Diagnosis and Treatment of Ascites

Diagnosis and Treatment of Ascites

1. Diagnosis and Treatment of Ascites
Clinical practice guidelines 2015
Mohamed El Sayed Sarhan (M.Sc)
Assistant lecturer of Internal Medicine
Tanta University Hospital
[email protected]

3. Ascitesmeanspathologicfluidcollectionwithin
theabdominalcavity.
80%hepaticcauses.
Thedevelopmentofascitesisassociatedwitha
poorprognosisandimpairedqualityoflifein
patientswithcirrhosis.

4. The International Ascites Club

5. 3majorpathophysiologiceventsleadingto
ascites:
•Increasedhydrostaticpressure.
•Increasedcapillarypermeability.
•Decreasedprotein/albumin.

7. Causes
Cirrhosis
ALD
Chronic Hep.C,B
NASH
Cryptogenic
Nephrotic syndrome
Hypoalbuminemia
Infections
Tuberculous peritonitis
Bacterial
Fungal
HIV associated
Malignancies
•Liver
•Breast
•Ovary
•Pancreas
•Colon
•Mesothelioma
•Pseudomyxoma peritonei

8. Cirrhosis
Heart failure
Peritoneal tuberculosis
Cirrhosis is the Most Common Cause of Ascites
Others
Pancreatic
Budd-Chiarisyndrome
Nephrogenicascites
Peritoneal malignancy
85%

9. About85%ofpatientswithasciteshavecirrhosis,Past
historyofcancer,heartfailure,orTB.
Symptoms:
◦Abdominaldistension:
Painlessorwithabdominaldiscomfort
Courseofdays(eg,bloodyascitesduetotrauma)or
months(eg,malignantascites)

10. ◦Weightgain,shortnessofbreath,earlysatiety,
anddyspneaduetofluidaccumulationand
increasedabdominalpressure.
◦Spontaneousbacterialperitonitisfever,
abdominaltenderness,andalteredmental
status.

11. Approximately 1.5 L must be present before flank
dullness is detected.
Shifting dullness & fluid thrill mean that more fluid
is present.
Pleural effusion ??
Firmlymphnodesintheleftsupraclavicular
regionorumbilicusmaysuggestintra-abdominal
malignancy

14. Inpatientswithnew-onsetascites,Asciticfluid
sampleshouldbesentforcellcount,albumin
level,culture,totalprotein,Gramstain,and
cytology.

15. Diagnostic paracentesis
Indications
1.Diagnostictap
2.Newonsetascitesorattimeofhospitalization
3.To detect the presence of cancerous cells
4.Suspectedspontaneousorsecondarybacterialperitonitis

16. Contraindications
Absolutecontraindication
Acuteabdomenthatrequiressurgery.
Relativecontraindications
Severethrombocytopenia(plateletcount<20X103/μL),
coagulopathy.
Pregnancy.
Distendedurinarybladder.
Abdominalwallcellulitis.

17. Ascitic fluid sample
Inspection:
Mostasciticfluidistransparentandtinged
yellowBlood-tingedfluid.Thismayresultfrom
eitheratraumatictapormalignancy.
Bloodyfluidfromatraumatictapis
heterogeneouslybloody,nontraumaticbloodyfluid
ishomogeneouslyred.(Rupteredhepatoma)?
CTwithcontrast.

18. Cloudy ascitic fluid with a purulent consistency
indicates infection.
Green bilious, or deep jaundice/ upper GI
perforation
White Chylous

19. Cell count:
APMNcountofgreaterthan250cells/µL
ishighlysuggestiveofbacterialperitonitis
(neutrocyticascites)eitherprimaryor
secondarybacterialperitonitis.
Intuberculousperitonitisandperitoneal
carcinomatosis,lymphocytesusually
predominate.

20. Chylous ascites
Turbid,milky,orcreamyperitonealfluidduetothe
presenceofthoracicorintestinallymph.
ShowsstainingfatglobuleswithSudanblack
Opaquemilkyfluidusuallyhasatriglyceride
concentrationof>1000mg/dL.

