Leading Diseases that results to Abdominal Ascites:

> Causes of high Serum-ascites albumin gradient  ("transudate") are:

Cirrhosis - 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%)
Heart failure - 3%
Budd-Chiari syndrome or veno-occlusive disease
Constrictive pericarditis
Kwashiorkor

> Causes of low Serum-ascites albumin gradient  ("exudate") are:

Cancer (primary peritoneal carcinomatosis and metastasis) - 10%
Tuberculosis - 2%
Pancreatitis - 1%
Serositis
Nephrotic syndrome
Hereditary angioedema
Etiology of Cirrhosis

Cirrhosis of the liver is a chronic, diffuse (widely spread throughout the

organ), degenerative disease in which the parenchyma (the functional organ tissue)
deteriorates; the lobules are infiltrated with fat and structurally altered; dense
perilobular connective tissue forms; and often areas of regeneration develop. The
surviving cells multiply in an attempt to regenerate and form "islands" of living cells
that are separated by scar tissue. These islands of living cells have a reduced blood
supply, resulting in impaired liver function. As the cirrhotic process continues, blood
flow through the liver becomes blocked; portal hypertension may occur (high blood
pressure in the veins connecting the liver with the intestines and spleen); glucose and
vitamin absorption decrease; the manufacturing of hormones and stomach and bowel
function are affected; and noticeable facial veins may appear. Most patients die from
cirrhosis in the fifth or sixth decade of life (Wolf 2001).
Approximately one-third of cirrhosis cases are "compensated," meaning
there are no clinical symptoms. Compensated cases are usually discovered during
routine tests for other problems or during surgery or autopsy. Cirrhosis is irreversible.
Unless the underlying cause of cirrhosis is removed and the person takes measures to
treat the condition, the liver will continue to incur damage, eventually leading to liver
failure, ammonia toxicity, gastrointestinal hemorrhage, kidney failure, hepatic coma,
and death. For some people, the only chance for a long-term cure is a liver transplant.
According the Centers for Disease Control (CDC), in the year 2000,
preliminary data compiled by the Division of Vital Statistics revealed that even though
cause of death from cirrhosis and chronic liver disease had fallen a rank from 7th to
12th, the number of people who died from liver disease was 26,219, almost the same
as when cirrhosis was ranked 7th (Minino et al. 2001).
Cirrhosis was the tenth leading cause of death in the United States, according to a
2000 Vital Statistics Report, in which data was collected through 1998. Ascites is the
most common of the 3 major complications of cirrhosis; the other complications are
hepatic encephalopathy and variceal hemorrhage.
 Most patients (approximately 85%) with ascites in the United States have cirrhosis.
In about 15% of patients with ascites, there is a nonhepatic cause of fluid retention.

