Ascites Related ComplicationsChaired by : Dr. Ardaman Singh Presented by : Dr. Amith Kumar S

Ascitesderived from Greek term “askos”

Other Etiologies of Ascites (account for <2% of all cases)

ComplicationsAscitic Fluid Infections Hepatic HydrothoraxRefractory Ascites Hepatorenal SyndromeMiscellaneous

Ascitic Fluid Infections

When to suspect…Fever Abdominal painAbdominal TendernessRebound tendernessAltered sensoriumLeucocytosis

Why to suspect….Prevalence of SBP

33% of patients with SBP land up in renal impairment

Untreated mortality is 90% which is reduced to 20% with early diagnosis and prompt treatment.

No survivors have been reported when the diagnosis of SBP has been made after Serum Creatinine is more than 4 mg/dl or after shock had developed

Prevalence

Outpatients 1.5 –3.5%

In hospital >10%

Classification Culture Negative Neutrocytic

Ascites Monomicrobial non-neutrocytic

bacterascitesPolymicrobial BacterascitesSecondary Bacterial PeritonitisSpontaneous Bacterial

Peritonitis

Diagnosis Abdominal Paracentesis &

Ascitic fluid analysis Ascitic fluid culture Complete Blood count Renal function tests Blood culture GI endoscopy X ray abdomen erect

Ascitic fluid culture Culture is positive in ~ 80% of casesMost common pathogens include Gram-

negative bacteria (GNB), usually Escherichia coli and Gram-positive cocci

Ascitic fluid culture methods: ◦Conventional - chocolate agar and

thioglycolate broth ◦Modified - inoculation of 10 ml of ascitic

fluid in a tryptic soy broth blood culture bottle at the patient's bedside

Blood agar plate inoculated with the ascitic fluid showing a growth of Klebsiella pneumonia

Bacteriology Frequency (%)

Organism SBP MNNB Sec BP SBP with SID

E. Coli 37 27 20 0

Klebsiella pneumonia

17 11 7 7

Strep Pneumonia

12 9 0 29

Strep viridans 9 2 0 0

Staph aureus 0 7 13 0

Misc gram neg 10 14 7 7

Misc gram positive

14 30 0 50

Polymicrobial 1 0 53 7

Pathogenesis Bowel Flora

Bacteria in mesentric LN, abdominal lymphatics and thoracic duct

Bactremia

Bacteria in Hepatic Lymph

Bacterascites

SBP CNNASterile Non neutrocytic

ascites

Respiratory tract infectionComplement deficiencyUrinary tract infection RE system dysfunction

