ASCITES

SECONDARY TO
KIDNEY DISEASE

Submitted to: Ms. Jesusa L. Capispisan

Submitted By: Marianne Claire P. Bartolome
Year/ Section: 3A-BS Nursing
Group # 3

DEFINITION:
Ascites is an accumulation of serous fluid in the peritoneal cavity.
Causes include cirrhosis of the liver, tumour, tuberculous peritonitis, and interference in venous
circulation, cardiac or renal failure. MALIGNANT A.., A condition sometimes occurring in the
end stage of cancer with metastasis to the peritoneum; treatment may consist of peritoneovenous
shunt.-SYN. Hydroperitoneum, abdominal dropsy.
Ascites is the accumulation of fluid in the peritoneal cavity, causing abdominal swelling. Causes
include infection (such as tuberculosis), heart failure, portal hypertension, cirrhosis, and various
cancers (particularly of the ovary and liver). Obstruction to the drainage of lymph from the
abdomen results in chylous ascites. (Chyle)
Chyle is an alkaline milky liquid found within the lacteal after a period of absorption. It consists
of lymph with a suspension of minute droplets of digested fats, which have been absorbed from
the small intestine. It is transported in the lymphatic system to the thoracic duct.

PATHOPHYSIOLOGY:
The mechanism responsible for the development of ascites is not completely understood. Portal
hypertension and the resulting increase in capillary pressure and obstruction of venous blood
flow through the damaged liver are contributing factors. The vasodilation that occurs in the
splanchnic circulation is also suspected causative factor. The failure of the liver to metabolize
aldosterone increases sodium and water retention by the kidney. Sodium and water retention,
increased intravascular fluid volume, increased lymphatic flow and decreased synthesis of
albumin by the damaged liver all contribute to the movement of fluid from the vascular system
into the peritoneal space. The process becomes self-perpetuating as loss of fluid into the
peritoneal space causes further sodium and water retention by the kidney in an effort to maintain
the vascular fluid volume.
As a result of liver damage, large amount of albumin rich fluid, 15L or more, may accumulate in
the peritoneal cavity as ascites. With the movement of albumin from the serum to the peritoneal
cavity, the osmotic pressure of the serum decreases. This, combined with increased portal
pressure, results in movement of fluid into the peritoneal cavity.

CLINICAL MANIFESTATION:
Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites.
The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and
distended veins may be visible over the abdominal wall. Umbilical hernias also occur frequently
in those patients with cirrhosis. Fluid and electrolyte imbalances are common.

STRIAE AND DISTENDED VEINS VISIBLE OVER THE ABDOMINAL WALL

SHORT OF BREATHE AND UNCOMFORTABLE FROM ENLARGE ABDOMEN

DISTENDED VEIN IN THE ABDOMEN

INCREASED ABDOMINAL GIRTH AND RAPID WEIGHT GAIN

UMBILICAL HERNIAS

FLUID AND ELECTROLYTE IMBALANCE

ASSESSMENT AND DIAGNOSTIC EVALUATION:

The presence and extent of ascites are assessed by percussion of the abdomen. When fluid has
accumulated in the peritoneal cavity, the flanks bulge when patient assumes a supine position.
The presence of fluid can be confirmed either by percussing for shifting dullness or by detecting
a fluid wave. A fluid wave is likely to be found only if a large amount of fluid is present. Daily
measurement and recording of abdominal girth and body weight are essential to assess the
progression of ascites and its response to treatment.

ASSESSING FOR FLUID WAVE

DAILY MEASUREMENT AND

RECORDING OF WEIGHT

DAILY MEASUREMENT AND RECORDING OF ABDOMINAL GIRTH

MEDICAL MANAGEMENT:
DIETARY MODIFICATION:
The goal of treatment for the patient with ascites is a negative sodium balance to reduce fluid
retention. Table salt, salty foods, salted butter and margarine, and all ordinary canned and frozen
foods that are not specifically prepared for low-sodium (2-g sodium) diets should be avoided. It
may take 2-3 months for the patients taste buds to adjust to unsalted foods. In the meantime, the
taste of unsalted foods can be improved by using salt substitutes such as lemons juice, oregano,
and thyme. Commercial salt substitutes need to be approved by the physician, because those that
contain ammonia could precipitate hepatic coma. Most salt substitutes contain potassium and
should be avoided if the patient has impaired renal function. The patient should make liberal use
of powdered, low-sodium milk and milk products. If fluid accumulation is not controlled with
this regimen, daily sodium allowance may be reduced further to 500 mg, and diuretics may be
administered.
Dietary control of ascites via strict sodium restriction is difficult to achieve at home. The
likelihood that the patient will follow even a 2-g sodium diet increases if the patient and the
person preparing the meals understand the rationale for the diet and receive periodic guidance
about selecting and preparing appropriate foods. Approximately 10% of patient with ascites
respond to these measures alone. Nonresponders and those who finds sodium restriction difficult
require diuretic therapy.

DIURETICS:
Use of diuretics along sodium restriction is successful in 90% of patients with ascites.
Spironolactone (Aldactone), an aldosterone-blocking agent, is the most often the first-line
therapy in patient with ascites from cirrhosis. When used with other diuretics, spironolactone
helps prevent potassium loss. Oral diuretics such as furosemide (Lasix) may be added but should
be used cautiously, because long-term use may induce severe sodium depletion (hyponatremia).
Ammonium chloride and acetazolamide (Diamox) are contraindicated because of the possibility
of precipitating hepatic coma. Daily weight loss should not exceed 1 to 2 kg (2.2 to 4.4 lbs) in
patients with ascites and peripheral edema or 0.5 to 0.75 kg (1.1 to 1.65 lbs) in patients without
edema. Fluid restriction is not attempted unless the serum sodium concentration is very low.
Possible complications of diuretic therapy include fluid and electrolyte disturbances (including
hypovolemia, hypokalemia, and hyponatremia and hypochloremic alkalosis) and
encephalopathy. Encephalopathy may be precipitated by dehydration and hypovolemia. In
addition, when potassium stores are depleted, the amount of ammonia in the systemic circulation
increases, which may cause impaired cerebral functioning and encephalopathy.

