Ascites

Question 1

A 68 year old woman presents complaining of abdominal distension. On examination she has 10cm of shifting dullness but no organomegaly. How would you assess her?

Answer 1

Impression
This is a presentation of abdominal ascites. Likely related to portal venous hypertension (high SAAG) secondary to chronic liver disease. A range of aetiologies of liver disease should be considered, alcoholism and viral hepatitis being the most common. I am concerned about potential complications of abdominal ascites including infection and hepatic encephalopathy.

Goals

• Perform assessment and treat the abdominal ascites to prevent complications
• Delineate the underlying aetiology utilising thorough H/E/I
• institute appropriate acute and ongoing management

Question 2

Ascites - History

Answer 2

History

• sx: distension, pain, dyspnoea, lower limb oedema, weight gain, bowel changes, gastric symptoms
• Other: jaundice, weight loss, night sweats, fevers, fatigue
• HPC/risk factors: preceding illness, IVDU, alcoholism, previous episodes, medications

Question 3

Ascites - Examination

Answer 3

Examination

• General observation + vital signs
• Gastrointestinal examination: shifiting dullness, bowel sounds, stigmata of chronic liver disease (jaundice, leukonychia, clubbing, telangiectasia’s), signs of portal venous HTN
• Cardiorespiratory: pleural effusion, peripheral oedema

Question 4

Ascites - Investigations

Answer 4

Investigations
- Key/diagnostic: US guided paracentesis and MCS + biochem (infection, SAAG calculation)

• Bedside: vitals, VBG,
• Bloods: LFTs, UEC, CRP/ESR, Lipase, coags, Hepatitis serology, and other Ix based on clinical suspicion of aetiology
• Imaging: US elastography, CT abdo (portal venous phase)
• Other: Liver biopsy for histopathological diagnosis of cirrhosis

Question 5

Ascites - Management

Answer 5

Management
- Would escalate care, contact on-call med reg and involve gastro in care of patient to institute appropriate acute and long-term management to prevent complications

Definitive

• Therapeutic paracentesis
• treat reversible causes of portal venous HTN
• salt and fluid restriction
• diuretics if fluid overload

Supportive

• analgesia
• patient education
• alcohol cessation
• electrolyte replacement

Complications
- if suspected bacterial peritonitis, then IV ceftriaxone