21. Chylous ascites
Is most often the result of lymphatic obstruction
from ;
Trauma / surgeries
Tumor
Tuberculosis
Filariasis
Congenital abnormalities
Nephrotic syndrome

22. SAAG
Serum Ascites Albumin Gradient

23. The SAAG is the best single test for
classifying ascites into portal hypertensive
(SAAG >1.1 g/dL) and non –portal
hypertensive (SAAG < 1.1 g/dL) causes.
The accuracyof the SAAG results is
approximately97% in classifying ascites.
Calculatedby substractingthe ascitic fluid
albumin from serum albumin.
Albumin
Serum –Albumin
Ascites
(g/dL) (g/dL)
in the same day

27. Culture: has a 92% sensitivity
Gram stain:
( Both Gram+ve&-vestaining in peritonitis due to
prforatedviscus)
Cytology:
Cytology smears are reported to be 58-75%
sensitive for detection of malignant ascites.

29. Recommendations
Adiagnosticparacentesisshouldbeperformed
inallpatientswithnewonsetgrade2or3
ascites,andinallpatientshospitalizedfor
worseningofascitesoranycomplicationof
cirrhosis(LevelA1).

30. Recommendations
Itisimportanttomeasureascitictotalprotein
concentration,sincepatientswithanascitic
proteinconcentrationoflessthan15g/Lhave
anincreasedriskofdevelopingspontaneous
bacterialperitonitis(LevelA1)andmaybenefit
fromantibioticprophylaxis(LevelA1).

31. Recommendations
Measurementoftheserum–ascitesalbumin
gradientmaybeusefulwhenthediagnosisof
cirrhosisisnotclinicallyevidentorinpatients
withcirrhosisinwhomacauseofascites
differentthancirrhosisissuspected(LevelA2).

32. Radiological features
Abdominalultrasoundisusefulinconfirming
thepresenceofascitesandintheguidanceof
paracentesis.
BothultrasoundandCTimagingareusefulin
distinguishingbetweencausesofportaland
nonportalhypertensiveascites.
DopplerultrasoundandCTcandetect
thrombosisofthehepaticveins(Budd-Chiari
syndrome)orportalveins.

33. Radiological features
Ascites
Liver

34. Laparoscopy
Laparoscopyisanimportanttestinthe
evaluationofsomepatientswithnonportal
hypertensiveascites(lowSAAG)ormixed
ascites.
Itpermitsdirectvisualizationandbiopsyofthe
peritoneum,liver,andsomeintra-abdominal
lymphnodes.
Casesofsuspectedperitonealtuberculosisor
suspectedmalignancywithnondiagnosticCT
imagingandasciticfluidcytologyarebest
evaluatedbythismethod.

35. Ascites: Treatment
Goals:
◦Minimize ascitic volume and peripheral edema
◦Avoid intravascular volume depletion
Benefits:
◦Patient comfort
◦Reduced risk of hernia formation
◦Possible reduction in SBP
◦Improve nutrition

36. Management of uncomplicated ascites
Patientswithcirrhosisandascitesareathigh
riskforothercomplicationsofliverdisease,
including:
1.Refractoryascites,
2.SBP,
3.Hepatorenalsyndrome(HRS).
Theabsenceoftheseascites-related
complicationsqualifiesascitesasuncomplicated.

37. Patientswithmoderateascitescanbe
treatedasoutpatientsanddonot
requirehospitalizationunlessthey
haveothercomplicationsofcirrhosis.

38. Treatment of high SAAG ascites
1-Medical
A) Diet.
B) Diuretics.
C)Therapeutic paracentesis
2-Surgical
TIPS
Liver transplantation
Peritoneovenous shunting

39. Recommendations
Sincethedevelopmentofgrade2or3
ascitesinpatientswithcirrhosisisassociated
withreducedsurvival,livertransplantation
shouldbeconsideredasapotentialtreatment
option(LevelB1).

40. Recommendations
Moderate restriction of salt intake is an
important component of the management of
ascites (intake of sodium of 80–120 mmol/day,
which corresponds to 4.6–6.9 g of salt/day)
(Level B1).
This is generally equivalent to a no added salt
diet with avoidance of pre-prepared meals.
Many low –sodium foods are now available.

