Ascites

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Etiologies

Portal hypertension related SAAG 2:1.1

Nonportal hypertension related SAAG <1.1

Sinusoidal cirrhosis (81%), including SBP acute hepatitis extensive malignancy (HCC or mets) Postsinusoidal right-sided CHF incl constriction & TR Budd-Chiari syndrome. SOS Presinusoidal portal or splenic vein thrombosis schistosomiasis

Peritonitis:TB. ruptured viscus (T amy) Peritoneal carcinomatosis

Pancreatitis Vasculitis

Hypoalbuminemic states: nephrotic syndrome, protein-losing enteropathy Meigs' syndrome (ovarian tumor) Bowel obstruction infarction Postoperative lymphatic leak

Pathophysiology

• "Underfill" theory: portal hypertension transudation of fluid into peritoneum

I plasma volume -» renal Na retention

• "Overflow" theory: hepatorenal reflex — Na retention

• Peripheral vasodilatation theory (favored): portal hypertension — systemic vasodilatation

(? due to release of NO) -» i effective arterial volume — renal Na retention

• Hypoalbuminemia -♦ I serum oncotic pressure

• t hepatic lymph production

Workup

• Detection: flank dullness ( >1500 cc must be present), shifting dullness;

ultrasound detects if 100 cc

• Paracentesis (N£jM 2006;355:e2i) indicated in all Pts w/ new-onset ascites, as well as s/s of infxn (abd pain, fever. AMS, leukocytosis, acidosis); coagulopathy not a contraindic.

• Serum-ascites albumin gradient (SAAG): -95% accuracy (Aw** 1992,117:215)

-1.1 g dl — portal hypertension related; <1.1 g dl — nonportal hypertension related

• Ascites fluid total protein (AFTP): useful when SAAG -1.1 to distinguish cirrhosis (AFTP <2.5 g dl) from cardiac ascites (AFTP >2.5 g dl)

• If portal hypertensive etiology, consider standard cirrhosis w u (see "Cirrhosis")

• Rule out infection: cell count with differential (infection if WBC 500 mm3 or PMN

250 mm3), culture - bedside inoculation of blood culture bottles (yield 90%) (Cotw 1988.95 1351). gram stain (less Se; most helpful w free perforation)

• Other tests as indicated: amylase (pancreatitis, gut perforation), triglycerides (chylous ascites). AFB adenosine deaminase (TB), bilirubin (biliary upper gut perforation), cytology (peritoneal carcinomatosis) Treatment (portal hypertension related) (NEJM 2004:3501646)

• I Na intake (1-2 g d); free HjO restriction if hyponatremic

• Diuretics (effective in 80% of cases)

spironolactone (start 100 mg PO qd) • furosemide (start 40 mg PO qd); Î in proportion goals: diurese 1L d, steady wt loss ( 0.5-1.0 kg d). urinary Na K ratio >1 (indicating effective blockade of endogenous aldosterone)

• Options for refractory ascites (ensure diet & medicine compliance)

Large volume paracentesis: remove 4-6 U • albumin replacement (fewer asx chemical abnl; no A in mortality) (Castro 1988.^4 1493) TIPS: U ascites in 75%. i CrCI. T transplantation-free survival (nejm 2000:342.1701). but Î encephalopathy. 40% need TIPiS revision, no A quality-of-life (Gaan 2003:124 634) consider if refractory ascites. Child's class A or B. minimal encephalopathy Liver transplantation if Pt is a candidate

• Treatment for nonportal HTN-related ascites depends on cause (TB. malignancy, etc)

Complications

• Spontaneous bacterial peritonitis (see below)

• Hepatorenal syndrome (see "Cirrhosis")

• Pleural effusions (usually unilateral and R L; hepatic hydrothorax 2° diaphragmatic defect); chest tube contraindicated as î complications

• Other complications: cellulitis, tense ascites, abdominal wall hernias

Bacterial peritonitis

• Definitions and diagnosis

Bacterial peritonitis

• Definitions and diagnosis

Type

Ascites cell count/mm1

Ascites culture

Sterile

<250 polys

Spontaneous bacterial peritonitis (SBP)

250 polys

© (one organism)

Culture-negative neutrocytic ascites (CNNA)

>250 polys

e

Nonneutrocytic bacterascites (NNBA)

<250 polys

& (one organism)

Secondary

>250 polys

i (polymicrobial)

Peritoneal dialysis-associated

>100 with poly predom.

epidemiology: occurs in 19% of cirrhotics; risk factors AFTP • 1 g dl. history of prior

SBP. current Gl hemorrhage clinical manifestations: fever, abdominal pain, rebound tenderness. A MS

clinical signs may be unreliable; . have a low threshold for diagnostic paracentesis pathogens: 70% GNR (£. coff. Klebsiella). 30% GPC (S. pneumoniae, other streptococci. Emerococcus) treatment: cefotaxime 2 gm IV q8h > 5 d: IV albumin 1.5 g kg at time of diagnosis and 1 g kg on day 3 results in survival benefit (NEJM 199*341:403) repeat paracentesis after 48 h if w o significant improvement prophylaxis (if h o SBP. current GIB. or AFTP 1 g dl) norfloxacin 400 mg PO qd or Bactrim DS qd however, selects for resistant gut flora, limit use of prophylactic abx as follows: inpatients w AFTP <1 g dl. with discontinuation of abx at time of discharge acute variceal hemorrhage: norfloxacin 400 mg PO bid. Bactrim DS PO bid. or ceftriaxone 1g IV qd x 7 d h o one or more episodes of SBP: indefinite treatment

• CNN A: variant of SBP w similar clinical course; Rx same as for SBP

• NNBA: often resolves w o Rx; follow closely Rx only if sx or persistently culture ©

• Secondary (intraabdominal abscess or perforated viscus)

polymicrobial usually AFTP >1 g dl. ascitic fluid glucose <50 mg dl. or ascitic fluid LDH >225 U L treatment: 3rd-gen. cephalosporin • metronidazole plains films (supine upright). CT scan, and likely exploratory laparotomy for definitive diagnosis and treatment

• Peritoneal dialysis-associated clinical manifestations: cloudy abdominal fluid, abdominal pain, rebound, fever, nausea pathogens: 70% GPC. 30% GNR

treatment: vancomycin - gentamicin (IV load then administer in PD)

Portal vein thrombosis (PVT)

• Thrombosis, constriction, or invasion of portal vein portal HTN — splenomegaly and formation of portosystemic collaterals (esophageal, gastric, duodenal, jejunal varices)

• Etiologies: cirrhosis, neoplasm (pancreas. HCC). intra-abdominal inflammation infection.

hypercoagulable state (including MPS), surgery, trauma

• Clinical manifestations:

acute PVT: can p w pain, but usually clinically silent; dx as incidental finding on U S or

CT performed for other reasons chronic PVT: can present as incidental finding or as hematemesis 2° variceal bleeding; splenomegaly; occasionally ascites

• Diagnostic studies: LFTs usually normal; U S with Doppler, MRA. CT (I'). angiography

• Treatment: as for portal hypertension; anticoagulation for acute portal vein thrombosis;

consider surgical shunts or TIPS if refractory or recurrent bleeding

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