BED REST:
In patients with ascites, an upright posture is associated with activation of the renin- angiotensinaldosterone system and sympathetic nervous system. This causes reduced renal glomerular
filtration and sodium excretion and a decreased response to loop diuretics. Therefore, bed rest
may be useful therapy, especially to the patients whose condition is refractory to diuretics.

PARACENTESIS:
Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or
small surgical incision through abdominal wall under sterile conditions. Ultrasound guidance
may be indicated in some patients who are at high risk for bleeding because of an abnormal
coagulation profile and in those who have had previous abdominal surgery and may have
adhesion. Paracentesis once considered a routine form of treatment for ascites. However, it is
now performed primarily for diagnostic examination of a ascetic fluid, for treatment of massive
ascites that is resistant to nutritional and diuretic therapy and that is causing severe problems to
the patients, and as prelude to diagnostic imaging studies, peritoneal dialysis, or surgery. A
sample of ascetic fluid may be send to the laboratory for cell count, albumin and total protein
levels, culture, and other tests.
Large-volume (5-6 L) paracentesis has been shown to be a safe method for treating patients with
severe ascites. This technique, in combination with the IV infusion of salt-poor albumin or other
colloid, has become a standard management strategy yielding an immediate effect. Refractive,
massive ascites is unresponsive to multiple diuretics and sodium restriction for 2 weeks or more
and can result in sequelae such as respiratory distress, which requires rapid intervention.
Albumin infusions help to correct decreases in effective arterial blood volume that lead to
sodium retention. Use of this colloid reduces the incidence of hyponatremia and renal
dysfunction associated with decreased effective arterial volume. The beneficial effects of
albumin administration on hemodynamic-stability and renal functional status may be related to
an improvement in cardiac function as well as a decrease in the degree of arterial vasodilation.
Although the patient with cirrhosis has greatly increased extracellular blood volume, the kidney
incorrectly senses that the effective volume has decreased. The renin-amgiotensin- aldosterone
axis is stimulated, and sodium is reabsorbed. In addition, antidiuretic hormone (ADH) secretion
increases, which leads to increased retention of free water and sometimes to the development of
dilutional hyponatremia. Therapeutic paracentesis provides only temporary removal of fluids;
ascites rapidly recurs, necessitating repeated fluid removal.

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)

TIPS is a method of treating ascites in which a cannula is threaded into the portal vein by the
transjugular route. To reduce portal hypertension, an expandable stent is inserted to serve as an
intrahepatic shunt between the portal circulation and the hepatic vein. TIPS is the treatment of
choice for refractive ascites. It is extremely effective in decreasing sodium retention, improving
the renal response to diuretic therapy and preventing recurrence of fluid accumulation.
Because of the development of ascites in patients with cirrhosis is associated with a 50%
mortality rate, any patient who is considered a candidate for liver transplantation should be
referred for TIPS.

OTHER METHODS OF TREATMENT:

Ascites can also be treated by the insertion of a peritoneovenous shunt to redirect ascitic fluid
from the peritoneal cavity into the systemic circulation. However, this procedure is seldom used
because of the high complication rate and high incidence of shunt failure. In fact, use of this
shunt has virtually been abandoned, except for patients who are not candidates for liver
transplantation.

PARACENTESIS

SURGERY ON PATIENTS WITH ASCITES

Surgery is prone to complications in patients with ascites. Abdominal surgery is prone to
infection and there is a potential for poor wound/anastomotic healing. The underlying liver
disease may cause a coagulopathy. Renal failure complicating liver disease (hepatorenal
syndrome) is a major risk which can be minimised by ensuring optimal renal perfusion. Patients
who have obstructive jaundice are often surgical candidates, at least for some form of bypass
procedure. The presence of ascites in these patients increases the mortality, particularly from
hepatorenal syndrome, and thus less invasive procedures such as biliary stenting are preferred.

NURSING MANAGEMENT:

If a patient with ascites from liver dysfunction is hospitalized, nursing measures include
assessment and documentation of intake and output, abdominal girth, and daily weight to assess
fluid status. The nurse monitors serum ammonia and electrolyte levels to assess electrolyte
balance, response to therapy, and indicators of encephalopathy.

PROMOTING HOME AND COMMUNITY-BASE CARE

TEACHING PATIENTS SELF-CARE
The patient treated for ascites is likely to be discharged with some ascites still present. Before
hospital discharge, the nurse teaches the patient and family about the treatment plan, including
the need to avoid all alcohol intakes, adhere to a low-sodium diet, take medication as prescribed,
and check with physician before taking any new medications. Additional patient and family
teaching addresses skin care and the need to weigh the patient daily and to watch for and report
the signs and symptoms of complications.

CONTINUING CARE:
A referral for home care may be warranted, especially if the patient lives alone or cannot provide
self care. The home visits enable the nurse to assess the changes in the patients condition and
weight, abdominal girth, skin and cognitive and emotional status. The home care nurse assesses
the home environment and the availability of resources needed to adhere to the treatment plan
(e.g. a scale to obtain daily weights, facilities to prepare and stores appropriate foods, resources
to purchase needed medications). It is important to assess the patients adherence to the treatment
plan and the ability to buy, prepare, and eat appropriate foods. The nurse reinforces previous
teaching and emphasizes the need for regular follow-up and the importance of keeping scheduled
health care appointments.