41. Recommendations
Thereisinsufficientevidencetorecommendforced
bedrestaspartofthetreatmentofascites.There
arenodatatosupporttheuseoffluidrestriction
inpatientswithasciteswithnormalserum
sodiumconcentration(LevelB1). AASLD
Fluidrestrictionisnotnecessaryunlessserumsodium
islessthan120-125mmol/L.)

42. Recommendations
Therearenodatatosupportthe
prophylacticuseofsaltrestrictionin
patientswhohaveneverhadascites.

43. Siteofactionofdiuretics.
1=loopdiuretics:frusemide(furosemide),
bumetamide.
2=distaltubule/collectingduct:spironolactone,
amiloride,triamterene.
Spironolactone
Furosemide

44. Recommendations
Patientswiththefirstepisodeofgrade2
(moderate)ascitesshouldreceivean
aldosteroneantagonist(thediureticsof
choiceinmanagementofascites)suchas
spironolactonealone,startingat100mg/day
andincreasingstepwiseevery7days(in100mg
steps)toamaximumof400mg/dayifthereis
noresponse(LevelA1).

45. Recommendations
Inpatientswhodonotrespondtoaldosterone
antagonists,asdefinedbyareductionofbody
weightoflessthan2kg/week,orinpatients
whodevelophyperkalemia,furosemideshould
beaddedatanincreasingstepwisedosefrom
40mg/daytoamaximumof160mg/day(in40
mgsteps)(LevelA1).

46. Recommendations
Patientswithrecurrentascitesshouldbe
treatedwithacombinationofan
aldosteroneantagonistplusfurosemide,
thedoseofwhichshouldbeincreased
sequentiallyaccordingtoresponse,as
explainedbefore(LevelA1).

47. Recommendations
Themaximumrecommendedweightloss
duringdiuretictherapyshouldbe0.5
kg/dayinpatientswithoutedemaand
1kg/dayinpatientswithedema
(LevelA1).

48. Recommendations
Thegoaloflong-termtreatmentistomaintain
patientsfreeofasciteswiththeminimumdose
ofdiuretics.Thus,oncetheasciteshaslargely
resolved,thedoseofdiureticsshouldbe
reducedanddiscontinuedlater,whenever
possible(LevelB1).

49. Recommendations
Alldiureticsshouldbediscontinuedif
thereis
1.Severehyponatremia(serumsodium
concentration<120mmol/L),
2.Progressiverenalfailure,
3.Worseninghepaticencephalopathy,
4.Incapacitatingmusclecramps
(LevelB1).

50. Recommendations
Furosemideshouldbestoppedifthereissevere
hypokalemia(<3mmol/L).
Aldosteroneantagonistsshouldbestoppedif
patientsdevelopseverehyperkalemia(serum
potassium>6mmol/L)(LevelB1).

51. Recommendations
Diureticsaregenerallycontraindicatedin
patientswithoverthepaticencephalopathy
(LevelB1).
Gynaecomastiaiscommonwiththeuseof
aldosteroneantagonists,butitdoesnotusually
requirediscontinuationoftreatment.

52. Forpatientswho experience
spironolactonesideeffects(e.g.,
Hyperuricemia,Hyperkalemia&painful
gynecomastia),amiloridemaybegivenat
10mgperday.
Thiazidesinhibitsodiuminthedistalconvolutedtubule,havealonger
half-life,maycausehypotension,andshouldnotbeusedinthe
treatmentofascites.

53. Grade 3 or large ascites

54. Tapping ascitic fluid (1672)
German National Museum, Nürnberg, Germany

55. Therapeutic paracentesis
Tenseasciteswithpainmay
leadtoeversionand
ulcerationofanumbilical
hernia,whichisnearto
rupture.Thiscomplication
hasaveryhighmortality,
duetoshock,renalfailure
andsepsis,andurgent
paracentesisisindicated.

56. LVPshouldbeperformedunderstrictsterile
conditionsusingdisposablesterilematerials.
Itisgenerallyagreedthatthereareno
contraindicationstoLVPotherthanloculated
ascites,HemorrhagiccomplicationsafterLVP
areinfrequent.
Inonestudy,whichalsoincludedpatientswith
INR>1.5andplateletcount<50,000/µl,only
twopatientsexperiencedminorcutaneous
bleedingsoutof142paracenteses.