In cirrhosis, healthy, functioning liver cells are destroyed, and scarring and
distortion of the liver eventually takes place. As fewer liver cells function, smaller amounts of
albumin (a protein) are manufactured. Lower albumin levels facilitate water retention
(edema) in the legs and abdomen (ascites). Excessive bile product deposits cause intense
skin itching, often accompanied by jaundice (yellowed skin). Other symptoms are testicular
atrophy (Swelling of Testicles) , gynecomastia (enlargement of the male breast), and loss of
chest and armpit hair. Psychotic mental changes such as extreme paranoia can also occur in
cases of advanced cirrhosis.
WHAT IS ASCITES?
Ascites is the build-up of additional fluid in the abdomen, otherwise called the
peritoneal cavity. In mild cases, this extra fluid may not be easily observed, but in
more serious cases, the abdomen protrudes greatly, thus coming up easily in the
diagnosis of ascites.
Ascites is most often caused by cirrhosis of the liver, generally related to
alcoholism. The "beer belly" referred to by many may actually be ascites. Heart
failure can lead to accumulation of fluid in the abdomen as well as in the ankles,
wrists, feet and hands. Tuberculosis, pancreatitis and cancer of the abdomen can
also produce ascites.
The greater the accumulation of fluid, the greater pressure on the diaphragm,
which can cause shortness of breath. Most other symptoms associated with ascites
relate directly to its underlying causes. For example, a person with ascites who
also has persistent coughing and fever may be evaluated for tuberculosis. Yellow
discoloration of the skin and mucus membranes, or jaundice, indicates liver
dysfunction as the cause of ascites.
Diagnosis includes determining the presence and the cause of ascites. Physicians
usually order several blood tests, among them a complete blood count, which can
accurately gauge factors like liver function and blood-clotting ability. Most
commonly, physicians perform a paracentesis, in which a small amount of ascitic
fluid is removed via needle from the abdomen. Evaluation of this fluid can point to
specific causes of ascites.
Fluid from ascites is analyzed to evaluate serum-ascites albumen gradient (SAAG).
This gradient can either be low or high, and helps to determine the underlying
cause of ascites. In general, high SAAG indicates liver dysfunction or heart failure.
Low SAAG suggests cancer or tuberculosis.
When patients present with severe ascites, physicians use paracentesis
to slowly extract excess fluid from the abdominal cavity. For mild ascites,
patients are often put on a low sodium diet and prescribed diuretics like
furosemide, brand name Lasix.
While the patient undergoes treatment to reduce or slow the build-up of
fluid, finding and treating the cause, when possible, is ultimately the best
way to reduce ascites. Medical or surgical treatment of underlying heart
failure will slowly reduce building fluid when heart failure is causing
ascites. Antibiotics are given to treat tuberculosis. Anti-viral medications
can help resolve some forms of hepatitis.
For ascites caused by severe cirrhosis of the liver, the only appropriate
treatment may be liver transplant. Obtaining a liver transplant can be
difficult for patients who have cirrhosis due to ongoing alcoholism. Unless
a patient can successfully stop drinking, transplant units are reluctant to
list him or her, because cirrhosis will recur if alcoholic behavior
continues.
In general, when the underlying cause of ascites can be determined and
treated, outlook is good, and careful monitoring can prevent recurrence.
For those whose underlying conditions cannot be addressed, treatment
focuses on reduction of discomfort caused by ascites. Unfortunately,
ascites often signifies severe underlying conditions that shorten life
expectancy.
Current Trends in the Management of Ascites

Transjugular intrahepatic portosystemic shunt

Percutaneous creation of a transjugular intrahepatic portosystemic shunt (TIPS) through a
jugular route connects the hepatic and portal veins in the liver. The goal is to reduce portal pressure and
thus prevent variceal bleeding TIPS diverts portal blood flow from the liver, but it increases the risk of
encephalopathy. In most cases encephalopathy responds to standard therapy, but in some cases the
calibre of the shunt has to be reduced; rarely, when encephalopathy does not respond to treatment (in
5% of cases) the shunt should be occluded.Thrombosis and stenosis are other complications that can
cause TIPS dysfunction. Recently, it has been reported that the use of a polytetrafluoroethylene-
covered stent decreases the rate of shunt dysfunction.The putative increased risk of hepatocellular carcinoma
remains to be clarified.

Surgical portosystemic shunting

Portocaval shunt operation involves the anastomosis of the portal vein and the
inferior vena cava, consequently reducing the portal pressure. The shunt also produces a
marked diuresis and natriuresis. However, despite reported efficacy, surgical
portosystemic shunts are rarely used in the treatment of advanced cirrhotic ascites,
because of the high incidence of post-shunt encephalopathy.In addition, surgical shunts
may cause technical difficulties during subsequent orthotopic liver transplantation.
Objectives
Nurse Centered:
The group is expected to aid and facilitate in the delivery of
necessary care for the client, that through the proper nursing process
and interventions we may become an instrument with regards to
improving the condition, attending to client’s special needs and be able
to carry out important medications necessary for the rehabilitation of
client’s disease, on the other hand, prioritizing the perceived problems as
well, that we may understand how to deal and manage a specific care w/
a specific time frame and goal to attain the maximum level of holistic
function of the client that the group can manage.
Client Centered:
As the group goes along in the ongoing and direct care, the
client is expected to manifest a sense of participation and willingness to
achieve the goals and objective that the nurse implies to promote the
maximum level of holistic functioning that the nurse can manage thus
interrelating the facts and understanding why does nursing process and
such interventions should be done and carried out.
Why did you choose this study?
The group chose this study out of curiosity and willingness to improve
our knowledge about the condition. It was our first time to encounter
such case and because of that, the group was interested to it. Another
reason was that it was one of the suggestions of our clinical instructor to
be used in making case study. Lastly, this was the only patient that
needs most nursing care.