Ascites Flashcards
How do you classify the causes of ascites
Serum-ascitic albumin gradient
Portal hypertensive (transudative ascites) - SAAG greater than 1.1 g/dL Non-portal hypertensive (exudative ascites) - SAAG less than 1.1 g/dL
What are some causes of portal hypertensive ascites
Cirrhosis and secondary portal hypertension
Congestive cardiac failure
Hepatic venous occlusion (eg. Budd-Chiari syndrome)
What are some causes of non-portal hypertensive ascites
Malignant ascites Pancreatic ascites Nephrotic syndrome Infection (eg. TB) Hypothyroidism
What are some differentials of ascites
Fat Faeces Flatus Foetus Fibroids
What are the complications of ascites
Spontaneous bacterial peritonitis
What is spontaneous bacterial peritonitis
Acute bacterial infection of ascitic fluid
Occurs in aproximately 15% cirrhotic ascites
Can precipitate acute-on-chronic liver failure
How might spontaneous bacterial peritonitis present
30% asymptomatic
Abdo pain or tenderness Fever Altered mental status Nausea/vomiting Diarrhoea
Signs of sepsis may be present
What might you see on an AXR of a patient with ascites
Detection of intraperitoneal fluid requires at least 500mL
Ground glass appearance
Loss of psoas shadows (due to fluid accumulation)
How do you manage ascites
Management varies depending on cause
ETOH avoidance
Daily weights- aim to reduce 0.5kg per day
Fluid restrict: less than 1.5L/day
How do you treat cirrhotic ascites
Salt restriction
Diuretics- spironolactone ± frusemide
Paracentesis
What is paracentesis
Removal of fluid from the abdomen caused by ascites
Can be diagnostic or therapeutic
How do you treat malignant ascites
Palliative treatment
May require total paracentesis for comfort
How do you treat pancreatic ascites
Usually associated with a pseudocyst so requires surgical input
What is a pancreatic pseudocyst
A collection of fluid rich in amylase and other pancreatic enzymes
Usually appear several weeks after the onset of pancreatitis
What test is diagnostic of spontaneous bacterial peritonitis
Ascitic fluid absolute neutrophil count greater than 250 cells/mm3
How do you treat spontaneous bacterial peritonitis
Broad spectrum antibiotics
IV if sepsis, encephalopathy or GI bleeding
What are the indications for use of a shunt in the management of ascites
In diuretic-resistant ascites
How may shunting be performed in an ascitic patient
Peritoneovenous shunting
Denver shunt
Transjugular intrahepatic portosystemic stent shunt (TIPS)
What is peritoneovenous shunting
Subcutaneous silastic catheter used to drain the fluid into the jugular vein
Also called a LeVeen shunt
What is the Denver shunt
A modification to the peritoneovenous shunt
Adding a small subcutaneous pump that can be compressed externally
What is TIPS
Transjugular intrahepatic portosystemic stent shunt
Side-to-side shunt
Stenting a channel between a branch of the portal vein and the hepatic vein
What are important negatives in a patient with ascites?
CLD
ALF/decompensation
Signs of cause: Raised JVP, periorbital oedema
What does SAAG stand for?
Serum ascites albumin gradient
How is SAAG calculated?
Serum albumin - ascites albumin
How do you carry out a paracentesis?
Using a pig-tail drain or Bonnano catheter
What are the indications for a therapeutic paracentesis?
Pain or discomfort
Respiratory compromise
Renal impairment
What are the risks of paracentesis?
Severe hypovolaemia: Replenish albumin
SBP
