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Questions
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Evidence
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Topic
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 hydrostatic 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

Please rate topic.

Average 4.8 of 6 Ratings

Questions (1)

(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:
1

Alcoholic cirrhosis

50%

(2/4)

2

Cryptogenic cirrhosis

0%

(0/4)

3

Heart failure

25%

(1/4)

4

Pancreatitis

25%

(1/4)

5

Vascular occlusion

0%

(0/4)

M 10 E

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Evidence (5)
EXPERT COMMENTS (19)
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