57. Recommendations
Large-volumeparacentesis(LVP)isthe
first-linetherapyinpatientswithlarge
ascites(grade3ascites)(LevelA1).

58. Recommendations
LVPshouldbeperformedtogetherwiththe
administrationofalbumin(8g/Lofasciticfluid
removed)topreventcirculatorydysfunction
afterLVP(LevelA1).

59. Givendirectlyordilutedwithisotonicsolutions
(e.g5%glucose,0.9%sodiumchloride)
Notmixedwithwaterforinjectionor
componentofTPN
Sideeffects:fever,skinrash,flushing,nausea
anddyspnea
50mlsolution20%=10gmofhumanalbumin.
50mlsolution10%=5gmofhumanalbumin.
Pregnancy:Thesafetynotbeenestablishedin
clinicaltrials,Howeverclinicalexperience
suggestnoharmfuleffectonthemotherorthe
fetus.

60. Albumin in cirrhotic ascites
Large paracentesis > 5 L
8 g albumin/liter of ascites removed
SBP with renal impairement
First six hours1.5 g albumin / kg bw
Day 3 1g albumin / kg bw
HRS-I
First day 1 g / kg bw (maximum 100 g)
Following days20 –40 g / day

61. Recommendations
InpatientsundergoingLVPofgreaterthan5L
ofascites,theuseofplasmaexpandersother
thanalbuminisnotrecommendedbecausethey
arelesseffectiveinthepreventionofpost-
paracentesiscirculatorydysfunction(LevelA1).
Dextran
Hessteril
Paracentesis not more than 4Ls
( 150 ml/L of ascites removed )
show similar efficacy similar to
albumin

62. Recommendations
AfterLVP,patientsshouldreceivetheminimum
doseofdiureticsnecessarytopreventthe
re-accumulationofascites(LevelA1).

63. Inacontrolledtrial,seriallarge-volume
paracenteses(LVP)reducedhospitalstay
comparedwithstandarddiuretic
treatment.
However,readmissionstohospital,
survivalandcausesofdeathdidnotdiffer
signifi-cantlybetweentheLVPand
diureticgroups.

64. Theuseofterlipressin
(Glypressin)(e.g,1mgevery4
hoursfor48hours)rather
thanalbuminhasbeen
proposedforpreventionof
circulatorydysfunctionafter
large-volume paracentesis.
Initialstudiessuggestthat
terlipressinisaseffectiveas
albuminforthispurpose

65. Fresh frozen plasma ?

66. Therearenodatatosupporttheuseoffresh
frozenplasmaorpooledplateletsbeforeLVP,yet
inmanycenterstheseproductsaregivenifthere
isseverecoagulopathy(prothrombinactivityless
than40%)and/orthrombocytopenia(lessthan
40,000).

67. Evaluation of patients with refractory ascites
AccordingtothecriteriaoftheInternational
AscitesClub,refractoryascitesisdefinedas
‘‘ascitesthatcannotbemobilizedortheearly
recurrenceofwhich(i.e.,afterLVP)cannotbe
preventedbymedicaltherapy”.

68. Etiology Treatment
Lack of salt
restriction(poor
compliance)
Adequate salt restriction
Severe hypoalbuminemiaIValbumin
Hyponatremia Fluid restriction
Terminalcases Liver transplant,TIPS,PVS
SBP IV antibiotics(cefotaximeis
the drug of choice until C&S
is available ) for 10-14 days.
Albumine;1.5gm/kg day one
1gm/kg in day3

69. Hepatic
vein
Portal vein
Splenic
vein
Superior mesenteric
vein
TIPS
THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
TIPS
Consider TIPS in carefully selected
patients
Require > three LVP/month
Loculated ascites
Childs-Pugh score <12

70. TIPS
Interventionalradiologist
places a stent
percutaneouslyfromthe
rightjugularveinintothe
hepaticvein,thereby
creatingaconnection
betweentheportaland
systemiccirculations.
TIPSisgraduallybecoming
thestandardofcarein
patientswithdiuretic-
refractoryascites.
TIPS made with PTFE-covered stents between portal
and right hepatic veins.

