liver ascites
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1
MOST PATIENTS HAVE CIRRHOSIS
ASCITES
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Hepatocellular carcinoma
When to suspect?Sudden development of ascites in a stable cirrhotic patient
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Constrictive pericarditis
TuberculosisOne of the few curable causes of ascites
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Tuberculous peritonitis
Very important causeCurable
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Peritoneal carcinomatosis
Protein rich fluid by tumor cells lining the peritoneum ECF enters the peritoneal cavity to maintain
oncotic balance
Tuberculosis Also causes production of protein rich fluid
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Sister Mary Joseph's nodule
Hard periumbilical noduleMetastatic disease
Pelvic or gastrointestinal primary tumor
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Virchow's node
Supraclavicular adenopathy
GI malignancy
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IVC blockage
Large veins Back
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Portal hypertension
First pathogenetic abnormality in ascites formation in cirrhosis
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Obstruction of hepatic lymphatics
Cause exudation of hepatic lymph from the surface
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Increased hepatic lymph
Normal physiologyLymph produced in the hepatic
sinusoids To systemic circulation by the thoracic duct
When sinusoidal pressures riseLymph spills over from the surface of
the liver to the peritoneal cavity
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PATHOGENESIS OF ASCITES
Splanchnic vasodilatation Chief factor contributing to ascites
Increased hydrostatic pressure within the splanchnic capillary bed
Exudation of lymph from the surface of the cirrhotic liver
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Kidneys
Increased sodium and water reabsorption
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Hypoalbuminemia
Reduced plasma oncotic pressure
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PRECIPITATING FACTORS
1. Excessive salt intake2. Failure to take drugs3. Peritoneal infection4. Worsening of liver disease5. Hepatocellular carcinoma6. Portal vein thrombosis
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USS
Best test to detect even small amount of ascites
Can detect as little as 100 mL of fluid
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Morrison’s pouch
Earliest fluid collection Hepato-renal pouch POD
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More than 500 to 1000 mL
Shifting dullness Fluid thrill
Not very useful
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No flank dullness
Ascites unlikely
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Paracentesis
Final confirmation of ascitesBest method for diagnosing the cause
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Routine tests on ascitic fluid
1. Cell count2. Albumin3. Total protein
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Optional
4. Culture5. Glucose6. Gram’s stain7. Amylase8. Cytology
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Cell count
Single most helpful ascitic fluid test
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WBC count
Uncomplicated cirrhotic ascites < 500 WBCs/mm3 in
Absolute neutrophil count < 250/mm3 in uncomplicated cirrhotic ascitic
fluid Empiric antibiotic treatment
Based on absolute neutrophil count rather than the culture
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Spontaneous bacterial peritonitis
Most common cause of an elevated ascitic WBC count PMN > 70% of the total WBC count
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Elevated ascitic WBC count – other causes
1. Tuberculous peritonitis2. Peritoneal carcinomatosisPredominance of lymphocytes
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SAAG
Serum ascites albumin gradient Serum albumin in g/dL minus ascites albumin in
g/dL
To differentiate cirrhotic ascites from other causes of ascites Better than total protein content in the ascitic
fluid
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High SAAG (> 1.1 g/dL)
Uncomplicated cirrhotic ascitesSerum albumin concentration
At least 1 g/dL higher than that of the ascitic fluid albumin concentration.
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SAAG - indirect but accurate index of portal pressure
1.1 g/dL or morePortal hypertension
Accuracy 97%< 1.1 g/dL
No portal hypertension Accuracy 97%
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Accuracy > 97%
Even withAscitic fluid infectionDiuresisParacentesis IV albuminVarying causes of liver disease
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High SAAG
Does not confirm cirrhosisIndicates portal hypertension
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Typical of cirrhosis
1. SAAG >1.1 g/dL2. WBC count < 500 cells/mm3
3. Predominant lymphocytes4. Specific gravity less than 1016
5. Urine Na low
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High gradient (transudative) ascites
Right heart failureAnother common cause
Nephrotic syndrome
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HIGH GRADIENT ≥1.1 g/DL
Cardiac TR Constrictive pericarditis
Alcoholic hepatitisMassive liver metastasesFulminant hepatic failureBudd-Chiari syndromePortal vein thrombosisMyxedemaMeigs' syndrome
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LOW GRADIENT <1.1 g/DL
Peritonitis TB, Bacterial
Peritoneal carcinomatosisPancreatic ascitesBowel obstruction or infarctionBiliary ascitesPostoperative lymphatic leakSerositis in connective tissue diseases
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Blood-stained ascitic fluid
Traumatic tapFrequently clots
Tuberculous peritonitisHepatoma Peritoneal secondaries
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Peritonitis
Bacterial Polymorphonuclear cells predominate Gram's stain may be positive
TB Predominant lymphocytes Diagnosis
Granulomas on peritoneal biopsy AFB
Difficult to recover from ascitic fluid May take 4 to 6 weeks
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CHYLOUS ASCITES
Lymphatic obstruction Trauma Tumor TB Filariasis
Cirrhosis Nephrotic syndrome Congenital abnormalities
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Salt restriction
Most important treatment of cirrhotic ascites
Normal diet contains 5 to 15 grams of sodium chloride
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Spironolactone plus furosemide produce a diuresis in most patients
If sodium restriction alone does not cause diuresis and weight loss
Spironolactone Drug of choice
Furosemide Risk of excessive diuresisHypokalemia
Precipitate encephalopathy
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Fluid intake
Restricted only if there is dilutional hyponatremiaHigh levels of antidiuretic
hormone Diagnosis
Serum sodium < 130 mEq/L in the presence of ascites
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Large-volume paracentesis
Treatment of choice for large-volume ascites
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LARGE VOLUME PARACENTESIS
Tense ascitesRespiratory distressPoor response to medical therapy
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Hepatorenal syndrome
Renal failureProfound vasoconstriction in the
renal circulation Due to excessive activity of endogenous vasoactive substances
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Hemodynamic hallmark
Systemic vasodilationRenal vasoconstriction
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Clinical hallmarks
Worsening azotemiaHyponatremiaProgressive oliguriaHypotension
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Treatment
Vasoconstrictor drugsNorepinephrine, midodrine,
terlipressin or alpha-adrenergic agents
In combination with albumin
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Liver transplantation
Most effective treatment for hepatorenal syndrome
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SBP
No obvious primary source of infection
Contrast-enhanced CTTo exclude an intra-abdominal source for infection
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Cefotaxime and an aminoglycoside
90 %Monomicrobial
Enteric GNB
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What is the diagnosis
A 30-year-old male is admitted with mild abdominal swelling, fever, and loss of weight. Ascitic fluid shows the following changes. Macroscopic appearance - hemorrhagic. Proteins = 3 grams/dl. SAAG = < 1.1 g/dl. Cells = WBCs in plenty. 70% of cells are lymphocytes. Few mesothelial cells are also present. He occasionally takes alcohol. What is the most probable diagnosis?
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Answer
TB Predominant lymphocytes
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