Ascites Flashcards
Ascites and SAAG Score
The causes of ascites can be grouped into those with a serum-ascites albumin gradient (SAAG) <11 g/L or a gradient >11g/L as per the table below
SAAG > 11g/L: Cirrhosis Alcoholic hepatitis Cardiac ascites Mixed ascites Massive liver metastases Fulminant hepatic failure Budd-Chiari syndrome Portal vein thrombosis Veno-occlusive disease Myxoedema Fatty liver of pregnancy
SAAG <11g/L Peritoneal carcinomatosis Tuberculous peritonitis Pancreatic ascites Bowel obstruction Biliary ascites Post operative lymphatic leak Serositis in connective tissue diseases Nephrotic Syndrome
Ascites Mx
You are asked to see a young man on the gastroenterology ward because of increasing abdominal discomfort. Looking through his notes you notice that he is a patient with known alcoholic cirrhosis and that he’s been admitted with worsening ascites (which the consultant has described as grade 3/3 or large). The patient’s recent laboratory results are as follows:
Na+ 133 mmol/l K+ 4.1 mmol/l Urea 1.2 mmol/l Creatinine 64 µmol/l Bilirubin 23 µmol/l ALP 151 u/l ALT 7 u/l Albumin 26 g/l
Ascitic Tap:
WCC count 300cells/mm²
Differential 70% polymorphs
Albumin 14
Talking to the patient it is obvious that he’s uncomfortable with this ascites, and on examination his abdomen is significantly distended and tense. From his drug chart you can see that he is currently taking spironolactone 50mg twice daily and is currently on Pabrinex and chlordiazepoxide reducing regimen currently on 30mg four times daily.
What is the next step in managing his ascites?
Fluid restrict him to 1L Increase spironolactone to 100mg BD Add furosemide 40mg BD to his current diuretic regimen Therapeutic aspiration > Large volume abdominal paracentesis
Ascites can be graded as follows:
Grade 1: (mild) only detectable by ultrasound investigation
Grade 2: (moderate) ascites causing moderate symmetrical distension of the abdomen
Grade 3: (large) ascites causing marked abdominal distension
Therapeutic paracentesis is first line for management for patients with large volume (or diuretic resistant) ascites. This gentleman obviously has large volume ascites, we cannot say whether it is diuretic resistant at this point as he is on quite a low dose of spironolactone.
It would be sensible post procedure to increase his spironolactone (up to a maximum of 400mg/day in divided doses as tolerated). Furosemide can be used if spironolactone is not tolerated, contraindicated or insufficient.
Taken from the British Society of Gastroenterology guidelines on management of ascites 2006
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/liver/ascitescirrhosis.pdf
Underlying pathology re Ascites - Example Question
A 78 year old woman is admitted to the acute medical unit due to shortness of breath. She had been living alone at home for the last 3 years since her husband died. In the last 6 months she was struggling to manage due to fatigue, nausea and progressive breathlessness. She had noticed that her clothing was feeling tighter but could not understand why as she had reduced appetite and was eating less than normal. She is a non smoker and drank 1-2 bottles of wine per week since the death of her husband.
She has a history of ischaemic heart disease following an acute myocardial infarction two years previously. An echocardiogram 6 months after the acute event showed a mildly dilated left ventricle with good overall function (ejection fraction 45-55%) and mild aortic stenosis. Past medical history also includes a left mastectomy 17 years ago for a small breast carcinoma. Lymph node sampling at the time showed clear nodes so axillary clearance was not carried out. She has been discharged from follow up at the breast clinic.
On examination she is apyrexial with no evidence of clubbing or splinter haemorrhages nor any spider naevi. Her chest was clear to auscultation with dullness to percussion at both bases. The cardiac apex was non-displaced and heart sounds were normal with an additional ejection systolic murmur. Her abdomen appeared distended with large volume ascites but was soft and non tender. Bowel sounds were normal.
Bloods showed the following:
Haemoglobin 101 g/L Sodium 134 mmol/L
Platelets 159 x10^9/L Potassium 3.8 mmol/L
White cell count 9.0 x10^9/L Urea 3.5 mmol/L
Neutrophils 3.5 x10^9/L Creatinine 67 micromol/L
ESR 21 mm/h Albumin 31 g/L
CRP 34 mg/L Bilirubin 7 micromol/L
ALT 29 iu/L
Alkaline Phosphatase 51 iu/L
Ascitic fluid analysis:
Fluid albumin 22 g/L
Fluid glucose 4.2
Fluid gram stain negative
Which of the following is the most likely cause of her ascites?