71. Benefits:
◦Reduce portal pressure
◦Rapid reduction or elimination of ascites
◦Reduction or cessation of diuretic therapy
◦Improve renal function
◦Improve nutritional status
TIPS

72. TheAASLDsuggestsconsideringperitoneovenous
shuntingforpatientswithrefractoryasciteswhoare
notcandidatesforparacentesisortransplantorTIPS.

73. Recommendations
TIPSshouldbeconsideredinpatientswithvery
frequentrequirementoflarge-volume
paracentesis,orinthoseinwhomparacentesis
isineffective(e.g.duetothepresenceof
loculatedascites)(LevelB1).

74. Recommendations
ResolutionofascitesafterTIPSisslowand
mostpatientsrequirecontinuedadministration
ofdiureticsandsaltrestriction(LevelB1).

75. Recommendations
TIPS cannot be recommended in patients with
1.Severe liver failure (serum bilirubin >5 mg/dl,
INR >2 or Child-Pugh score >11,
2.Current hepatic encephalopathy or chronic
hepatic encephalopathy), concomitant active
infection,
3.Progressive renal failure,
4.Severe cardiopulmonary diseases
(Level B1).

76. Recommendations
InselectedpatientsTIPSmaybehelpful
forrecurrentsymptomatichepatic
hydrothorax(LevelB2).
The diagnosis of hepatic hydrothorax can
be established by radionuclide scanning
of the chest after the intraperitoneal
injection of Tc -99m -labelled sulphur
colloid or macroaggregated serum
albumin.( Presence of radiotracer in the
pleural space)

78. Drugs
contraindicated in
patients with
ascites

79. Non-steroidalanti-inflammatorydrugs
(NSAIDs)arecontraindicatedinpatientswith
ascitesbecauseofthehighriskofdeveloping
furthersodiumretention,hyponatremia,and
renalfailure(LevelA1).

80. Preliminarydatashowthatshort-term
administrationofselectiveinhibitorsof
cyclooxygenase-2doesnotimpairrenal
functionandtheresponsetodiuretics.
However,furtherstudiesareneededtoconfirm
thesafetyofthesedrugs

81. Drugsthatdecreasearterialpressureorrenal
bloodflowsuchasACE-inhibitors,
angiotensinIIantagonists,ora1-
adrenergicreceptorblockersshould
generallynotbeusedinpatientswithascites
becauseofincreasedriskofrenalimpairment
(LevelA1).

82. The use of aminoglycosidesis associated with
an increased risk of renal failure. Thus, their use
should be reserved for patients with bacterial
infections that cannot be treated with other
antibiotics (Level A1).

83. Inpatientswithasciteswithoutrenalfailure,the
useofcontrastmediadoesnotappeartobe
associatedwithanincreasedriskofrenal
impairment(LevelB1).
Contrastmediashouldbeusedwithcaution
andtheuseofgeneralpreventivemeasuresof
renalimpairmentisrecommended(LevelC1).

84. SBPisblood-borneandin90%monomicrobial.
Bacteriaofgutoriginarethemostcommonly
isolatedcausativeorganisms.
Therefore,migrationofentericbacteriaacross
theintestinalmucosatoextraintestinalsitesand
thesystemiccirculation(bacterial
translocation)
Highlights on SBP

85. Highlights on SBP

86. Highlights on SBP
Complicates ascites , doesnot
cause it (occurs in 10% of
cirrhotics)
1/3 of patients are
asymptomaticso do not
hesitate to do diagnostic
paracentesis
Fever,chills,abdominal pain ,
ileus, hypotnsion, worsening
encephalopathy
E.Coliis the most common
pathogen
(Gm-ve70%)
IV antibiotics(cefotaximeis
the drug of choice until C&S
is available 2gm i.vevery 8-12
hours or ceftriaxone1-2gm
every 24 hours ) for 10-14
days(Decontamination of
gut)&decrease mortality rate
Prophylaxis with daily
Norfloxacinfor5/7 days
may decrease frequency
of recurrent SBP
Untreated SBP Mortality
rate more than 80%
Albumine;1.5gm/kg day one
1gm/kg in day3

87. Recommendations
Spontaneousbacterialpleuralempyema
maycomplicatehepatichydrothorax.The
diagnosisisbasedonpositivepleuralfluid
cultureandincreasedneutrophilcountof
>250/mm3ornegativepleuralfluidcultureand
>500neutrophils/mm3intheabsenceof
pneumonia(LevelB1).

