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 login to view 1 more bullet decreased colloid osmotic pressure login to view 1 more bullet 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 login to view 5 more bullets may see signs of heart failure login to view 1 more bullet 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 login to view 3 more bullets Studies Serum labs electrolytes creatinine albumin may be low liver function panel may be elevated complete blood count Invasive studies diagnostic paracentesis indications login to view 2 more bullets studies login to view 8 more bullets serum albumin-ascites gradient (SAAG) SAAG = [serum albumin] – [ascites albumin] correlates with portal pressure SAAG > 1.1g/dL login to view 1 more bullet SAAG < 1.1 g/dL login to view 1 more bullet Differential Pregnancy key distinguishing factors no fluid wave or shifting dullness fetus on ultrasound Treatment Lifestyle dietary changes modalities login to view 2 more bullets Medical diuretics indications login to view 2 more bullets modalities login to view 2 more bullets antibiotics indications login to view 1 more bullet albumin indications login to view 1 more bullet Surgical therapeutic paracentesis indication login to view 1 more bullet transjugular intrahepatic portosystemic shunt (TIPS) indication login to view 1 more bullet complications login to view 1 more bullet 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