Ascitis

ASCITIS
DEFINITION
Ascites, from Greek askites, "bag like" is a
gastroenterological term for detectable and
accumulation of fluid in the peritoneal cavity.
It is a common clinical finding with a wide range of
causes, but develops most frequently as a part of the
decompensation of previously asymptomatic chronic
liver disease.
CAUSES OF ASCITES
A) Incresased hydrostatic pressure or Venous Hypertension

• Cirrhosis of liver.
•Hepatic vein occlusion or outflow obstruction (Budd- Chiari
syndrome)
• Inferior vena cava obstruction
• Constrictive pericarditis
• Congestive heart failure,or CCF.
B) Decreased colloid osmotic pressure
• End-stage liver disease with poor protein synthesis
• Nephrotic syndrome with protein loss
• Malnutrition
• Protein-losing enteropathy(Hypoalbuminemia)
C) Increased permeability of peritoneal capillaries
• Tuberculous peritonitis
• Bacterial peritonitis
• Malignant disease of the peritoneum
D) Leakage of fluid into the peritoneal cavity
• Bile ascites(seepage of bile)
• Pancreatic ascites(pancreatic duct injury)
•Chylous ascites(accumulation of lipid rich lymph due to disruption
of lymphatic system secondry to trauma and obstruction.)
• Urine ascites(Azotemia)
E) MISCELLANEOUS CAUSES
• Myxedema.
• Ovarian disease (Meigs' syndrome)
• Pseudomymyxoma peritonei
• Chronic hemodialysis
PATHOPHYSIOLOGY
Ascitic fluid can accumulate as a transudate or an exudate. Amounts
of up to 35 liters are possible.
Roughly, transudates are a result of increased pressure in the hepatic
portal vein (>8 mmHg, usually around 20 mmHg, e.g. due to
cirrhosis, while exudates are actively secreted fluid due to
inflammation or malignancy.
As a result, exudates are high in protein, high in lactate
dehydrogenase, have a low pH (<7.30), a 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 measure is the difference
between ascitic and serum albumin concentrations (SAAG). A
difference of less than 1 g/dl (10 g/L) implies an exudate
Reason for abdominal distention
Remember 5F’s
Fat
Flatulence
Feces
Fluid
Fetus
Clinical Manifestations and Diagnosis
Symptoms
• Large and small amount of ascites
• Asymptomatic
• Abdominal distention and discomfort
• Anorexia
• Nausea
• Heartburn (Gastroesophageal Reflux)
• Flank pain
• Respiratory distress
Signs
• Umbilicus may everted.
• Bulging flanks with patient lying supine.
• Weight of ascitic fluid pushes against side walls.
• Tympany at the top of the abdominal curve.
• Patient lies supine.
• Gas filled bowel floats upward over ascites
• Fluid Thrill Wave Test 120 ml
• Shifting Dullness Test 500 ml.
• Puddle Sign 120 ml
GRADES OF ASCITES
• Grade 1 :
Mild ascites detectable only by ultrasound examination 100 ml and
CT.
• Grade 2:
Moderate ascites manifested by moderate symmetrical distension
of the abdomen, detectable with flank bulging and shifting dullness.
• Grade 3 :
Large or gross ascites with marked abdominal distension, directly
visible, confirmed with the fluid wave/thrill test.
General examinations
Enlarged lymph nodes : Suggestive of TB , leukaemia ,

malignancy , and lymphomas .
Associated jaundice : Cirrhosis of liver .
Dyspnoea , PND , orthopnoea , and oedema :congestive cardiac
failure .
Periorbital oedema , puffiness of face and oedema associated with
ascites : acute nephritis nephrotic synd.
Severe anaemia : Ascites of haematologic origin .
Other signs of malnutrition with ascites : Kwashiorkor .
Systematic examination
Abdominal Examination
Inspection
Abdomen is distended .
Umbilicus is everted and slit transversely(laughing umbilicus)
The distance between umbilicus and xiphisternum is more than
the distance between umbilicus and pubic symphysis .
Flanks are full. Nearly 1500 mL of fluid is required to make the
flanks full .
Veins are dilated over the abdomen .
Scrotal oedema indicates nephrotic synd
ANALYSIS OF ASCITIC FLUID
Investigations:
Peritoneal fluid analysis.(albumin,protein, Rbc,Wbc, differential
PMN count.
Other studies of Ascitic fluid
Lactate
Alkaline phosphatase
Amylase
Cytology
pH
Best single test for classifying ascites into portal hypertensive
(SAAG >1.1 g /dL) and non–portal hypertensive (SAAG <1.1 g
/dL) causes.
Calculated by subtracting the ascitic fluid albumin value from the
serum albumin value,
It correlates directly with portal pressure.
The accuracy is approximately 97% .
DIAGNOSTIC PARACENTESIS
10 to 20 mL
The bladder should be emptied prior to the procedure
Most common Site
left lower quadrant
Other site
1. In the midline between the pubic-symphysis & umbilicus,
2. Right iliac fossa, lateral to the inf. epigastric artery or a few cm
above the inguinal lig.
Z-technique
Therapeutic Paracentesis
initially the recommendation was to

