ASCITES

IT IS THE CONDITION OF PATHOLOGICAL

ACCUMULATION OF FLUID IN ABDOMINAL
CAVITY
 CAUSES

Can Be Broadly Classified On The

Basis Of :

Normal peritoneum
Diseased peritoneum
 CAUSES

NORMAL PERITONEUM
Portal hypertension
Congestive Heart Failure
Constrictive Pericarditis
Tricuspid Insufficiency
Budd-Chiari Syndrome
Liver Cirrhosis
Alcoholic Hepatitis
Fulminant Hepatic Failure
Massive Hepatic Metastases
 CAUSES

NORMAL PERITONEUM
Hypoalbuminemia
Nephrotic Syndrome
Protein-losing Enteropathy
Severe Malnutrition with Anasarca
 CAUSES

NORMAL PERITONEUM
Miscellaneous conditions
Chylous ascites
Pancreatic ascites
Nephrogenic ascites
Meigs syndrome
 CAUSES

DISEASED PERITONEUM
Infections
Tuberculous Peritonitis
Bacterial Peritonitis
Fungal Peritonitis
HIV associated peritonitis
 CAUSES

DISEASED PERITONEUM
Malignant conditions
Peritoneum Carcinomatosis
Hepatocellula Carcinoma
Primary Mesothelioma
Pseudomyxoma Peritonei
CAUSES

DISEASED PERITONEUM
Other rare conditions
Granulomatous Peritonitis
Vasculitis
CLINICAL FEATURES

PRESENTING COMPLAINTS
Abdominal Distension
Diffuse Abdominal Pain
Bloated Feeling of Abdomen
Dyspnoea and Orthopnea (due to elevation of
daipharagm)
Indigestion and Heart burn (due to inc intra
abdominal pressure)
CLINICAL FEATURES

PHYSICAL EXAMINATION
Abdominal Distension
Fullness of Flanks
Umbilicus Flat and Everted
Diverticulation of Recti Muscles
Distended Abdominal Veins
Shifting dullness (esp. when >1000ml of fluid)
Fluid Thrill
Puddle Sign
CLINICAL FEATURES

PHYSICAL EXAMINATION
SIGNS RELATED TO SECONDARY EFFECTS
OF ASCITES
Scrotal Edema
Pleural effusion (due to defect in the diaphragm
and fluid pass into the pleural space)
Edema
Cardiac apex is shifted upward due to raised
diaphragm)
Distended neck veins due to inc rt atrial
pressure)
CLINICAL FEATURES

PHYSICAL EXAMINATION
SIGNS RELATED TO THE CAUSE OF ASCITES
LIVER DISEASE:
Jaundice,Anemia,Palmar erythema,Spider
angiomas,Hepatosplenomegaly,
CARDIAC DISEASE:
Elevated JVP
MALIGNANCY:
SISTER MARY JOSEPH NODUE in umblicus(peritoneal
carcinomatosis like gastric, pancreatic and hepatic malignancies)
VIRCHOW NODE (rt supraclavicular lymph node due to upper
abdominal malignancy)
NEPHROTIC SYNDROME:
Edema or Anasarca
 STAGING

Can Be Semi Quantified Into:

Stage 1+ is detectable only after careful

examination.
Stage 2+ is easily detectable but of relatively small
volume.
Stage 3+ is obvious ascites but not tense ascites.
Stage 4+ is tense ascites.
INVESTIGATIONS

Includes:

Imaging studies
Lab studies
Laparoscopy
INVESTIGATIONS

IMAGING STUDIES
CHEST AND ABDOMINAL PLAIN FILMS
Detects ascites if >500ml fluid
Elevated diaphragm
Pleural effusion (hepatic hydrothorax)
Diffuse abdominal haziness
USG ABDOMEN
can detect as small as 5ml fluid
can identify the cause like liver cirrhosis
CT SCAN:
can identify the cause like malignancies
INVESTIGATIONS

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC
PARACENTESIS)
Ascitic Fluid should be analyzed for
APPEARANCE
CELL COUNT
TOTAL PROTEINS
SAAG(SERUM ASCITIC ALBUMIN GRADIENT)
CYTOLOGY
CULTURE
MISCELLENOUS
BASELINE INVESTIGATIONS LIKE BLOOD CP,LFTS,PT
APTT
INVESTIGATIONS

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC
PARACENTESIS)
APPEARANCE
TRANSPARENT AND TINGED: NORMAL
STRAW COLORED: CIRRHOSIS
HEAMORRHGIC: MALIGNANCY
CLOUDY: INFECTION
BILE STAINED: BILIARY CONTAMINATION
CHYLOUS: LYMPHATIC OBSTRUCTION
 INVESTIGATIONS

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC
PARACENTESIS)
CELL COUNT
WBCS <500/mm3 and NEUTROPHILS<250/mm3:
NORMAL
NEUTROPHILS>250/microL: suggests SBP
LYMPHOCYTES PREDOMINANCE: ABDOMINAL TB OR
MALIGNANCY
 INVESTIGATIONS

