ASCITES

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ASCITES
ASCITES
Fluid in the peritoneal cavity (intraperitoneal
fluid)
Men have little to no fluid here
Women may have up to 20ml (it increases during
the follicular phase to peak in early luteal
signaling that it is of an ovarian exudative origin)
3 Grades
Grade 1: mild, only visible on ultrasound and CT
Grade 2: detectable with flank bulging and shifting
dullness
Grade 3: directly visible, confirmed with the fluid
wave/thrill test
Assessment
None of the tests are both
sensitive and specific, so to
increase the accuracy:
At least 2 maneuvers!
Bulging Flanks
Flank Dullness
Shifting Dullness
Fluid Wave
Pathophysiology
Increased Hydrostatic
Pressure
Cirrhosis, Heart
Failure, Constrictive
Pericarditis, Inferior
vena cava or hepatic
vein obstruction
Decreased Plasma
Oncotic Pressure
Nephrotic syndrome,
malnutrition
Pathophysiology
Transudate
Generally a result
of increased
pressure in the
hepatic portal Exudate
vein Due to
inflammation or
maligancy
 Uncommon Causes

Etiology Hepatitis B
Autoimmune hepatitis
Primary billiary cirrhosis
Haemochromatosis
Most Common Causes: Wilsons Disease
Hepatitis C Constrictive pericarditis
Budd-Chiari Syndrome
Alcoholic hepatitis Chronic Renal failure
Congestive Heart Failure Protein losing enteropathy
Nephrotic Syndrome Peritoneal Carcinomatosis
Myxoedema
Pancreatitis Schostosomiasis
SLE
Fulminant hepatic failure
Hepatic metastases
Secondary peritonitis
Chylous ascities
Urogenital surgical trauma
Bile ascites
Ovarian Tumours
Tricuspid Regurgitation
Causes Continued:
Normal Peritoneum
Portal Hypertension
(Extrahepatic) Hepatic congestion, CHF, constrictive pericarditis,
tricuspid insufficiency, Budd-Chiari Syndrome
(intrahepatic) Liver disease, cirrhosis, alcoholic hepatitis, fulminant
hepatic metastases
Hypoalbuminemia
Nephrotic syndrome
Protein-losing enteropathy
Malnutrition- anasarca
Misc:
Chylous ascites
Pancreatic ascites
Bile ascites
Nephrogenic ascites
Urine ascites
Ovarian Ascites
Myxoedema
Causes Contd:
Diseased Peritoneum
Infections
Bacterial
Tuberculous
Fungal
HIV-associated peritonitis
Malignancy
Peritoneal carcinomatosis
Primary mesothelioma
Pseudomyxoma peritonei
Hepatocellular carcinoma
Other
Familial Mediterranean Fever
Vasculitis
Granulomatous Peritonitis
Eosinophilic Peritonitis
Whipples
Endometriosus
WORK IT (up)
CBC
Basal Metabolic Profile
Liver enzymes
Coagulation Studies
Ultrasound
Paracentesis!
Inspection: transparent and tinged yellow
Cell Count
SAAG
Total Protein
Culture/Gram Stain
Amylase cultures/PCR
Paracentesis
Indications:
Basically anyone with new onset ascites or
worsening condition with ascites
Contraindication
Absolute: acute abdomen- surgery required
Relative
Coagulopathy
Pregnancy
Distended urinary bladder
Abdominal wall cellulitis
inspection
Translucent or yellow- normal or sterile
Brown- hyperbilirubinemia d/t gall bladder or
biliary perforation
Cloudy or turbid- infection
Pink or blood tinged- mild trauma
Grossly bloody- traumatic tap- malignancy or
abdominal trauma
Milky (chylous)- cirrhosis, thoracic duct injury,
lymphoma
 SAAG
Serum Ascites Albumin
Gradient
Single best test for classifying ascites into portal
hypertensive (SAAG>1.1g/dL) and non-portal
hypertensive (SAAG<1.1g/dL)

SAAG= [Serum
Albumin]- [Ascites
Albumin]
High Gradient = >1.1g/dL portal
hypertension
Low Gradient = <1.1g/dL NOT portal
hypertensive
High SAAG
Cirrhosis- 81%
Alcoholic- 65%
Viral- 10%
Heart Failure 3%
Hepatic veinous occlusion: Budd-Chiari
Constrictive pericarditis
Kwashiorkor
Low SAAG
Cancer-10%
Infection: Tuberculosis or spontaneous bacterial
peritonitis
Pancreatitis
Serositis
Nephrotic Syndrome
Hereditary angioedema
Transudate Vs. Exudate
5 Most Common Causes
Cause History Exam 1st
Investiga
Other
Investig
tion ations
Hepatit Exposure (drug Jaundice Serology Biopsy-
Hepatitis C
sC user) PCR fibrosis
and
inflamm
ation
Alcoholi Hx of excessive Jaundice, Elevated Low
c drinking, tender serum albumin,
Hepatiti jaundice, hepatomegaly, GGT prolonge
s abdominal d/c hepatic bruit, AST/ALT d PT,
or nausea spider ratio (AST ultrasou
angiomas, more nd
palmar elevated) changes
erythema,
hepatic
encephalopathy
CHF Dyspnea, Peripheral ECG-LVH Echo
fatigue, leg edema, rales, CXR- with
swelling, HTN, dyspea, JVD, cardiomeg doppler-
diabetes, cool aly, low EF
Cause History Exam 1st Other
Investigat Investigat
ion ions
Nephrotic Abdominal Edema, Urinalysis- Serum
Syndrome distension/ abdominal proteinuria albumin is
discomfor/ distension, low, serum
pain, HTN, cholesterol
limb/eye hypovolemi is high
swelling, c episodes
HTN,
oliguria
Pancreatiti Acute Epigastric Elevated Abdominal
s onset of abdominal serum ultrasound
pain tenderness lipase and may show
radiating elevated gallstones
to back, Abdominal
N/V CT show
pancreatic
THANK YOU!