perform daily 5-L paracentesis until
the disappearance of ascites, it was
subsequently determined that total
paracentesis (i.e. removal of all
ascites in a single procedure
accompanied by the concomitant
infusion of 6– 8 g albumin per liter of
ascites removed) was as safe as
repeated partial paracentesis.
Differences between
Transudative EXUDATIVE
Fluid pushed through the capillaries Fluid that leakes around the cell of
due to high pressure within the the capillaries cause by
capillary. inflammation.
Serum Albumin - Ascites Albumin Serum Albumin - Ascites Albumi
>1.1 gm/dl <1.1 gm/dl
Can be due to portal hypertension, Can be secondary to malignancy,
CHF, and Hypoalbuminemia. infection, or inflammation.
Gross apperance- watery, clear. Turbid or Husk colour.
Specific gravity-<1015 More than 1015
Protein-< 3mg/dl > 3mg/dl
Cells: usually benign, few Cells: more mesothelial cells, acute
mesothelial cells, histocytesand or chronic inflammatory cells, Rbc’s
lymphocytes. and malignant cells.
SYSTEMIC EXAMINATION
INSPECTI
ON
PALPATION
PERCUSSION
IMAGING STUDIES
Ultrasonography:
Volumes as small as 5- 10 mL can routinely be visualized.
With massive ascites, the small bowel loops have a characteristic polycyclic,
"lollipop,“ appearance
The smallest amounts of fluid tend to collect in the Morison pouch and around the
liver as a sonolucent band.
CT Scan:
Ascites is demonstrated well on CT scan.

A number of CT scan features suggest neoplasia. Hepatic, adrenal, splenic, or
lymph node lesions associated with masses arising from the gut, ovary, or
pancreas are suggestive of malignant ascites.
Management of ascites
Bed rest
Refractory Salt
ascites restriction
Management
Fluid
Diuretics
restriction
complications
1. Infection & peritonitis
2. Bladder or bowel perforation
3. Hypovolaemia & shock (>1 lit. remove rapidly), especially if the patient does not have oedema
4. Blockage of needle.
5. Spontaneous bacterial peritonitis ( SBP)
6. Hydrothorax
7. Gastro-oesophageal reflux
8. Respiratory distress and atelectasis due to
9. Elevation of diaphragm
10. Scrotal oedema
11. 7. Collection of fluid in the pleural sac
12. Mesenteric venous thrombosis
13. Functional renal failure.
Treatment
Patients with moderate ascites can be treated as outpatients and do

not require hospitalization unless they have other complications
of cirrhosis.
Since the development of grade 2 or 3 ascites in patients with
cirrhosis is associated with reduced survival, liver transplantation
should be considered as a potential treatment option
Treatment of high SAAG ascites
1 Medical
A) Diet.
B)Diuretics.
C)Therapeutic paracentesis
2 Surgical
TIPS
Liver transplantation
Peritoneovenous shunting
Diuretics
Aldosterone antagonist, acting mainly on the distal tubules as
Potassium-sparing diuretic (inhibit Na+ re-absorption and K+
excretion).
Spironolactone: drug of choice in the initial treatment.
Side effects are those related to its anti-androgenic activity, such as
decreased libido, impotence, and gynaecomastia in men and
menstrual irregularity in women.
Furosemide is a loop diuretic that generally used as an adjunct to
spironolactone .
it inhibit re-absorption of Na+/K+/2Cl- in the ascending limb of the
loop of Henle.
High doses are associated with severe electrolyte disturbance and
metabolic alkalosis, and should be used cautiously.
and Amiloride and triamterene act on the distal tubule. It blocks Na
reabsorption and induces diuresis in 80% of patients at doses of 15–
30 mg/day.
less effective compared with spironolactone.
Bumetanide is similar to frusemide in its action and efficacy
Torsemide are drugs of choice further.
Usual maximum doses are 400 mg/day of spironolactone and
160 mg/day of furosemide.
Overdose leads to intravascular volume depletion leading to renal
impairment, hepatic encephalopathy, and hyponatraemia.
All diuretics should be discontinued if
there is `1. Severe hyponatremia(135-145) (serum sodium
concentration <120 mmol/L),
2. Progressive renal failure,
3. Hepatic encephalopathy(loss of brain function when liver)
4. Incapacitating muscle cramps
Peritoneal tap
albumin infusion
Transjugular intrahepatic
portosystemic shunt (TIPS)
Liver transplant

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ASCITIS

A) Incresased hydrostatic pressure or Venous Hypertension

Enlarged lymph nodes : Suggestive of TB , leukaemia ,

initially the recommendation was to

Ascites is demonstrated well on CT scan.

Patients with moderate ascites can be treated as outpatients and do

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