
Disposition
- Frequently outpatient, once SBP is ruled out, if a known reason for ascites and sufficiently therapeutically drained
Complications
See Also
References
- Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.
- http://www.thepocusatlas.com/bowel/
- Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
- Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
- Runyon BA. Cardiac ascites: a characterization. J Clin Gastro. 1998; 10(4): 410-412.
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