Updated: 12/11/2021

Ascites

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  • Snapshot
    • A 60-year-old man presents to the emergency room for confusion and abdominal pain and distention. He has a history of alcoholism and alcoholic cirrhosis requiring multiple paracenteses. He has been on the liver transplant list for the past year. His vital signs are 98.4°F (36.9°C), blood pressure is 120/80 mmHg, pulse is 96/min, and respirations are 18/min. On physical exam, his abdominal girth is large, and there is shifting dullness, flank fullness, and a fluid wave.
  • Introduction
    • Overview
      • ascites is the non-physiologic accumulation of fluid in the peritoneum, most commonly secondary to liver disease or malignancy
        • treatment depends on the underlying etiology
    • Associated conditions
      • hepatic hydrothorax
  • Epidemiology
    • Risk factors
      • portal hypertension
        • cirrhosis (most common)
        • alcoholic hepatitis
        • heart failure
        • IVC obstruction
        • Budd-Chiari syndrome
      • malignancy
      • hypoalbuminemia
        • nephrotic syndrome
        • enteropathy
        • malnutrition
      • infections
        • peritoneal tuberculosis
  • ETIOLOGY
    • Pathogenesis
      • mechanism
        • increased hydrostatic pressure causes fluid extravasation into peritoneal space
          • portal hypertension
        • decreased colloid osmotic pressure
          • hypoalbuminemia
        • increased sodium levels
  • Presentation
    • Symptoms
      • common symptoms
        • abdominal pain
        • rapid weight gain
        • early satiety
    • Physical exam
      • inspection
        • distended abdomen
        • peripheral edema
        • may see signs of liver disease
          • spider angiomata
          • palmar erythema
          • gynecomastia
          • hepatomegaly
          • jaundice
        • may see signs of heart failure
          • jugular venous distention
      • motion
        • fluid wave
        • shifting dullness
        • flank dullness
  • Imaging
    • Abdominal ultrasound
      • indication
        • to detect ascites if not clinically apparent
      • findings
        • fluid in peritoneal cavity
        • may identify etiology of ascites
          • signs of liver disease
          • hepatic vein thrombosis
          • tumors
  • Studies
    • Serum labs
      • electrolytes
      • creatinine
      • albumin
        • may be low
      • liver function panel
        • may be elevated
      • complete blood count
    • Invasive studies
      • diagnostic paracentesis
        • indications
          • new-onset ascites
          • to assess for infection
        • studies
          • Gram stain
          • culture
          • glucose
          • lactate dehydrogenase
          • cell count with differential
          • total protein
            • if < 1 g/dL, patient is at risk for spontaneous bacterial peritonitis
          • albumin
      • serum albumin-ascites gradient (SAAG)
        • SAAG = [serum albumin] – [ascites albumin]
        • correlates with portal pressure
        • SAAG > 1.1g/dL
          • portal hypertension with 97% accuracy
        • SAAG < 1.1 g/dL
          • other causes of ascites (see above)
  • Differential
    • Pregnancy
      • key distinguishing factors
        • no fluid wave or shifting dullness
        • fetus on ultrasound
  • Treatment
    • Lifestyle
      • dietary changes
        • modalities
          • water and sodium restriction
          • cessation of alcohol
    • Medical
      • diuretics
        • indications
          • cirrhosis
          • congestive heart failure
        • modalities
          • spironolactone
          • furosemide
      • antibiotics
        • indications
          • suspected spontaneous bacterial peritonitis
      • albumin
        • indications
          • often given if patients undergo large-volume paracentesis (often 6-8 g of albumin per L of fluid removed)
    • Surgical
      • therapeutic paracentesis
        • indication
          • large amounts of ascites causing significant symptoms
      • transjugular intrahepatic portosystemic shunt (TIPS)
        • indication
          • ascites refractory to medical therapy but requiring multiple therapeutic paracenteses
        • complications
          • hepatic encephalopathy
  • Complications
    • Hepatorenal syndrome
      • severe complication resulting from overly aggressive diuresis or tapping
    • Spontaneous bacterial peritonitis
      • check peritoneal fluids for infection and treat with broad-spectrum antibiotics

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(M3.GI.15.35) A 56-year-old woman presents to the emergency department with abdominal swelling. She states that her abdomen has been swelling for the past several months but otherwise offers minimal history and is a poor historian. She thinks it worsened more rapidly last night. Her temperature is 97.0°F (36.1°C), blood pressure is 122/80 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. A bedside ultrasound is performed as seen in Figure A and a sample of the fluid is taken and sent for analysis as seen below.

Fluid sample:
Cell count: < 50 leukocytes/mm^3
Albumin: 4.8 g/dL
Culture: pending
Total protein: 18.0 g/dL
Gram stain: pending

Laboratory values are notable for a serum albumin of 4.0 g/dL. What is the most likely cause of this patient's ascites?

QID: 102565
FIGURES:

Alcoholic cirrhosis

18%

(2/11)

Cryptogenic cirrhosis

27%

(3/11)

Heart failure

18%

(2/11)

Pancreatitis

36%

(4/11)

Vascular occlusion

0%

(0/11)

M 10 E

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Evidence (5)
EXPERT COMMENTS (19)
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