Ascites

Question 1

Ascites Grading

Answer 1

• Grade 1: mild only detectable by USS
• Grade 2: moderate ascites causing moderate symmetrical distension of abdomen
• Grade 3: large ascites causing marked abdominal distension

Refractory ascites can be divided into two groups

• Diuretic resistant ascites is refractory to diuretics and sodium restriction for 1 week
• Diuretic-intractable ascites is refractory to diuretics due to diuretic-induced complications precluding diuretic use

Question 2

Ascites Aetiology

Answer 2

• Cirrhosis (75% have underlying cirrhosis, 50% of those with cirrhosis develop ascites within 10 years)
• Beware the patient with long Hx of cirrhosis and sudden ascites (think hepatocellular carcinoma)
• Malignancy accounts for 15%
• HF
• Nephrotic syndrome

Question 3

Ascites Presentation

Answer 3

• Abdominal distension
• Weight gain
• Discomfort
• Nausea and acid suppression
• Increasing dyspnoea (limited venous return from lower limbs (pressure on IVC)) impaired expansion of lungs (pressure on diaphragm)
• Signs of liver disease
• Shifting dullness
• Sister Mary Joseph’s nodule

Question 4

Ascites Differentials

Answer 4

• Obesity (differentiate with fluid thrill)

- Abdominal mass

Question 5

Ascites Ix

Answer 5

• Cause is often apparent
• Confirm presence, find cause, assess complications (SBP, hepatorenal syndrome)
• FBC, renal function test, LFTs, clotting screen, TFTs
• AUSS
• Ascites tapping

Question 6

Ascites Management

Answer 6

• Treat cause
• Restrict salt
• Spironolactone
• Therapeutic paracentesis
• TIPS if refractory