DR. FARWA SHABBIR

HOUSE OFFICER

GASTROENTEROLOGY

APPROACH TO A PATIENT WITH

ASCITES

ROAD MAP

DEFINITION

EPIDEMIOLOGY

CLASSIFICATION

ETIOLOGY

PATHOPHYSIOLOGY

WORKUP

TREATMENT

WHAT IS ASCITES?

Greek origin (askos)

and means bag or sac

It is the collection of

fluid in the peritoneal

cavity

EPIDEMIOLOGY

Mortality/Morbidity

Ambulatory patients with an episode of cirrhotic

ascites have a 3-year mortality rate of 50%. The

development of refractory ascites carries a poor

prognosis, with a 1-year survival rate of less than

50%.

Sex

Healthy men have little or no intraperitoneal fluid,

but women may normally have as much as 20

mL, depending on the phase of their menstrual

cycle.

CLASSIFICATION

Ascites exists in four grades:

Grade 1: mild, only visible on ultrasound and

CT

Grade 2: is easily detectable but of relatively

small volume.

Grade 3: detectable with flank bulging and

shifting dullness

Grade 4: directly visible, confirmed with

the fluid wave/thrill test.

ETIOLOGY

• Serum Albumin -Ascites Albumin >1.1 gm/dl

TRANSUDATIVE

• Serum Albumin -Ascites Albumin <1.1 gm/dl

EXUDATIVE

TRANSUDATIVE

CIRRHOSIS

HEART FAILURE

KWASHIORKORCONST.

PERICARDITIS

BUDD-CHIARI SYNDROME

EXUDATIVE

CANCER

INFECTIONS (TB, SBP)

HEREDITARY ANGIOEDEMA

NEPHROTIC SYNDROME

PANCREATITIS

MISCELLANIOUS

PERITONEUM MESOTHELIOMA

MEIGS

SYNDROME

HYPOTHYROIDISM

PATHOPHYSIOLOGY

MECHANISM:

Underfilling

overflow

peripheral arterial vasodilation.

UNDERFILLING

OVERFLOW

PORTAL HYPERTENSIO

N

HYPER

VOLUMIA

ASCITES

PERIPHERAL ARTERIAL

VASODILATION

WORK UPHISTORY

AGE

child :Tuberculous ascites and nephrosis

Middle age :cirrhosis of liver

Old age : malignance

SEX

Female : meigs synd., pelvic tumours and infection and ovarian tumours

Male: alcholoism, drug abuse

ORDER OF DEVELPOMENT

cardiac causes : Leg oedema precedes ascites

Kidney causes : Puffiness of face precedes ascites

Cirrhosis of liver : Ascites is the first feature

GENERAL EXAMINATION

SYSTEMIC EXAMINATION

INSPECTION

PALPATION

PERCUSSION

LABORATORY ANALYSIS

DIAGNOSTIC PERITONEAL TAP

Inspection:

Most ascitic fluid is transparent and tinged yellow.

more than 20,000 red blood cells/µL will produce

distinctly blood-tinged fluid. This may result from

either a traumatic tap or malignancy

Cloudy ascitic fluid with a purulent consistency

indicates infection.

Cell count:

Normal ascitic fluid contains fewer than 500

leukocytes/µL and fewer than 250

polymorphonuclear leukocytes (PMNs)/µl

A PMN count of greater than 250 cells/µL is highly

suggestive of bacterial peritonitis

In tuberculous peritonitis and peritoneal

carcinomatosis, lymphocytes usually

predominate.

SAAG:

SAAG is the best single test for classifying

ascites into portal hypertensive (SAAG >1.1 g/dL)

and non–portal hypertensive (SAAG < 1.1 g/dL)

Culture/Gram stain:

Culture has a 92% sensitivity for the detection of

bacteria in ascitic fluid

In contrast, Gram stain is only 10% sensitive for

visualizing bacteria in early-detected

spontaneous bacterial peritonitis

Cytology:

Cytology smears are reported to be 58-75%

sensitive for detection of malignant ascites.

IMAGING STUDIES

Ultrasonography:

Volumes as small as 5-

10 mL can routinely be

visualized.

With massive ascites,

the small bowel loops

have a characteristic

polycyclic, "lollipop,"

appearance

The smallest amounts

of fluid tend to collect in

the Morison pouch and

around the liver as a

sonolucent band

Certain ultrasonographic findings suggest that the

ascites may be infected, inflammatory, or

malignant. These findings include coarse internal

echoes (blood), fine internal echoes (chyle),

multiple septa (tuberculous peritonitis,

pseudomyxoma peritonei)

In malignant ascites, the bowel loops do not float

freely but may be tethered along the posterior

abdominal wall, plastered to the liver or other

organs, or surrounded by loculated fluid

collections.

The thickening of the gallbladder is primarily a

reflection of cirrhosis and portal hypertension.

CT Scan:

Ascites is

demonstrated well on

CT scan.

A number of CT scan

features suggest

neoplasia. Hepatic,

adrenal, splenic, or

lymph node lesions

associated with

masses arising from

the gut, ovary, or

pancreas are

suggestive of

malignant ascites.

Salt restriction

Diuretics1. Spironolactone

(Aldactone)

2. Furosemide

(Lasix)

3. Amiloride

(Midamor)

4. Mannitol

(Osmitrol)

Paracentesis

transjugular

intrahepatic

portosystemic

shunt (TIPS)

Liver transplant