Complications of ascites

ascites is a major complication of liver cirrhsos but also develops as a squally of other diseases ,ascites may be worsened with other events making it life threatening

1. Complications of ascites
By:-
Sayed hanzal
Ass. lecturer of hepato-gastroenterology
Fayoum university

2. facts
•Ascites develops as acute-on-chronic liver failure
(ACLF), due to a precipitating event, e.g. infection,
upper gastrointestinal bleeding, electrolyte
disturbances
•about 60% of patients with cirrhosis will develop
Ascites within 10 years of diagnosis
•50% mortality within 3 years

3. Complications of ascites
•Infection
•Tense ascites
•Abdominal wall hernias
•Hepatic hydrothorax
•Hepatorenal syndrome
•Dilutional Hyponatremia

5. Types of infection in the ascitic fluid
neutrophlic count < 250 Growth in the culture
✓ One microbe SBP
✘ One microbe

Monomicrobial
bacterascites
✓

No growth Culture-negative
neutrocytic ascites
✓

polymicrobial Secondary bacterial
peritonitis
✘ polymicrobial Polymicrobial bacterascites

6. spontaneous bacterial
peritonitis

7. •(SBP) is an acute bacterial infection of ascitic
fluid. Generally, no source of the infecting agent
is easily identifiable
•All patients with cirrhosis and ascites are at risk
of developing SBP
•Without ttt mortality exceeded 90% but with
early diagnosis treatment mortality has been
reduced to approximately 20%

8. Pathophysiology
•The mechanism for bacterial inoculation is
adebate (may be):-
1.direct transmural migration of bacteria
2.hematogenous transmission in combination
with an impaired immune system

9. factors contributes to peritoneal inflam. and
bacterial growth in ascitic fluid
1)delayed intestinal transit time.
2)Intestinal bacterial overgrowth

3)impaired phagocytic function
4)low serum and ascites complement levels

5)decreased activity of the reticuloendothelial
system

10. Etiology

•E,coli,

•Klebsiella pneumoniae,

•and Pneumococcus organisms

are the most common isolates in SBP

11. Symptoms of SBP
•frequently asymptomatic.
•Diagnosis should be suspected in patients with
worsening of liver function, hepatic
encephalopathy, renal failure and/or
gastrointestinal bleeding
•Symptoms of SBP include abdominal pain, fever
and vomiting.

12. Treatment
•cefotaxime 2 g every 8 hours, for 5 days
•ceftriaxone, amoxicillin-clavulanic acid, and
fluoroquinolones have been used in trials with
seemingly equivalent results.

13. •Patients with serum creatinine greater than
1mg/dL, blood urea nitrogen greater than 30
mg/dL, or total bilirubin greater than 4 mg/dL

14. Prophylaxis
•primary prophylaxis
•low ascitic protein conc.
<1,5 g/dl and severe liver
disease without previous
SBP episodes should be
considered for treatment
with, norfloxacin 400 mg
daily
•secondary prophylaxis
•Oral quinolones and
trimethoprim-
sulfamethoxazole are given
as prophylactic agents after
an initial episode of SBP
because of a reported 1-
year recurrence rate of 69%
in the absence of
prophylaxis.

15. Monomicrobial bacterascites

16. •Monomicrobial bacterascites is defined as the presence of a
positive result from ascitic fluid culture of a single organism with a
concurrent fluid neutrophil count lower than 250 cells per μL.
•One series of patients with bacterascites demonstrated a
predominance of , whereas another
showed flora similar to SBP.
• Because of the high mortality rate of untreated bacterascites (22–
43%), antibiotic treatment is warranted for many patients.
•paracentesis may be repeated for cell count and culture.

17. Culture-negative neutrocytic
ascites

18. •Culture-negative neutrocytic ascites is defined as ascitic fluid with a
neutrophil count higher than or equal to 250 cells per μL with
negative fluid culture results in patients who have received no prior
antibiotics.
•Spontaneously resolving SBP is the likely explanation of culture-
negative neutrocytic ascites;
•however, empirical antibiotics generally are given. A decline in
ascitic neutrophil counts on repeat paracentesis indicates an
appropriate response to therapy.
•If there is no response to antibiotics, cytological analysis and culture
of the ascitic fluid for tuberculosis may be indicated.

19. Secondary bacterial peritonitis

20. •polymicrobial infection with a very high ascitic fluid neutrophil
count from an identified intra-abdominal source such as
appendicitis, diverticulitis, or intra-abdominal abscess.
•usually requires surgical intervention.
•Gut perforation is suspected with two of the following three
criteria:
1) ascitic protein concentration higher than 1 g/dL,
2) glucose level lower than 50 mg/dL,
3) and lactate dehydrogenase level higher than 225 mU/mL.
•In patients with secondary peritonitis but no perforation, repeat
paracentesis 48 h after initiating antibiotic treatment will usually
demonstrate increasing neutrophil counts.

21. Polymicrobial bacterascites

22. •Polymicrobial bacterascites with an ascitic neutrophil
count less than or equal to 250 cells per μL is
suggestive of inadvertent gut perforation by the
paracentesis needle.
•It is usually treated with broad-spectrum antibiotics
that include coverage for anaerobes.
•Alternatively, the decision to treat may be deferred
until the results of a repeat paracentesis are obtained.