3. ASCITES part 1.pdf

This is lecture notes for 5th sem MBBS students. Introduction to ascites. Includes causes , pathophysiology and approach to a patient with ascites

1. Hepatology lectures for
5
th
Sem;MBBS
Pratap Sagar Tiwari
MBBS,MD (Medicine),DM (Hepatology)

2. Summary
? Predisposing
conditions
Etiologies
Liver Fibrosis/cirrhosis
Portal Hypertension
VaricesSplenomegalyAscites
Normal Liver

3. PORTAL HYPERTENSION
Ascites1
2
3
Causes
4 Management
Approach

4. DEFINITION: ASCITES
H/o VH
VH prevention measures
for pts with a known
H/o VH
Secondary Prophylaxis
•Ascitesisthepathologicalaccumulationoffluidwithin
theperitonealcavity.
Theperitonealcavitynormallycontainsapproximately50–75mlsof
fluidthatservestolubricatethetissuesthatlinetheabdominalwall
andviscera.1,2
1.RumackC,WilsonS,CharboneauJ,etal.Diagnosticultrasound,4thedStLouis,MO:Mosby,
2011.
2.HanbidgeA,LynchD,WilsonS.USoftheperitoneum.Radiographics2003;23:663–685.
Pleural fluid: 10-20 ml
Pericardial fluid: 15-50 ml

5. CAUSES OF ASCITES
Causesofascitescanbecategorizedonbasisofseveralaspectslike
•etiology(infection,malignancy),
•pathophysiology(portalhypertension-related,non-PHTNrelated),
•organ/systemspecific(cirrhotic,cardiac,renal)
•others(exudativevstransudative:(protein < 25 g/L))
Howeverthecommoncausesofascitesare;

6. CAUSES OF ASCITES
Common Causes Less Common causes
Cirrhosis -84 % •Massive hepatic metastasis
Cardiac causes •Infection (tuberculosis, chlamydia
infection)
Peritoneal carcinomatosis •Pancreatitis
•Primary peritoneal malignancies-
mesothelioma and sarcoma
•Abdominal malignancies-gastric or colonic
adenocarcinoma
•Metastatic disease from breast or lung
carcinoma
•Melanoma
•Renal disease

7. RARE CAUSES OF ASCITES
Rare Causes
•Hypothyroidism
•Familial mediterraneanfever
•Collagen vascular disease
•Amyloidosis
•Fitz-hugh-Curtis syndrome
•Protein-loosing enteropathy, malnutrition
•Trauma (Bile ascites, urine ascites), Chylous ascites

8. PATHOPHYSIOLOGY
Portal hypertension-related Non-portal hypertension related
Exudation
Lymphatic
obstruction
Hypoalbuminemia
Transudation
PATHOPHYSIOLOGY

9. PATHOPHYSIOLOGY
Normally;
•Theperitoneumbehaveslikea
semipermeablemembranethatenablesthe
continuousexchangeofwaterandsolutes
betweentheperitonealcavityandthe
intraperitonealbloodandlymphvessels.
PATHOPHYSIOLOGY

10. PATHOPHYSIOLOGY
Non-portal hypertension related
Exudation
Lymphatic
obstruction
Hypoalbuminemia
Any causes leading to
hypoalbuminema
Protein-loosing enteropathy
Malnutrition
Nephrotic syndrome
•Albumincomprises75-80%ofnormalplasmacolloidoncoticpressureand50%of
proteincontent.
•Whenplasmaproteins,especiallyalbumin,nolongersustainsufficientcolloid
osmoticpressuretocounterbalancehydrostaticpressure,edema/ascites
develops.
PATHOPHYSIOLOGY

11. PATHOPHYSIOLOGY IN ASCITES: due to Portal HTN

12. APPROACH
✓Smallamountsofascitesareasymptomatic,butwithlargeraccumulationsoffluid(>
1L)thereisabdominaldistension,fullnessintheflanks,shiftingdullnesson
percussionand,whentheascitesismarked,afluidthrill/fluidwave.
✓Otherfeaturesincludeeversionoftheumbilicus,herniae,abdominalstriae,
divaricationoftherectiandscrotaloedema.
✓Dilatedsuperficialabdominalveinsmaybeseeniftheascitesisduetoportal
hypertension.
HISTORY EXAMINATION INVESTIGATION

13. Approach to Ascites
History
Examination
Investigation
•Bowelobstruction,severeconstipationandileus-inabilityto
passstoolandflatustogetherwithnausea/vomiting
•Weightloss,nightsweatsandanorexia
•↑eructationorflatus-aerophagiaor↑intestinalproduction
ofgas
•Symptomsofothermedicalconditions-heartfailureandtb
•Questionaboutriskfactorslikeexcessivealcoholuse,ivdrug
abuse,chronicviralinfectionandjaundice
APPROACH TO ASCITES

