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