Poor opsonic activity Good opsonic activity

Modr opsonic activity

Culture Negative Neutrocytic Ascites

1. Ascitic fluid culture grows no bacteria

2. Ascitic fluid PMN count is > or = 250 cells/mm3

3. No antibiotics has been prescribed

4. No other explanation for an elevated ascitic PMN count

Monobacterial Non-neutrocytic Bacterascites

1. Positive ascitic fluid culture for a single organism

2. Ascitic fluid PMN count lower than 250 cells/mm3

3. No evidence of an intra abdominal surgically treatable source of infection

Polymicrobial Bacterascites 1. Multiple organisms are seen on

gram stain or cultured from the ascitic fluid

2. Ascitic fluid PMN count is lower than 250 cells per mm3

Associated with traumatic paracentesis

Secondary Bacterial Peritonitis 1. Ascitic fluid culture is positive

for multiple organisms2. Ascitic fluid PMN count more

than 250 cells per mm3

3. Intrabdominal surgically treatable primary source of infection

Spontaneous Bacterial Peritonitis

1. Positive ascitic fluid culture for a single organism

2. Elevated ascitic fluid PMN count of more than 250 cells/mm3

3. No evidence of surgically treatable source of infection

Risk Factors for SBPCirrhosis

◦Low ascitic fluid proteins◦Phagocytic dysfunction

GI bleed ◦40 % cumulative probablity of

infection◦Risk peaks 48 hrs after bleed

Systemic infections Earlier episodes of SBP

SBP Vs Secondary Bacterial Peritonitis

Ascitic Fluid PMN count > or = 250 cells/ mm3

Abdominal imaging showing free air or extravasations of contrast media

Any two out of the following three1. Ascitic Fluid protein > 1

g/dL2. Ascitic fluid glucose < 50

mg/dL3. LDH > ULN

Spontaneous Bacteria Peritonitis

Perforation peritonitis

Non perforating secondary peritonitis

Yes

No

Yes No

Indications for Empirical Antibiotic Therapy of

Suspected Spontaneous Ascitic Fluid Infection

•Ascitic fluid neutrophil count ≥ 250/mm3 or positive “dipstick” test

•Convincing symptoms or signs of infection

Inj. Cefotaxim 2 gm i/v q8h

Diagnosis Treatment

Monobacterial Nonneutrocytic bacterascites

Five days of intravenous antibiotic to which the organism is highly susceptible

Culture negative neutrocytic ascites

Five days of intravenous third generation cephalosporin

Secondary bacterial Peritonitis

Surgical intervention plus approx 2 weeks of intravenous cephalosporin plus anti anaerobic drug (metronidazole)

Polymicrobial Bacterascites

intravenous third generation cephalosporin plus anti anaerobic drug (metronidazole)

Spontaneous Bacterial Peritonitis

Five days of intravenous antibiotic to which the organism is highly susceptible

If preliminary cultures are negative, paracentesis can be repeated after 48 hrs of therapy to assess the response of PMN count to antibiotics

Patients with cirrhosis and ascites

with convincing features of infections should be put on antibiotics even if ascitic fluid PMN count is less than 250 cells/mm3

Treatment contd…Injectable amoxicillin

clavulanic acid, oral ofloxacin, ciprofloxacin may be used instead of cephalosporin

Intravenous albumin – 1.5 gm/kg on the day of diagnosis, with a second dose of 1.0 gm/kg on the day three.

PrognosisSBP is an indication of End

Stage Liver Disease33% of patients with SBP land up

in renal impairment No survivors have been reported

when the diagnosis of SBP has been made after Serum Creatinine is more than 4 mg/dl or after shock had developed

Prevention Indications for preventive

measures◦Ascitic fluid protein < 1.0 g/dl ◦Variceal hemorhage ◦Previous episode of SBP

Prior SBP

Cirrhosis with gastrointestinal hemorrhage

Norfloxacin 400 mg orally once daily until death or liver transplantation

66% Reduction in recurrence

Intervention • Norfloxacin 400 mg orally twice daily x 7

days• Ceftriaxone 1 g intravenously/day x 7

days

Outcome • 73% Reduction in infection• 67% Reduction in infection compared

with norfloxacin

Cirrhosis with ascitic fluid ◦ Total protein <1.5 g/dL and either◦ Child-Turcotte-Pugh score ≥9 and total

bilirubin ≥3 mg/dL, or ◦ Creatinine ≥1.2 mg/dL, or ◦ Blood urea nitrogen ≥25 mg/dL, or serum

sodium ≤130 mEq/L

Intervention• Norfloxacin 400 mg/day orally x1 year

Outcome • 89% Reduction in SBP• 32% Reduction in hepatorenal

syndrome• 52% Increase in 3-month survival• 25% Increase in 1-year survival

Cirrhosis with ascitic fluid total protein <1.5 g/dL

Intervention : Ciprofloxacin 500 mg orally daily x1 year

Outcome • 31% Reduction in infection• 30% Improvement in survival

Hepatic Hydrothorax Hepatic hydrothorax develops in

approximately 5%–10% of patients with cirrhosis,

Mechanism ◦Hypoalbuminemia ◦Azygous vein hypertension ◦Leakage of ascitic fluid through diaphragmatic

defect ◦Trans diaphragmatic migration of fluid via

lymphatics Pleural effusion is right-sided in 85%, left-

sided in 13%, and bilateral in 2% of the casesMainstay of therapy - sodium restriction and

diuretics.