Alcoholic hepatitis Heart failure > Peritoneal metastases from colon cancer Portal vein thrombosis Myxoedema due to hypothyroidism
The presenting symptoms in this scenario are fairly vague. The history does not help you narrow down you differentials for causes of ascites. The answer can be determined by working through the list of results. In particular, by calculating the serum-ascites albumin gradient (SAAG) you can work out the correct answer.
In this scenario the SAAG is 9 (31-22). The only answer where this is possible is C as it is the only cause of ascites that has a SAAG < 11g/L.
Ascitic Tap - Contraindications re Coagulation Profile?
Paracentesis is not contraindicated in patients with an abnormal coagulation profile. The majority of patients with ascites due to cirrhosis have prolongation of the prothrombin time and some degree of thrombocytopenia. There are no data to support the use of fresh frozen plasma before paracentesis although if thrombocytopenia is severe (<40 * 109/l) most clinicians would give pooled platelets to reduce the risk of bleeding.
Taken from the British Society of Gastroenterology guidelines on management of ascites 2006
Example Question
A 45 year old man admitted to the gastroenterology ward to detox from excessive alcohol consumption. He is known to have alcohol dependence syndrome but has no other past medical history and no known diagnosis of alcoholic cirrhosis. On examination he is noted to have a distended abdomen with evidence of shifting dullness and a succussion splash. He is taken down for an ultrasound of his abdomen and an appropriate site for an ascitic tap is marked in the left iliac fossa by the radiologist. Before doing the ascitic tap you check his bloods from today, they are as follows:
Hb 83 g/l
Platelets 56 * 109/l
WBC 3.5 * 109/l
Na+ 128 mmol/l
K+ 3.2 mmol/l
Urea 2.2 mmol/l
Creatinine 45 µmol/l
Bilirubin 35 µmol/l
ALP 145 u/l
ALT 24 u/l
Albumin 32 g/l
INR 1.8
APTT 55 s
Fibrinogen 1.3 g/L
Before doing an ascitic tap, what needs to be done?
1 unit of red blood cells FFP till fibrinogen >1.5 IV vitamin K till INR <1.5 > Nothing - the parameters are adequate 1 pool of platelets
Indications for an Ascitic Tap - Example Question
A 42-year-old woman presents to the emergency department generally unwell. She has been feeling progressively worse over the last five days, complaining of a productive cough, worsening abdominal swelling and severe constipation. A friend who is with her as also noticed she has been increasingly confused, and also mentions to you that she has an extensive alcohol history. She has a past medical history of cirrhosis and COPD. She does not remember what her medications are called, but she does take several tablets in the morning and evening and uses a red inhaler regularly.
Examination shows her to look generally unwell, feel hot and clammy. She appears jaundiced. There are crepitations in the left lower lobe. Her abdomen is distended and there is evidence of ascites. She also has distended veins on her chest.
Observations Saturations 93% Respiratory rate 18/min Blood pressure 121/58mmHg Heart rate 109/min Temperature 38.2°C
Blood tests: Hb 121 g/l Platelets 52 * 109/l WBC 16 * 109/l Na+ 147 mmol/l K+ 4.8 mmol/l Urea 11.1 mmol/l Creatinine 153 µmol/l Bilirubin 57 µmol/l ALP 173 u/l ALT 121 u/l Albumin 26 g/l INR 2.3 PT 25s
Further to his blood tests a CXR demonstrates left lower lobe consolidation. Blood cultures are sent, alongside calcium, phosphate, magnesium and glucose. An ultrasound scan of her abdomen is requested, as is a urine dip. What other investigation is most appropriate in the acute setting?
CT chest CT head Abdominal X-ray Lumbar puncture > Ascitic tap
The correct answer is ascitic tap. This is a case of acute decompensated cirrhosis secondary to lower respiratory tract infection. A CT head and lumbar puncture can both be useful in excluding causes of confusion, and a CT head would definitively have been indicated if there was any evidence of head trauma. However; there is a clear cause for confusion in the context of sepsis and likely hepatic encephalopathy. An abdominal X-ray and CT chest are unlikely to be helpful, but an ascitic tap can give valuable information about the nature of the ascites by looking at the serum-ascites albumin gradient (SAAG). It is also important to obtain a sample prior to starting antibiotics.
