Ascites Flashcards
pathogenesis of ascites
- portal HTN
- splanchnic arterial vasodilation
- decreased effective circulating volume
- activation of RAA, SNS, ADH
- Na and H20 retention
- increased plasma volume
- persistent Na retention
- ascites
hepatic vein obstruction
- leads to ascites formation
portal vein obstruction
- almost never develops into ascites
HVPG magic number for ascites
- > 12 mmHg is necessary for ascites to develop and is associated with low sodium excretion
diagnosis of ascites
- shifting dullness, fluid wave
- US to confirm
- paracentesis
indications of abdominal paracentesis
- new onset of ascites
- repeated as part of admission PE
- repeated during hospitalization if signs of infection
ascites fluid analysis
- DO AT BEDSIDE
- routinely do albumin, protein, PMN cell count
serum-ascites albumin gradient
- SAAG = serum albumin - ascites albumin
- if > 1.1 = portal HTN
- if < 1.1 = non-portal HTN
- specimens of serum and ascites should be obtained on the same day
decreased accuracy of SAAG
- patient is hypotensive
- during open abdominal surgery
SAAG > 1.1 and ascites protein < 2.5
- sinusoidal HTN
- cirrhosis and late Budd-Chiari
SAAG > 1.1 and ascites protein > 2.5
- post-sinusoidal HTN
- cardiac ascites
- early Budd-Chiari
- veno-occlusive disease
SAAG < 1.1 and ascites protein > 2.5
- peritoneal pathology
- malignancy or TB
- ovarian malignancy is a big cause of ascites that doesnt come from the liver
indications of cultures
- DO AT BEDSIDE
- new onset ascites
- admission PE
- signs of infection
definition of uncomplicated ascites
- ascites responsive to diuretics in the absence of infection and renal dysfunction
management of uncomplicated ascites
- salt restriction
- diuretics (spironolactone based)
- large volume paracentesis
side effects of spironolactone therapy
- GYNECOMASTIA
- renal dysfunction, hyponatremia, hyperkalemia, encephalopathy
consider ascites refractory if
- spironolactone dose = 400mgs/day + furosemide 160 mgs/day without any significant weight loss
indications of large volume paracentesis
- respiratory compromise (ascites pushing up on diaphragm)
- impending rupture of umbilical hernia
- severe peripheral venous stasis
- inconvenience: retaps required every 2-4 weeks
fluid restriction as treatment for ascites
- unnecessary unless serum sodium very low (< 125 mEg/L)
indications of peritoneo-jugular shunts
- refractory ascites
benefits of TIPS
- immediately decreases portal pressure
- increases urine sodium excretion
- decreases plasma renin and angiotensin levels
- mobilizes ascites
complications associated with TIPS
- increased risk of encephalopathy
definition of spontaneous bacterial peritonitis
- acute bacterial infection of the ascitic fluid that occurs in the absence of an infection elsewhere in the body
- occurs most frequently in patients with cirrhotic ascites and carries a high mortality rate
diagnosis of spontaneous bacterial peritonitis
- PMNS > 250 AND/OR positive culture
organisms most common in spontaneous bacterial peritonitis
- E. coli most common
- Klebsiella, staph, strep
risk factors for spontaneous bacterial peritonitis
- bilirubin > 2.5
- platelet count < 98,000
- GI bleeding
- previous SBP
- low protein ascites (< 1)
treatment of spontaneous bacterial peritonitis
- avoid nephrotoxic meds such as aminoglycosides
- consider repeat paracentesis in 48 hours to assess increase in PMNs, if unchanged consider new antibiotic
- cefotaxime with ampicillin for 5 days is DOC
prophylaxis for spontaneous bacterial peritonitis
- quinolones
secondary bacterial peritonitis
- measurement of ascitic fluid total protein, glucose, and LDH has been reported to be of value in distinguishing spontaneous bacterial peritonitis from gut perforation into ascites
if neutrocytic ascitic fluid meets two of the following three criteria, they are likely to have surgical peritonitis
- total protein > 1 g/dL
- glucose < 50 mg/dL
- LDH > the upper limit of NL for serum
characteristics of hepatorenal syndrome
- renal failure in patients with cirrhosis, advanced liver failure, and severe sinusoidal portal HTN
- absence of significant histological changes in kidney
- vasodilation in extra-renal circulation
- renal vasoconstriction leading to reduced glomerular filtration rate
type 1 hepatorenal syndrome
- poor prognosis, need a liver transplant
- rapidly progressive renal failure
- doubling of creatinine to > 2.5 or halving of creatinine clearance to < 20ml/min
type 2 hepatorenal syndrome
- slower progression
- creatinine > 1.5 mg/dL or creatinine clearance < 40 ml/min
- associated with refractory ascites
diagnosis of hepatorenal syndrome
- advanced hepatic failure and portal HTN
- creatinine > 1.5 or creatinine clearance of < 40 ml/min
- no improvement in renal function after plasma volume expansion with 1.5 L of isotonic saline
2 symptoms always present in hepatorenal syndrome
- ascites and hyponatremia
- if ascites is absent, renal failure is most likely due to another cause
treatment of hepatorenal syndrome
- vasoconstrictors should always be used in combination with albumin
- liver transplant has proven efficacy
- hemodialysis DOES NOT WORK