Refractory Ascites

Refractory ascites is defined as fluid overload that isI. Unresponsive to sodium-

restricted diet and high-dose diuretic treatment (400 mg/day spironolactone and 160 mg/day furosemide) or

II. Recurs rapidly after therapeutic paracentesis

Diuretic-resistant ascites ascites that cannot be mobilized or the early

recurrence of which cannot be prevented because of lack of response to dietary sodium restriction and maximal doses of diuretics

Diuretic-intractable ascites ascites that cannot be mobilized or the early

recurrence of which cannot be prevented because of the development of diuretic-induced complications that preclude the use of effective diuretic dosages.

Treatment durationPatients must be on intensive diuretic

therapy (spironolactone 400 mg/d and furosemide160mg/d) for at least 1 wk and on a saltrestricted diet of less than 90 mmol/d

Lack of responseMean weight loss of < 0.8 kg over 4 days and

urinary sodium output less than the sodium intake.

Early Ascites Recurrence ◦ There is an reappearance of grade 2 or 3

ascites (clinically detectable) within 4 wk of initial mobilization.

Management

a) Serial large volume therapeutic paracentesis,

b) Liver transplantation, c) Transjugular intrahepatic

portasystemic stent-shunt (TIPSS)

d) Peritoneovenous shunte) Experimental medical therapy

Hepatorenal Syndrome Potentially reversible functional

renal failure in the setting of liver dysfunction (cirrhosis with ascites, acute liver failure and severe alcoholic hepatitis), in the absence of intrinsic renal disease.

International Ascites Club Consensus Criteria

Cirrhosis with ascitesSerum Creatinine level > or = to 1.5

mg/dl (133 micromol/L) or creatinine clearance of < 40 ml/min

No or insufficient improvement in serum creatinine level, 48 hours after diuretic withdrawal and adequate volume expansion with intravenous albumin

Absence of shockNo evidence of recent use of

nephrotoxic agentsAbsence of intrinsic renal disease

ClassificationType 1 Hepatorenal Syndrome

Serum creatinine doubles to a value higher than, 2.5mg/dl, in a period of two week or less

Type 2 Hepatorenal Syndrome Observed in patients with diuretic resistant ascites

Serum creatinine less than 2.5 mg/dl

Drugs Dosage Endpoint DurationTerlipressin

Started at a dose of 1 mg/4–6 h and increased to a maximum of 2 mg/4–6 h if there is no reduction in serum creatinine of at least 25% compared to the baseline value at day 3 of therapy

Slowly progressive reduction in serum creatinine (to below 1.5 mg/dl, and an increase in arterial pressure, urine volume, and serum sodium concentration.

Maximum of 14 days/ Sr. Creatinine < 1.5 / Liver Transplant

Midodrine Initiate at a dose of 2.5 – 5.0 mg orally three times daily and may be increased to a max dose of 15 mg three times daily.

An increase in mean arterial pressure of atleast 15 mm Hg

Sr. Creatinine < 1.5 / Liver Transplant

AndOctreotide 100 microgm s/c three times

daily and increase to a max of 200 microgm s/c thrice daily

An increase in mean arterial pressure of atleast 15 mm Hg

Sr. Creatinine < 1.5 / Liver Transplant

25 microgm i/v bolus and a continuous infusion at a rate of 25 microgm/hour

Drugs Dosage Endpoint Duration

Noradrenaline 0.1 – 0.7 microgm /kg/min as i/v infusion, with an increase the dose by 0.05 microgm/kg/min every 4 hours

Titrate to an increase in MAP of 10 mm Hg or an increase in 4 hour urine output to more than 200 ml

Sr. Creatinine < 1.5 / Liver Transplant

Intravenous albumin

Bolus of 1gm/kg at presentation (max of 100 gm). Continue at a dose of 20 – 60 gm daily as needed to maintain central venous pressure between 10 and 15 cm of H20

Continue at a dose of 20 – 60 gm daily as needed to maintain central venous pressure between 10 and 15 cm of H20. To be discontinued if serum albumin concentration exceeds 4.5g/dl or in case of pulmonary edema

Sr. Creatinine < 1.5 / Liver Transplant

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