88. Recommendations
Patientswithsuspectedsecondarybacterial
peritonitisshouldundergoappropriate
radiologicalinvestigationsuchasCTscanning
(LevelA1).

89. Recommendations
Recommendations.Empiricalantibioticsshould
bestartedimmediatelyfollowingthediagnosis
ofSBP(LevelA1).
Sincethemostcommoncausativeorganismsof
SBPareGram-negativeaerobicbacteria,suchas
E.coli,thefirstlineantibiotictreatmentare
third-generationcephalosporins(LevelA1).

90. Recommendations
Alternative options include
amoxycillin/clavulanicacidandquinolonessuch
asciprofloxacinorofloxacin.However,theuse
ofquinolonesshouldnotbeconsideredin
patientswhoaretakingthesedrugsfor
prophylaxisagainstSBP.(LevelB1).

91. Recommendations
ResolutionofSBPshouldbeprovenby
demonstratingadecreaseofasciticneutrophil
countto<250/mm3andsterileculturesof
asciticfluid,ifpositiveatdiagnosis(LevelA1).
Asecondparacentesisafter48hofstartof
treatmentmayhelpguidetheeffectofantibiotic
therapy.

92. Recommendations
All patients who develop SBP should be
treated with broad spectrum antibiotics
and intravenous albumin (Level A2).

93. Recommendations
PatientswhorecoverfromanepisodeofSBP
haveahighriskofdevelopingrecurrentSBP.
Inthesepatients,theadministrationof
prophylacticantibioticsreducestheriskof
recurrentSBP.Norfloxacin(400mg/day,orally)
isthetreatmentofchoice(LevelA1).
Alternativeantibioticsincludeciprofloxacin
(750mgonceweekly,orally)orco-trimoxazole
(800mgsulfamethoxazoleand160mg
trimethoprimdaily,orally),butevidenceisnot
asstrongasthatwithnorfloxacin(LevelA2).

94. Recommendations
Inpatientswithgastrointestinalbleedingand
severeliverdiseaseceftriaxoneisthe
prophylacticantibioticofchoice.(Level
A1).

97. Treatmentinitiallyiswithdrawalof
diureticsandnephrotoxins,followedby
salineand/oralbumininfusion.
Vasoactiveagents,octreotide,midodrine,
andvasopressin,aswellasTIPShavebeen
usedwithsomeencouragingresultsin
largelyuncontrolledstudiesandliver
transplantationistheonlydefinitivecure

98. Take home message
Ascitesisthemostcommondecompensating
eventincirrhosis
Itspathophysiologyismostlyexplainedby
splanchnicandperipheralvasodilatationthat
leadtoadecreaseineffectivebloodvolume.

99. Mostpatientsrespondtodiuretics.Patients
whonolongerrespondshouldbetreatedwith
repeatedlarge-volumeparacenteses.
Transjugularintrahepaticportosystemicshunt
(TIPS)shouldbeconsideredinthoserequiring
frequentparacenteses.
Take home message

100. Fluidrestrictionisrecommendedinpatients
withhyponatraemia.Vasoconstrictorsmay
reversehepatorenalsyndromeandareusefulas
abridgetolivertransplantation.
Take home message

101. Ascitesperseisnotlethalunlessitbecomes
infected(spontaneousbacterialperitonitis).
Infectionoftenprecipitatesthehepatorenal
syndromeleadingtodeath.
Antibioticprophylaxisisindicatedforsecondary
preventionofspontaneousbacterialperitonitis
andinhigh-riskpatients.
Take home message

103. Vasoconstrictors in HRS: doses
used and adverse events