SBP
Spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
Diagnosis
paracentesis: neutrophil count > 250 cells/ul
Management
intravenous cefotaxime is usually given
Antibiotic prophylaxis should be given if:
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
Alcoholic liver disease is a marker of poor prognosis in SBP.
Indications for Ascitic Tap in Liver Cirrhosis - Example Question
A 50-year-old female with known cirrhosis due to alcoholic liver disease is admitted with confusion. Examination reveals asterixis, jaundice and ascites. She is clinically stable and apyrexial.
Serum bloods are as follows:
International Normalised Ratio 3.5
Platelets 100 x 10^9/L
WCC 14.1 x 10^9/L
CRP 132 mg/L
What is the next most appropriate step?
Ultrasound scan of abdomen Administer prothrombin complex concentrate with a view to performing an ascitic tap Intravenous tazocin > Ascitic tap Lactulose
One of the precipitants of hepatic encephalopathy is spontaneous bacterial peritonitis (SBP) which should always be in the differential in a patient presenting decompensated chronic liver disease and ascites. The most important initial step is an ascitic tap and abnormal clotting is not a contraindication to this. It should ideally be performed before antibiotics are given as they would affect the results of the tap.
Paracentesis is not contraindicated in patients with an abnormal coagulation profile. The majority of patients with ascites due to cirrhosis have prolongation of the prothrombin time and some degree of thrombocytopenia. There are no data to support the use of fresh frozen plasma before paracentesis although if thrombocytopenia is severe (<40, 000) most clinicians would give pooled platelets to reduce the risk of bleeding.1
Lactulose 20-30ml QDS (aiming for 2 soft stools/day) is important in the management of patients with decompensated chronic liver disease who are encephalopathic but is not the next most appropriate step as SBP is potentially life-threatening.
Abdominal ultrasound will be a useful investigation in decompensated liver disease, in particular identifying thrombotic precipitants. However, an ascitic tap must be first performed to identify the serious possibility of SBP.
- Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut 2006; 55; 1-12
Prophylaxis of SBP - Example Question
A 45-year-old man with alcoholic liver cirrhosis is admitted with a one-week history of increasing abdominal distension and pain. His medications include thiamine 100mg BD, vitamin B co-strong one OD, spironolactone 100mg OD and omeprazole 20mg OD. He has no known drug allergies.
On examination, his temperature is 38.2ºC, pulse rate is 120 beats per minute and blood pressure is 100/60 mmHg. His sclera is icteric and there are multiple bruise marks all over his body. Examination of his abdomen reveals a distended abdomen which is generally tender all over on palpation. There are reduced breath sounds at his lung bases on auscultation.
Investigations reveal:
Hb 90 g/l Na+ 129 mmol/l Bilirubin 60 µmol/l Platelets 78 * 109/l K+ 3.6 mmol/l ALP 110 u/l WBC 13.5 * 109/l Urea 1.2 mmol/l ALT 40 u/l Neuts 10.5 * 109/l Creatinine 35 µmol/l γGT 150 u/l Lymphs 1.0 * 109/l Albumin 24 g/l Eosin 0.1 * 109/l
An ascitic tap was performed and shows:
Neutrophil count 600 neutrophils/mm3
Fluid protein <10 g/L
Serum albumin-ascites gradient >11
He was treated with piperacillin-tazobactam for spontaneous bacterial peritonitis (SBP). Which antibiotic should be considered for long-term prophylaxis to prevent recurrence of SBP?
> Ciprofloxacin Doxycycline Amoxicillin Trimethoprim Co-amoxiclav
After the first episode of SBP, long-term prophylaxis with a quinolone such as ciprofloxacin or norfloxacin has been shown to reduce the recurrence rate of SBP. This is particularly important in patients who have a particularly low ascitic fluid protein.
SBG Sepsis - Example Question
A 63-year-old man is seen in the Emergency Department with fevers and abdominal pain. He has a history of alcoholic liver disease with cirrhosis, hypertension and oesophageal varices. He has noticed increasing abdominal distension over the last week, associated with fatigue and malaise. In the last day he has developed generalised abdominal pain and has been feeling hot and cold. His temperature at triage was 38.2 ºC. He feels nauseated but has not vomited. He has not opened his bowels in 2 days but is passing flatus. He has had no dysuria, cough or shortness of breath.
