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Summary An Approach to Ascites
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Ascites- Ascites
o Fluid Thrill (hands on flanks, tap one side, and feel thrill on
other side)
o Shifting Dullness
- Note: the umbilicus may be everted in ascites
Causes of Ascites:
Transudate Exudate
(high serum:ascites albumin (low serum:ascites albumin
conc. gradient) conc. gradient)
Cirrhosis (75%) Tuberculosis
- Mainly due to alcoholic Pathophysiology of Ascites:
cirrhosis Nephrotic Syndrome (<10% of
- May be viral or patients) Ascitic fluid can accumulate as a transudate or
cryptogenic as well an exudate. Amounts of up to 25 liters are
Peritoneal Ca (malignancy possible.
Heart failure (5%) accounts for 10% of ascites) Roughly, transudates are a result of increased
pressure in the portal vein e.g. due to cirrhosis,
(primary/metastatic)
while exudates are actively secreted fluid due to
Other: inflammation or malignancy.
Kwashiokor (protein Pancreatitis As a result, exudates are high in protein, high in
malnutrition) lactate dehydrogenase, have a low pH (<7.30), a
Constrictive Pericarditis low glucose level, and more white blood cells.
Transudates have low protein (<30g/L), low LDH,
high pH, normal glucose, and fewer than 1 white
cell per 1000 mm³. Clinically, the most useful
Investigations: measure is the difference between ascitic and
serum albumin concentrations. A difference of
- Peritoneal Paracentesis
less than 1 g/dl (10 g/L) implies an exudate.
o Check for Albumin, LDH, pH, Glucose and WCC
o Can be used therapeutically as well Portal hypertension plays an important role in
- Ultrasound the production of ascites by raising capillary
o May detect smaller volumes hydrostatic pressure within the splanchnic bed.
o May help guide paracentesis
- Serum-to-ascites Albumin Gradient (SAAG)
o Useful to classify ascites and may lead to underlying cause
Diuretic regimen:
Treatment:
- Spironolactone (aldosterone antagonist)
- Restrict Salt intake
o 100mg single morning dose
- Restrict water intake
- Furosemide (loop diuretic)
- Diurese the patient
o 40mg single morning dose
- Tense Ascites:
o 4-6L abdominal peritoneal paracentesis
o Then continue with salt restriction and diuretics
Prognosis:
- 50% of cirrhotic patients with ascites die within two years
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