Ascites

Question 1

What is it?

Answer 1

Fluid in the peritoneal cavity

Question 2

What causes it?

Answer 2

If albumin is not produced in the liver due to e.g. cirrhosis = hypoalbuminemia: low albumin levels cause a decrease in oncotic pressure therefore allowing fluid to leak out the capillaries and into the peritoneal cavity* producing ascites

Blood cant get through the liver due to e.g. cirrhosis: blood backs up causing portal hypertension causing fluid to leak out of blood vessels into the peritoneal cavity* producing ascites

Question 3

What would be found on investigation?

Answer 3

Physical exam reveals dullness in flanks and shifting dullness (approximately 1.5L/1500cc)
Can be confirmed by US which can detect up to 100cc
Corroborating evidence e.g. fetor hepaticus/spider naevi or JVP elevation

Question 4

What should all patients with new-onset ascites have?

Answer 4

A diagnostic paracentesis

Question 5

What analysis should be carried out on the sample of ascitic fluid?

Answer 5

SAAG (serum-ascites albumin gradient):
>1.1g/dl = portal HTN related (97% accuracy)
<1.1g/dl = non portal HTN causes (97% accuracy)

Question 6

What are some causes of a high albumin gradient (>1.1g/dl)?

Answer 6

Portal hypertension
CHF
Constrictive pericarditis
Massive liver metastases

Question 7

What are some causes of a low albumin gradient (<1.1g/dl)?

Answer 7

Malignancy
Tuberculosis
Pancreatic
Biliary ascites

Question 8

What are the treatment options?

Answer 8

Diuretics
Large volume paracentesis
Aquaretics
TIPS
Liver transplant