Ascites

Background

  • Abnormal buildup of peritoneal fluid
  • Most commonly caused by portal hypertension
  • Ascites fluid can become infected (spontaneous bacterial peritonitis), carrying a mortality rate between 30%-90%[1]

Causes

Clinical Features

Ascites secondary to cirrhosis.

Differential Diagnosis

Abdominal distention

Hepatic Dysfunction

Infectious

Neoplastic

Metabolic

Biliary

  • Biliary cirrhosis

Drugs

Miscellaneous

Evaluation

Ascites appearance on ultrasound
POCUS showing ascites[4]
Liver cirrhosis with ascites on CT

Ascites in females with no other reason for it = gynecologic neoplasm until proven otherwise (ovarian cancer)

Workup

Ascites Fluid Workup

  • Cell count and differential
  • Albumin
  • Total protein
  • Only if suspicious:[5]
    • Gram stain
    • Glucose
    • LDH
    • Amylase
    • AFB smear and culture
    • Cytology
    • Triglyceride

Ascites Diagnosis

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)
  • 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

  1. Sundaram V, Manne V, Al-Osaimi AM. Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers. Saudi J Gastroenterol. 2014;20(5):279-287. doi:10.4103/1319-3767.141686
  2. Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.
  3. Tintanelli's
  4. http://www.thepocusatlas.com/bowel/
  5. Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
  6. Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
  7. Runyon BA. Cardiac ascites: a characterization. J Clin Gastro. 1998; 10(4): 410-412.