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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
  • 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
  • Pathogenesis
    • mechanism
      • increased osmotic pressure causes fluid extravasation into peritoneal space
        • portal hypertension
      • decreased colloid osmotic pressure
        • hypoalbuminemia
      • increased sodium levels
  • Associated conditions
    • hepatic hydrothorax
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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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.GI.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: 2.0 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?
Review Topic

QID: 102565
FIGURES:
1

Alcoholic cirrhosis

33%

(1/3)

2

Cryptogenic cirrhosis

0%

(0/3)

3

Heart failure

33%

(1/3)

4

Pancreatitis

33%

(1/3)

5

Vascular occlusion

0%

(0/3)

M2

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