Ascites

Aka: Ascites, Abdominal Dropsy

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II. Definitions

  1. Ascites
    1. Accumulation of peritoneal fluid

III. Symptoms

  1. Small amount of Ascites
    1. Asymptomatic
  2. Large amount of Ascites
    1. Abdominal Distention and discomfort
    2. Anorexia
    3. Nausea
    4. Early satiety
    5. Heartburn (Gastroesophageal Reflux)
    6. Flank Pain
    7. Respiratory distress

IV. Signs

  1. Umbilicus may evert
  2. Bulging flanks with patient lying supine
    1. Weight of ascitic fluid pushes against side walls
  3. Tympany at the top of the abdominal curve
    1. Patient lies supine
    2. Gas filled bowel floats upward over Ascites
  4. Fluid Wave Test
  5. Shifting Dullness Test
  6. Puddle Sign

V. Causes

  1. See Ascites Causes
  2. Most common causes
    1. Cirrhosis (Cirrhotic Ascites): 85% of cases
    2. Cancer (Malignant Ascites)
    3. Congestive Heart Failure
    4. Tuberculosis

VI. Labs

  1. Diagnostic abdominal Paracentesis in all cases
  2. Ascites Fluid: Serum Ascites albumin gradient (SAAG)
    1. Gradient is the difference between Serum Albumin and Ascites albumin
      1. Greater difference (SAAG>1.1 g/dl) implies Portal Hypertension
    2. Exudate or Low Gradient Ascites (Serum to Ascites albumin gradient <1.1 g/dl)
      1. Peritonitis
      2. Neoplasm (Malignant Ascites, peritoneal carcinomatosis)
      3. Pancreatitis
      4. Vasculitis
      5. Nephrotic Syndrome
      6. Biliary or chylous Ascites
    3. Transudate (Serum to Ascites albumin gradient >1.1 g/dl)
      1. Low ascitic fluid total Protein (<1 g/dl)
        1. Cirrhosis (Cirrhotic Ascites)
        2. Alcoholic Hepatitis
      2. High ascitic fluid total Protein (>2 g/dl)
        1. Congestive Heart Failure
        2. Budd-Chiari Syndrome
        3. Myxedema
        4. Constrictive Pericarditis
  3. Ascites Fluid: Cell Count with Differential
    1. Ascites Red Blood Cells (RBC) elevated
      1. Neoplasm (Malignant Ascites)
      2. Tuberculous Peritonitis (variably elevated)
      3. Pancreatitis (variably elevated)
    2. Ascites White Blood Cells <250 cells/mm3
      1. Serum to Ascites Albumin Gradient (SAAG) < 1.1 g/dl
        1. Fluid total Protein >2.5: Cardiac Ascites
        2. Fluid total Protein <2.5: Cirrhotic Ascites
      2. Serum to Ascites Albumin Gradient (SAAG) > 1.1 g/dl
        1. Fluid total Protein <2.5: Nephrotic Ascites
    3. Ascites White Blood Cells >500 (or PMNs >250)
      1. WBC Differential <50% Neutrophils (PMNs)
        1. Peritoneal carcinomatosis (>50% Lymphocytes)
          1. Search for primary tumor
        2. Tuberculous Peritonitis (>70% Lymphocytes)
          1. Culture fluid for Tuberculosis
      2. WBC Differential >50% Neutrophils (PMNs)
        1. Pancreatic Ascites (Fluid amylase >100 U/L)
          1. Evaluate with Abdominal CT
        2. Spontaneous Bacterial Peritonitis (single colony)
          1. Fluid total Protein <1 g/dl
          2. Fluid Glucose >50 mg/dl
          3. Fluid LDH <225 U/L
        3. Bacterial peritonitis (polymicrobial)
          1. White Blood Cell Count often > 10,000
          2. Fluid total Protein >1 g/dl
          3. Fluid Glucose <50 mg/dl
          4. Fluid LDH >225 U/L
  4. Ascites fluid color
    1. Transparent to cloudy yellow or clear (typical)
    2. Dark brown: Obtain quantitative fluid Bilirubin
    3. Milky: Obtain Triglyceride concentration
    4. Bloody: Adjust Leukocyte count
      1. Subtract 1 White Blood Cell per 750 Red Blood Cells
      2. Subtract 1 Neutrophil (PMN) per 250 Red Blood Cells
  5. Ascites fluid assorted labs
    1. Lactate Dehydrogenase
    2. Amylase
    3. pH
    4. Lipids
    5. Culture and cytology

VII. Diagnostics: Diagnostic Paracentesis

  1. Identify site at linea alba, 2 cm below Umbilicus
  2. Use 22 gauge needle with catheter

VIII. Imaging

  1. Ultrasound Abdomen or CT Abdomen
    1. Very sensitive for ascitic fluid

IX. Management

  1. Treat the underlying condition (e.g. Right Heart Failure)
  2. Cirrhosis
    1. See Cirrhotic Ascites
  3. Malignant Ascites
    1. Paracentesis offers symptomatic relief as needed
    2. Medication Management
      1. Spironolactone and
      2. Thiazide or Loop Diuretic

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