Ascites

Question 1

What is Ascites?

Answer 1

Pathological collection of fluid in the peritoneal cavity

Question 2

What is the most common cause of ascites?

Answer 2

Cirrhosis (75% of cases)

Question 3

What are the presenting symptoms of ascites?

Answer 3

Abdominal distension

Fluid on PE (shifting dullness)

Question 4

What imaging can confirm diagnosis of ascites?

Answer 4

US
CT
MRI

Question 5

What are the causes of ascites?

Answer 5

Disease that lead to:
Portal hypertension
Hypo-albuminaemia e.g. nephrotic syndrome, protein losing enteropathy
Neoplasms

Congestive heart failure
Constrictive pericarditis 
Alcoholic liver disease
Fulminant hepatitis 
Subacute hepatitis
Massive liver mets
Budd-Chiari syndrome

Question 6

How does ascites form in cirrhosis?

Answer 6

Renal dysfunction
Abnormalities in portal and splanchnic circulation

Sodium retention is a major factor

Question 7

How do abnormalities in splanchnic circulation causes ascites?

Answer 7

Vasodilatation secondary to hepatic fibrosis

Increased lymph formation

Activation of the RAS and sympathetic nervous system

Release of ADH –> sodium and water retention

Increased resistance to portal flow

Portal hypertension, collateral vein formation and shunting of blood to systemic circulation

Question 8

What are some common differentials for ascites?

Answer 8

Hep C
Alcoholic liver disease
Congestive heart failure
Nephrotic syndrome
Pancreatitis

Question 9

Summarise findings for Hep C

Answer 9

blood/bodily fluid exposure in history

jaundice

hep C serology +
PCR for hep C RNA +

liver biopsy showing fibrosis and inflammation

Question 10

Summarise findings for alcoholic liver disease

Answer 10

Drinking, abdo discomfort, nausea on history

Jaundice, tender, hepatomegaly, heaptic bruit, spider angiomas, palmar erythema on PE

Serum GGT (gamma glutamyl transferase) elevated

LFTs - elevated bilirubin, aspartate aminotransferase

Prolonged PT time
Low albumin

Question 11

Summarise findings of pancreatitis

Answer 11

Acute onset abdo pain radiating to back, nausea and vom

Epigastric tenderness on PE

Serum lipase/amylase elevated

Inflammation and necrosis on abdo CT

Question 12

Summarise findings of nephrotic syndrome

Answer 12

Abdo distension, limb/eye swelling, hypertension, oliguria

Oedema, orthostatic hypotension, tachycardia, hypertension

Heavy proteinuria on urinalysis

Low serum albumin

High serum cholesterol

Question 13

How can you manage ascites?

Answer 13

Diuretics e.g. spironalactone with/without furosemide
Therapeutic paracentesis (removing fluid)
Dietary sodium restriction
Monitor weight
Fluid restrict if plasma sodium < 120 mmol/L
Avoid alcohol and NSAIDs