Hepatobiliary - Ascites

Question 1

Ascites - what is it?

Answer 1

Ascites is the abnormal accumulation of fluid in the abdomen

Question 2

Ascites - how can the causes of ascites be grouped?

Answer 2

The causes of ascites can be grouped into those with a serum-ascites albumin gradient (SAAG) <11 g/L or a gradient >11g/L

Question 3

Ascites - what does a SAAG of >11g/L indicate?

Answer 3

Indicates Portal Hypertension

Question 4

Ascites - what are the main causes of SAAG > 11g/L ascites?

Answer 4

Liver disorders are the most common cause
cirrhosis/alcoholic liver disease

acute liver failure

liver metastases

Cardiac

right heart failure

constrictive pericarditis

Other causes

Budd-Chiari syndrome

portal vein thrombosis

veno-occlusive disease

myxoedema

Question 5

Ascites - what are the causes of SAAG <11g/L ascites?

Answer 5

Hypoalbuminaemia

nephrotic syndrome

severe malnutrition (e.g. Kwashiorkor)

Malignancy

peritoneal carcinomatosis

Infections

tuberculous peritonitis

Other causes

pancreatitisis

bowel obstruction

biliary ascites

postoperative lymphatic leak

serositis in connective tissue diseases

Question 6

Ascites - management?

Answer 6

• reducing dietary sodium
• Fluid restriction recommended if sodium is < 125 mmol/L
• aldosterone antagonists: e.g. spironolactone
  
  • loop diuretics are often added
• drainage if tense ascites - therapeutic abdominal paracentesis
  
  • large-volume paracentesis for the treatment of ascites requires albumin ‘cover’
  • paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres)
• prophylactic antibiotics to reduce the risk of spontaneous bacterial peritonitis, offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites
• a transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some patients