Ascites

By R.Gnanaraj

DefinitionDefinition• From greek derivation askhos which

refers to a ‘bag’ or ‘sack’.• Pathologic fluid accumulation in the

peritoneal cavity.

Causes of ascitesCauses of ascites• Hepatic• Renal• Cardiac• Infectious• GI • Neoplasm• Gynecological• Pancreatic• miscellaneous

Causes of ascitesCauses of ascites• Ascites in newborn is classified as 1.associated with hydrops 2.isolated ascites 3.ascites due to peritonitis

Associated with hydropsAssociated with hydrops1.CVS(20%)- heart block auricular tachycardia hypoplastic left heart ebstein disease2.Hematological (10%)-isoimmune hemolytic disease homozygous alpha thalassemia3.Chromosomal(10%)-turner syndrome trisomy 13,18,214.Infection(10%)-TORCH group syphilis5.Pulmonary(5%)-diaphramatic hernia

Contd…Contd…6.Gastrointestinal(5%)-atresia7.Renal(5%)-nephrosis8.Maternal conditions(5%)-Toxemia, Diabetes9.Miscellaneous(5%)- Wilm’s tumors Neuroblastoma10.Liver-Cirrhosis Alpha-1 antitrypsin deficency Neonatal hemochromatosis11.Placenta or cord-Cord compression Chorangioma12.Unknown(20%)

• Isolated ascites-Chylous ascites Obstructive uropathy Biliary ascites• Ascites due to peritonitis Bacterial Chemical

Causes of ascites in childrenCauses of ascites in children• Extrahepatic-Venous obstruction CHF AV fistula• Intrahepatic-Biliary tract disease Hepatocellular disease Toxins Schistosomiasis• Other causes-TB Nephrotic syndrome Pancreatitis Chlamydial infection Rheumatoid arthritis

Causes of acute ascitesCauses of acute ascites• Venous obstruction• Peritonitis• Fulminant hepatic failure

PathophysiologyPathophysiology

•Underfill theory•Overflow theory•Peripheral vasodilation theory

Clinical featuresClinical features• Distension of abdomen• Abdominal pain• Respiratory distress

Signs of ascites Signs of ascites • 5 classic physical signs Bulging flanks Flank dullness Shifting dullness Fluid wave Puddle sign

Look for…Look for…• Triad of PHT• Umbilical herniation• Pedal edema & anasarca • Hepatojugular reflux & dilated veins

with flow upwards• Fever & abdominal pain with

guarding & rigidity• Evidence of malignancy

Investigations Investigations • Blood – cell counts,viral markers• Urine analysis• LFT• Mantoux test• Renal & cardiac evaluation• Ascitic fluid analysis• USG, CT scan , MRI

Grading of ascites Grading of ascites • Mild - only seen in USG or puddle

sign• Moderate – shifting dullness present• Severe – fluid thrill present

Abdominal paracentesisAbdominal paracentesis• Position• Site• Technique – ‘Z’ tract

Ascitic fluid analysisAscitic fluid analysis• Colour • Cell count• Protein• Culture• SAAG• LDH• Amylase• TG, bilirubin

Serum ascites albumin Serum ascites albumin gradient(SAAG)gradient(SAAG)

• Ratio >1.1 portal hypertension• Ratio <1.1 peritoneal pathology -TB -SBP -Malignancy

Exudative & transudative Exudative & transudative causescauses

• Exudative(<1.1) 1.Peritonitis 2.IVC obstruction 3.Malignancy 4.Pancreatitis 5. Chylous

ascites 6.Hemorrhagic

• Transudative(>1.1) 1.Nephritic

syndrome 2.Hypoproteinemia 3.CCF 4.End stage liver

cell failure 5.Protein losing

enteropathy

Complications Complications • Spontaneous bacterial peritonitis• Hernias• Respiratory distress

Management Management • Depends on the SAAG Low albumin gradient ascites High albumin gradient ascites

Low albumin gradient Low albumin gradient ascitesascites

• Does not respond to salt restriction & diuretics• Treatment depends on the cause TB peritonitis- ATT Pancreatic ascites- endoscopic stenting somatostatin therapy surgery Chlamydial-tetracycline Nephrotic & lupus ascites-steroids Malignancy-chemotherapy surgery

High albumin gradient High albumin gradient ascitesascites

• Bed rest• Diet restriction• Diuretics• Beta blockers

Diet restrictionDiet restriction• Sodium restriction upto 5 mEq/day (1-4 yrs)

upto 20mEq/day (4-11 yrs) upto 30mEq/day (>12 yrs)

• No fluid restriction

Diuretics Diuretics • Potassium sparing diuretics• Loop diuretics• Thiazides

SpironolactoneSpironolactone

• Starting Dose - 1-2mg/kg/day• Gradually increased upto

6mg/kg/day• Onset – 2-4days• Side effects – hyperkalemia metabolic acidosis gynecomastia• Others – triamterene,amiloride

Loop diureticsLoop diuretics• Furosemide,bumetanide,ethacrynic acid• Starting Dose - 1-2mg/kg/day• Gradually increased upto 6mg/kg/day• Onset – 2-4days• Side effects – hypokalemia hyperchloremic acidosis ototoxicity

Thiazide diureticsThiazide diuretics• Hydrochlorthiazide indicated when

diuresis on high doses are inadequate.

• Dose – 2-3mg/kg/day• Side effects-hypokalemia hyperglycemia hyperuricemia

Duration of diureticsDuration of diuretics• Treatment – till ascites is cured• Maintenance – in case of cirrhosis for

months to years.

Beta blockers Beta blockers • Causes increased natriuresis by 1.lowering of portal pressure 2.inhibition of renin secretion

Refractory ascitesRefractory ascites• Fluid overload unresponsiveness to

salt restriction & high dose diuretic• Causes-infection malignancy TB liver cell failure renal causes

Treatment for refractory Treatment for refractory ascites ascites

• Paracentesis• LeVcen shunt (peritoneal venous

shunt)• Orthotropic liver transplantation

Paracentesis Paracentesis • LVP - 200-400ml/kg/day slowly over

4-6hrs • Simultaneous infusion of 6g of 20%

albumin for every liter of fluid removed.

• Mechanism-paracentesis decreases systemic venous congestion, increases GFR & renal plasma flow

Chylous ascitesChylous ascites• Causes• Anomaly of lymphatics• cirrhosis• trauma• Tumor• Rheumatoid arthritis• Infections

Clinical featuresClinical features• Abdominal distension• Poor weight gain• Loose stools• Anasarca

Management Management • Fluid analysis-white in colour Increased protein Increased TG Decreased gamma globulin Lymphocytosis• Treatment 1.diet- low fat diet with MC TG High protein diet 2.paracentesis 3.surgery

Reference OP Ghai Nelson IAP Pediatricks

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