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ASCITES

CAUSES:

(REF: Textbook of Gastroenterology 1991 - Runyon, Reynolds TB - Lippincott)

Ascitic Fluid Analysis:

A. Transudative ascites (Serum Albumin - Ascites Albumin >1.1 gm/dl)

  1. Liver cirrhosis
  2. Congestive heart failure
  3. Hepativ vein obstruction (Budd Chiari syndrome) a. Assoc. with tumors (hepatoma, hypernephroma, pancreatic Ca) b. Assoc. with hematologic disorders (myeloproliferative disease, polycythemia vera, myeloid metaplasia c. Due to infections
  4. Nephrotic syndrome
  5. Meig's ovarian tumor syndrome
  6. Constrictive pericarditis
  7. Inferior vena cava obstruction
  8. Viral hepatitis with submassive or massive hepatic necrosis

B. Exudative ascites (Serum Albumin - Ascites Albumin <1.1 gm/dl)

  1. Neoplastic diseases involving the peritoneum: Peritoneal carcinomatosis, Lymphomatous disorders
  2. Tuberculous peritonitis
  3. Pancreatitis
  4. Post surgery talc or starch powder peritonitis
  5. Transected lymphatics following portal caval shunt surgery
  6. Myxedema
  7. Sarcoidosis
  8. Lymphatic obstruction: a. Intestinal lymphangiectasia, b. Lymphoma
  9. Pseudomyxoma peritonei
  10. Struma oovarii
  11. Amyloidosis
  12. Prior abdominal trauma with ruptured lymphatics
  13. Hemodialysis CRF related ascites

C. Disorders simulating ascites

  1. Pancreatic pseudocyst
  2. Hydronephrosis
  3. Ovarian cyst
  4. Mesenteric cyst
  5. Obesity

RX of ascites depending on underlying cause.

  1. Paracentesis to remove large amount of ascitic fluid 4-6 L/day.
    Several large randomized, controlled trials have shown that repeated large-volume paracentesis (4 L-6 L) is safer and more effective for the treatment of tense ascites compared with larger-than-usual doses of diuretics.
  2. Bed rest
  3. Low salt diet <2 g NaCL/d and fluid restriction <1500 mL/day.
  4. Aldactone 25-50 mg qid PO (if urine Na 5-25 meq)
  5. Furosemide 40-80 mg/day (if urine Na < 5 meq)
  6. LeVeen or Denver peritoneaovenous shunt
  7. TIPS (Transjugular Intrahepatic Portosystemic Stent Shunt)
  8. Extracorporeal ultrafiltration of ascitic fluid.
  9. Liver transplantation

(REF: NEJM 2/3/94; 330:337 Runyon BA)

                  


Ascites - Differential Diagnosis  

A.  Normal Peritoneum

B.  Diseased Peritoneum (usually exudative)

C. Transudative (Serum Albumin - Ascites Albumin >1.1gm/dl)

D. Exudative (Serum Albumin - Ascites Albumin <1.1)

E. Budd-Chiari Syndrome

Ref: Outlines in Clinical Medicine on Physicians' Online 2000


            

The Management of Cirrhotic Ascites  Elaine Yeung, MD; Florence S. Wong, MD, FRCP(C)
Medscape General Medicine 10/22/2002

Spontaneous Bacterial Peritonitis (SBP)  

It is defined as an ascitic fluid infection associated with

In hospitalized patients with cirrhosis, 10% to 25% will have an episode of SBP with a mortality rate of 17% to 50%, with outcome dependent on the association with a recent gastrointestinal bleed, the severity of infection, and degree of renal and liver failure.

Pathogenesis

Types of SBP

Clinical Signs and Symptoms

A rigid abdomen is not necessary for diagnosis, especially in patients with large-volume ascites, which prevents the contact of visceral and parietal peritoneal surfaces to elicit the spinal reflex that causes rigidity.

Treatment of SBP

Treatment should be started empirically if SBP is suspected clinically, regardless of the availability of laboratory results.

In community-acquired SBP and in patients not on SBP prophylaxis, Escherichia coli and Klebsiella pneumoniae are seen in up to 60% of isolates. About 25% are Gram-positive cocci, mostly streptococcal species. Anaerobes are rarely seen.