Ascites

Question 1

What are ascites?

Answer 1

the abnormal accumulation of fluid in the abdomen

Question 2

The causes of ascites can be grouped into?

Answer 2

those with a serum-ascites albumin gradient (SAAG) <11 g/L

or a gradient >11g/L

Question 3

SAAG > 11g/L
(indicates portal hypertension) Causes:

Answer 3

Liver disorders are the most common cause
- cirrhosis/alcoholic liver disease
- acute liver failure
- liver metastases

Cardiac
- right heart failure
- constrictive pericarditis

Other causes
- Budd-Chiari syndrome
- portal vein thrombosis
- veno-occlusive disease
- myxoedema

Question 4

SAAG <11g/L ascites causes

Answer 4

Hypoalbuminaemia
- nephrotic syndrome
- severe malnutrition (e.g. Kwashiorkor)

Malignancy
- peritoneal carcinomatosis

Infections
- tuberculous peritonitis

Other causes
- pancreatitisis
- bowel obstruction
- biliary ascites
- postoperative lymphatic leak
- serositis in connective tissue diseases

Question 5

Management of ascites

Answer 5

reducing dietary sodium

fluid restriction is sometimes recommended if the sodium is < 125 mmol/L

aldosterone antagonists: e.g. spironolactone
- loop diuretics are often added. Some authorities only add loop diuretics in patients who don’t respond to aldosterone agonists whereas other authorities suggest starting both types of diuretic on the first presentation of ascites

drainage if tense ascites (therapeutic abdominal paracentesis):

• large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
• paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate

Question 6

Prophylactic management of ascites?

Answer 6

prophylactic antibiotics to reduce the risk of spontaneous bacterial peritonitis. NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved’

Question 7

TIPS stands for?

Answer 7

a transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some patients