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Snap Shot
  •  A 65-year-old man presents to the emergency department with worsening abdominal distention. He has a long history of alcohol abuse. On physical exam, shifting dullness and a fluid wave is present. An image of his abdomen is given.
Introduction
  • Peritoneal edema as a result of
    • portal hypertension
    • hypoalbuminemia
Presentation
  • Symptoms
    • abdominal distention
  • Physical exam
    • shifting dullness
    • fluid wave
Evaluation
  • Paracentesis
    • send ascitic fluid for WBC count, gram stain, culture, glucose, protein
  • Serum Albumin Ascites Gradient (SAAG) 
    • SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid)
    • if > 1.1 g/dL) indicates the ascites is due to portal hypertension with 97% accuracy
    • if < 1.1 g/dL indicates causes of ascites not associated with increased portal pressure
Treatment
  • Order of treatment involves
    • salt and water restriction
      • limit to approximately 2 L per day
    • diuretic therapy
      • spironolactone
      • loop diuretic added
    • ascitic fluid taps
      • 2-4 L drained often with albumin infusion during procedure
Prognosis, Prevention, and Complications
  • Complications
    • hepatorenal syndrome
      • severe complication result from over aggressive diuresis or tapping
    • spontaneous bacterial peritonits
      • check peritoneal fluids for infection and treat with broad spectrum antibiotics
      • diagnosis made by > 500 PMNs in the peritoneal fluid
      • glucose is low and protein is high with bacterial peritonitis
    • abdominal hernias
 

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