On examination he is tachycardic at 120 beats per minute and has a blood pressure of 111/78 mmHg. He looks dehydrated and is jaundiced. His chest is clear and heart sounds are normal. He has a distended abdomen with generalised tenderness but no guarding and normal bowel sounds. There is shifting dullness and pitting oedema to the mid-shin.
His chest x-ray demonstrates clear lung fields but poor inspiration due to ascites.
His ECG shows sinus tachycardia.
His urine dip shows 1+ of protein.
His bloods are as follows:
Hb 110 g/l Na+ 146 mmol/l Bilirubin 37 µmol/l
Platelets 205 * 109/l K+ 4.6 mmol/l ALP 272 u/l
WBC 17.3 * 109/l Urea 8.1 mmol/l ALT 62 u/l
Neuts 14.6 * 109/l Creatinine 141 µmol/l γGT 591 u/l
Lymphs 2.1 * 109/l CRP 150 mg/l Albumin 29 g/l
He is started on intravenous normal saline and broad spectrum antibiotics. Blood cultures are sent. An ascitic tap is performed which demonstrates cloudy fluid with a neutrophil count of 300 per mm³. This is sent for gram stain and culture. He is diagnosed with spontaneous bacterial peritonitis and resultant acute kidney injury and antibiotics are switched to cefotaxime.
Which further management has been shown to reduced mortality in this condition?
Dialysis > Human albumin solution Repeat ascitic tap in 48 hours Rifaximin Steroids
This gentleman has sepsis secondary to spontaneous bacterial peritonitis (SBP). Use of human albumin solution to rehydrate patients with cirrhosis and SBP has been shown to reduce mortality.
Although this gentleman has an acute kidney injury, he is not yet at the threshold for dialysis and should be rehydrated.
All patients with SBP should have repeat ascitic tap at 48 hours to ensure neutrophil count of fluid is improving on antibiotics. However, this has not been proven to reduce mortality.
Rifaximin is an antibiotic licensed for use in patients with alcoholic cirrhosis with previous hepatic encephalopathy. It can be used prophylactically to prevent ammonia-releasing bacteria in the gut precipitating further episodes, However, it is not used in SBP.
Steroids may be used in acute alcoholic liver failure to improve outcome but are not used in SBP.
Reference: Sort et al. Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. New England Journal of Medicine. 1999.
Ascites and SAAG Gradient - Example Question
A 65-year-old woman is admitted to the medical assessment unit for evaluation of ascites. she has a history of excess alcohol consumption for many years and admits to previous elicit drug use. Other past history of note includes hysterectomy with preservation of ovaries, and symptoms of irritable bowel syndrome during the past 6 months. On examination her blood pressure is 110/70 mmHg, pulse is 87 beats per minute and regular. There are no heart murmurs, chest is clear. Abdomen is distended with obvious ascites, and body mass index is 26 kg/m².
Hb 100 g/l Na+ 134 mmol/l Bilirubin 24 µmol/l Platelets 112 * 109/l K+ 3.9 mmol/l ALP 190 u/l WBC 8.0 * 109/l Urea 6.3 mmol/l ALT 112 u/l Neuts 4.5 * 109/l Creatinine 85 µmol/l γGT 135 u/l Lymphs 2.1 * 109/l Albumin 32 g/l Eosin 0.5 * 109/l Serum ascites albumin gradient 7.5
Which of the following is the most likely diagnosis?
Hepatic cirrhosis > Ovarian carcinoma Viral hepatitis Nephrotic syndrome Right heart failure
A low serum ascites albumin gradient (SAAG <11 g/L) indicates causes of ascites not associated with increased portal pressure. These include tuberculosis, other causes of peritoneal sepsis, pancreatitis, serositis, nephrotic syndrome and peritoneal carcinomatosis. Clues towards a diagnosis of ovarian carcinoma include the history of irritable bowel syndrome and the fact that she still has her ovaries post hysterectomy.
The lack of history of any previous renal disease counts against nephrotic syndrome, cirrhosis, right heart failure and viral hepatitis would be associated with an elevated SAAG.
Calculating SAAG Score
Serum:Ascitic Albumin Gradient (SAAG) = serum albumin – ascitic fluid albumin
SBP Prophylaxis
After the first episode of SBP, long-term prophylaxis with a quinolone such as ciprofloxacin or norfloxacin has been shown to reduce the recurrence rate of SBP. This is particularly important in patients who have a particularly low ascitic fluid protein.
SBP and HAS
Use of human albumin solution to rehydrate patients with cirrhosis and SBP has been shown to reduce mortality.