14. Approach to Ascites
History
Examination
Investigation
Clues for Cardiac disease
•Elevated JVP
•Kussmaul’ssign
•Pericardial knock
•Murmur of TR
APPROACH TO ASCITES

15. Approach to Ascites
History
Examination
Investigation
Clues for Chronic liver disease
•Pt is sarcopenic with distended abdomen
•Peripheral signs of CLD
Jaundice ,Parotid swelling, Gynaecomastiain males,
Breast atrophy in females, Loss of axillary hairs,
Spider naevi, Caput medusae, Testicular atrophy,
palmar erythema, Dupytrenscontracture,
Leuconychia
APPROACH TO ASCITES

16. Approach to Ascites
History
Examination
Investigation
Abdomen Examination
•Inspection: generalized distention (localized incase
of loculated ascites or mass), bulging flanks,
distended superficial veins, everted umbilicus and
umbilical nodule may be seen in malignancy
•Grey-Turner's or Cullen's sign can be present in case
of Acute Pancreatitis
APPROACH TO ASCITES

17. Approach to Ascites
History
Examination
Investigation
Abdomen Examination
•Palpation: tenderness, guarding( peritonitis)
,enlarged liver or splenomegaly
•Percussion: Shifting dullness, fluid thrill
APPROACH TO ASCITES

18. INSPECTION
•Asymptomatic
•Abdominal distension
•fullness in the flanks
Shifting dullness on percussion, a fluid thrill/fluid wave.
•Eversion of the umbilicus
•Hernia
•Abdominal striae
•Divarication of the recti
•Scrotal oedema
Other features include
*Dilated superficial abdominal veins may be seen if the ascites is due to portal hypertension.
PERCUSSION
SUMMARY

19. Approach to Ascites
History
Examination
Investigation
Imaging, egUSG
Ascites fluid
Evaluation
Others; like ECHO

20. ➢IMAGING: ULTRASOUND & CT SCAN

21. ASCITES FLUID EVALUATION
•Appearance
•SAAG ?
•Exudative ascites ? SBP ?
•Others
Why SAAG ?
Thepresenceofagradient≥1.1g/dLindicatesthatthepthasPHTN-relatedasciteswith
96%accuracy.
ASAAG<1.1g/dLindicatesthattheptdoesnothavePHTN-relatedascites,andanother
causeoftheascitesshouldbesought.

22. SAAG (SERUM ASCITES ALBUMIN GRADIENT)

23. OTHERS; ASCITES EVALUATION
➢Pancreatic ascites: Ascitic amylase > 1000 mg/dl
➢Cytology
➢Tuberculous peritonitis:
•lymphocytosis and ADA> 40 U/L
•Ascitic fluid AFB smear: sensitivity 0-3 %
•Ascitic fluid culture: sensitivity 35-50 %
•Elevated ADA: sensitivity >90% (cutoff value 35-40 U/L)
LaparatomyorLaparascopywithbiopsy-goldstandardifcauseisuncertain

24. OTHERS; LABORATORY EVALUATION
➢Serumamylaseandlipase-toruleoutpancreatitis
➢24hr.urinaryprotein-nephroticsyndrome
➢Malabsorptionandincreasedsmallintestinalbacterialovergrowth-detectionof
hydrogenandmethanegasinexpiredbreath
➢ECHO
➢Hepatic venous pressure gradient
➢Liver biopsy

25. SPONTANOUS BACTERIAL PERITONITIS
Definition:aninfectionofinitiallysterileasciticfluidwithoutadetectableintra-
abdominalsurgicallytreatablesourceofinfection.
Thepresenceofinfectionisdocumentedby
-positiveasciticfluidbacterialculture(essentiallymonomicrobial)&
-anelevatedasciticfluidabsolutePMNcount(>250cells/mm3)
Note;AbsolutePMNcount=totalwhitebloodcellcountX%ofPMN

26. SECONDARY BACTERIAL PERITONITIS

27. TREATMENT
Note: The ascites that recurs at least on three occasions within a 12-month period despite dietary sodium restriction and
adequate diuretic dosage is defined as recidivantascites.
➢Ascites is uncomplicatedwhen it is not infected, refractory or a/with HRS.

28. TREATMENT
➢Sodium and water restriction
➢Diuretics
➢Paracentesis
➢TIPSS
➢Liver Transplantation
➢OTHERS;