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC
PARACENTESIS)
TOTAL PROTEINS
PROTEINS<2.5g/dl: TRANSUDATE
PROTEINS>2.5g/dl: EXUDATE
 INVESTIGATIONS

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC
PARACENTESIS)
SAAG (Serum Ascitic Albumin
Gradient)
The Difference bw Serum Albumin and Ascitic fluid Albumin
Best single test to differentiate between ascites due to portal
hypertension and non-portal hypertension
When saag >1.1g/dl: strongly suggest portal hypertension
When saag < 1.1g/dl: non portal hypertensive causes
Accuracy more than 97%
 INVESTIGATIONS

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC
PARACENTESIS)
CYTOLOGY
58-75% HELPING FOR DETECTING MALIGNANT ASCITES

CULTURE AND GRAM STAIN

MORE IMPORTANT IN SBP
 INVESTIGATIONS

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC
PARACENTESIS)
MISCELLENOUS
GLUCOSE: low in TB peritonitis
AMYLASE: HIGH IN PANCREATIC ASCITES
PH: <7 SUGGEST BACTERIAL INFECTION
RBCS: MORE THAN 50,000/microL SUGGESTS
TB,MALIGNANCY OR TRAUMA
 INVESTIGATIONS

LAPROSCOPY
IN SOME PATIENTS FOR DIRCET VISUALIZATION

TO TAKE BIOPSIES OF
LIVER
PERITONEUM
INTRA ABDOMINAL LYMPHNODES
 MANAGEMENT

COMPRISES OF:

General care
Medical care
Surgical care
 MANAGEMENT

GENERAL CARE
MONITORING OF
INPUT OUT PUT
ABDOMINAL GIRTH
WEIGHT
DIETRY MODIFICATIONS
SODIUM RESTRICTION UPTO 1g/day
WATER RESTRICTION (If Serum Sodium Level Is
<120mmol/L Hyponatremia)
BED REST:
Improves renal perfusion which leads to diuresis
 MANAGEMENT

MEDICAL CARE
THE AIM OF THE THERAPY IS WT LOSS OF BODY WIGHT DAILY
300g-500g IF ONLY ASCITES
800g-1000g IF ASCITES AND EDEMA
DIEURETICS
MAINSTAY THERAPY FOR ASCITES
SPIRONOLACTONE 25-200 mg/d PO qd or divided bid
FUROSEMIDE:20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe
edematous states
AMILORIDE:5-20 mg PO qd
COMBINATION THERAPY:
SPIRONOLACTONE + FUROSEMIDE
FUROSEMIDE + AMILORIDE
 MANAGEMENT

MEDICAL CARE
THERAPEUTIC PARACENTESIS
In patients with massive ascites (grade 3 or 4)
In ascites refractory to dieuretics
If cardio respiratory distress due to ascites
3-5litres can be removed with the replacement of
salt free albumin.
 MANAGEMENT

MEDICAL CARE
TIPS(TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNT)

Becoming standard of care in dieuretic resistant

ascites
 MANAGEMENT

SURGICAL CARE
LEE VEEN SHUNT:
It is a peritoneovenous shunt
Alternative for medically intractable ascites
Improves Cardiac Out Put, renal Blood Flow,
Glomerular Filtration Rate, Urinary Volume, And
Sodium Excretion And Decreased Plasma Renin
Activity And Plasma Aldosterone Concentration
Doesnt Improve Patients Survival So With The
Advent Of Tips Its Becoming Obsolete
 COMPLICATIONS

THE MOST COMMON COMPLICATION

IS:

SBP (Spontaneous Bacterial Peritonitis)

 COMPLICATIONS

SBP
Most common bacteria is E. Coli.Bacteria are believed to gain access to
peritoneum by hematogenous route.
Low ascitic fluid albumin (<1g/dl) predisposes SBP
Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Rebound
Tenderness.
Ascitic Fluid analysis shows wbcs >500/mm3l and Eutrophil>250/mm3
Third generation Cephalosporins 2g tid started empirically for 5 days till
c/s report is available.
Recurrence is common. Ciprofloxacin 750 mg once weekly can be given
prophylacticaly.
 MCQs

Q. No 1
IF SAAG IS >1.1 THEN THE CAUSE
WOULD BE ALL EXCEPT:
PORTAL HYPERTENSION
MYXEDEMA
NEPHROTIC SYNDROME
TUBERCULOUS PERITONITIS
 MCQs

Q. No 2
THE MOST EFFICACIOUS TREATMENT
FOR REFRACTORY ASCITES IS
MAXIMUM DOSE OF DIEURETICS
THERAPEUTIC PARACENTESIS
TIPS
LEE VEEN SHUNT
 MCQs

Q. No 3
SBP IS MORE LIKELY WHEN
WBCS >250/microL
NEUTROPHILS>250/microL
LYMPHOCYTES>500/microL
ALL OF THE ABOVE