Ascites

Question 1

Definition

Answer 1

Excessive accumulation of fluid in abdo cavity 1500ml but can be more/less depending if person is obese.

Question 2

Types of ascites

Answer 2

• Diuretic-resistant ascites is refractory to dietary sodium restriction and intensive diuretic treatment for at least one week.
• Diuretic-intractable ascites is refractory to therapy due to the development of diuretic-induced complications that preclude the use of an effective dose of diuretic.

Question 3

Causes?

Answer 3

• Cirrhosis
• Fluid retention most common complication of end stage liver disease
• Malignancy: GI, Ovarian, Hodgkin’s lymphoma, non-hodgkin’s lymphoma, mets in abdo cavity
• Heart failure
• Nephrotic syndrome
• TB
• Pancreatitis
• Iatrogenic
• Protein losing enteropathy

Question 4

Risk factors?

Answer 4

Cirrhosis
Hepatorenal syndrome
Portal hypertension
Chronic liver disease

Question 5

Clinical presentation

Answer 5

Abdo distension
Weight gain as a result of water retention
Discomfort
Nausea and appetite suppression
Increasing dyspnoea (due to limited venous return)
Consider: -OH consumption, jaundice, chronic hepatitis B or hep C, obesity, hypercholesterolaemia and T2DM

Question 6

What are the grades of ascites?

Answer 6

Grade 1 – mild and only detectable by USS
Grade 2 – moderate causing symmetrical distension of abdomen.
Grade 3 – large causing marked abdominal distension

Question 7

Signs?

Answer 7

Stomach distension. 
Jaundice muscle wasting.
Gynaecomastia
Spider naevi
Palmar erythema. 
Shifting dullness is used to detect.
Monitor abdo girth and weight

Question 8

Differentials?

Answer 8

Hep C & B
Alcoholic Hep
Congestive HF
Nephrotic Syndrome
Pancreatitis
Autoimmune Hep
1 biliary cirrhosis
Haemochromatosis

Question 9

Investigations

Answer 9

Hx and exam.
FBC, renal function tests, LFTs, clotting screen, TFTs.
USS
CXR

Question 10

Management

Answer 10

Restrict salt diet and treat underlying cause
Diuretics – spironolactone, increases sodium excretion and potassium reabsorption in distal tubules monitor for hyperkalaemia.
Loop diuretics
Surgical – transjugular intrahepatic portosystemic shunt.
Palliative (diuretics)
Therapeutic paracentesis
Catumaxomab – trifunctional bispecific monoclonal antibody

Question 11

Prognosis

Answer 11

One-year mortality of 15% and five-year survival rate of 44%

Question 12

Complications

Answer 12

Hyponatraemia on diuretics
Spontaneous bacterial peritonitis – 10-30% of patients with ascites and mortality of 20%.
Hepatorenal syndrome