Ascites resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Steven Bellm, M.D. [2]

Ascites resident survival guide Microchapters
Overview
Classification/Causes
Diagnosis
Treatment
Do's
Dont's

Overview

Accumulation of fluid within the peritoneal cavity results in ascites. Most important for a successful treatment of ascites is an accurate diagnosis of its cause. Most common causes are portal hypertension, malignancy and heart failure. The diagnosis is made with a combination of physical examination and abdominal imaging. The next step is typically a paracentesis to evaluate the ascitic fluid for causes.

Classification/Causes

Ascites can be classified based on the underlying causes. Common causes are:

Causes

Portal hypertension: ❑  Cirrhosis ❑  Alcoholic hepatitis ❑  Acute liver failure ❑  Hepatic veno-occlusive disease (eg, Budd-Chiari syndrome) ❑  Heart failure ❑  Constrictive pericarditis ❑  Hemodialysis-associated ascites (nephrogenic ascites)

Hypoalbuminemia: ❑  Nephrotic syndrome ❑  Protein-losing enteropathy ❑  Severe malnutrition

Peritoneal disease: ❑  Malignant ascites ❑  Infectious peritonitis ❑  Eosinophilic gastroenteritis ❑  Starch granulomatous peritonitis ❑  Peritoneal dialysis

Other etiologies: ❑  Chylous ascites ❑  Pancreatic ascites (eg, from a disrupted pancreatic duct) ❑  Myxedema ❑  Hemoperitoneum

A grading system for ascites has been proposed by the International Ascites Club: ❑  Grade 1:Mild ascites detectable only by ultrasound examination ❑  Grade 2:Moderate ascites manifested by moderate symmetrical distension of the abdomen ❑  Grade 3:Large or gross ascites with marked abdominal distension

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

History and symptoms: ❑  Hints for etiology (i.e. signs and symptoms for cirrhosis, malignancy)? ❑  Abdominal distension/abdominal discomfort? ❑  Duration and onset of illness/ symptoms? ❑  Severity and triggers? ❑  Weight loss/weight gain/early satiety? ❑  Presence of peripheral edema, anasarca? ❑  Problems with breathing at night/ sleep? ❑  Fever, abdominal tenderness, and altered mental status? ❑  Diarrhea and steatorrhea, malnutrition, nausea, enlarged lymph nodes ❑  Medical history ❑  Prior hospitalizations? ❑  Medication?

Physical examination: ❑  Vital signs: ❑  Pulse (strength and regularity) ❑  Blood pressure ❑  Respiratory rate ❑  General appearance: ❑  BMI(weight loss/weight gain) ❑  Jaundice, muscle wasting, gynecomastia, and leukonychia, lymphadenopathy ❑  Peripheral edema ❑  JVD ❑  Heart: ❑  Murmur ❑  Carotid and peripheral pulses ❑  Lungs: ❑  Rales? ❑  Pleural effusion? ❑  Abdomen: ❑  Hepatomegaly ❑  Pulsatile liver and/or ascites (volume overload) ❑  Flank dullness, shifting dullness, a fluid wave, evidence of pleural effusions ❑  Stigmata of cirrhosis (spider angioma, palmar erythema, and abdominal wall collaterals) ❑  Umbilical nodule that is not bowel or omentum

Laboratory findings: ❑  Complete blood count ❑  Chemistry: ❑  Troponin, BNP or NT-proBNP ❑  Serum electrolytes (including calcium and magnesium) ❑  Kidney function tests: Blood urea nitrogen, serum creatinine, GFR ❑  Liver function tests (including ammonia blood test) ❑  Glucose ❑  Fasting lipid profile, hypoalbuminemia, decreased gamma globulin levels? ❑  Coagulation testing (i.e. INR)

Imaging and additional tests: ❑  Ultrasound with Doppler: ❑  Dilation of the portal vein to ≥13 mm ❑  Dilation of the splenic and superior mesenteric veins to ≥11 mm ❑  Reduction in portal venous blood flow velocity ❑  Splenomegaly (diameter >12 cm), and recanalization of the umbilical vein ❑  Nodular liver, hepatocellular carcinoma? ❑  Consider computed tomographic (CT) ❑  Consider magnetic resonance imaging (MRI) ❑  Consider check for esophageal varices/ hypertensive gastropathy ❑  Paracentesis: ❑  Determining cause and confirming spontaneous bacterial peritonitis

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Treatment

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References