DESCRIPTION

• Pathologic accumulation of serous fluid in the peritoneal cavity
• Portal hypertension (>12 mm Hg) starts fluid retention.
• Avid sodium retention state
• Retained sodium and water increases plasma volume.
• Water excretion becomes impaired.
• Increased release of antidiuretic hormone (ADH)
• Urinary sodium retention, increased total body sodium, and dilutional hyponatremia
• Degree of hyponatremia correlates with disease severity; prognostic factor.
• Decreased plasma oncotic pressure from hypoalbuminemia
• Peritoneal irritation owing to infection, inflammation, or malignancy

ETIOLOGY

• Parenchymal liver disease:
  • Cirrhosis and alcoholic hepatitis:
    • 80% of adult patients
  • Fulminant hepatic failure
• Hepatic congestion:
  • CHF
  • Constrictive pericarditis
  • Veno-occlusive disease and Budd–Chiari syndrome
• Malignancies:
  • Peritoneal carcinomatosis
  • Hepatocellular carcinoma or metastatic disease
• Infections:
  • TB, fungal, or bacterial peritonitis
• Hypoalbuminemic states:
  • Nephrotic syndrome
  • Malnutrition; albumin < 2.0 g/dL
• Other conditions:
  • Pancreatic ascites
  • Biliary ascites
  • Nephrogenous ascites
  • Ovarian tumors
  • Chylous ascites from lymphatic leak
  • Connective tissue disease
  • Myxedema
  • Granulomatous peritonitis

Pediatric Considerations

Most pediatric cases owing to:

• Malignancy (Burkitt lymphoma, rhabdomyosarcoma)
• Nephrotic syndrome
• Malnutrition

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

• Abdominal distention, discomfort
• Weight gain; sometimes weight loss
• Dyspnea
• Orthopnea
• Edema
• Abdominal hernias
• Muscle wasting
• Shifting dullness, flank fullness, fluid wave, puddle sign
• Signs and symptoms of underlying disease
• Stigmata of chronic liver disease

History

• Risk factors for liver disease
• Description of onset of symptoms:
  • Distinguishes ascites from obesity
  • Patients less tolerant of rapid accumulation of ascitic fluid
• New-onset ascites in known cirrhotic signifies 1 of the following:
  • Progressive liver disease
  • Superimposed acute liver injury (alcohol, viral hepatitis)
  • Hepatocellular carcinoma

Physical Exam

• Detection difficult in obese patients
• Flank dullness is a prominent physical finding:
  • 500 mL for flank dullness
  • Fluid wave
  • Shifting dullness

ESSENTIAL WORKUP

• Search for liver disease, CHF, TB, malignancy, and other systemic disorders.
• Abdominal paracentesis:
  • Necessary for:
    • New ascites
    • Worsening encephalopathy
    • Fever
    • Abdominal pain/tenderness
• Determine if fluid infected or presence of portal hypertension
• Test ascitic fluid for:
  • Cell count and differential:
    • Most helpful to determine infection quickly
    • Order on every specimen
  • Albumin
  • Protein
  • Gram stain
  • Culture twice in blood culture bottles with 10 mL of fluid
  • Lactate dehydrogenase (LDH)
  • Glucose
  • TB culture
  • Amylase
  • Triglyceride
  • Cytology
  • Bilirubin
  • Carcinoembryonic antigen
• Spontaneous bacterial peritonitis (SBP):
  • Ascitic fluid infection without an intra-abdominal surgically treatable source
  • Fever, abdominal pain/tenderness, altered mentation
  • Polymorphonuclear neutrophils (PMNs) > 250 cells/mm³
  • Ascitic fluid protein < 1 g/dL
  • Low concentration of opsonins
• Secondary bacterial peritonitis:
  • Bacterial peritonitis from a surgically treatable intra-abdominal source
  • Gut perforation or intra-abdominal abscess (i.e., perinephric abscess)
  • PMNs > 250 cells/mm³ with multiple micro-organisms on Gram stain + 2 of the following found with secondary bacterial peritonitis:
    • Total protein > 1 g/dL
    • Glucose < 50 mg/dL
    • LDH greater than the upper limit of normal for serum

DIAGNOSIS TESTS & INTERPRETATION

Lab

• CBC
• Basic chemistry
• LFTs
• PT, PTT, INR
• Arterial blood gas (ABG) or pulse oximeter
• Urinalysis
• Urine sodium
• Hepatitis panel
• Amylase/lipase
• α-fetoprotein
• TSH

Imaging

• US:
  • Confirm ascites, especially if < 500 mL
  • Evaluate liver, pancreas, spleen, and ovaries
  • Guides paracentesis
• Doppler study: Evaluate hepatic blood flow
• CT scan
• CXR: CHF, effusions, cavitary, or mass lesion
• ECG

Diagnostic Procedures/Surgery

• Peritoneoscopy: Ascites of unknown cause; especially TB
• Paracentesis:
  • Clinical diagnosis of SBP without paracentesis is inadequate.
  • Safety of paracentesis:
    • 70% of ascitic patients have coagulopathy.
    • Benefits of a diagnostic paracentesis outweigh the risks.
    • Paracentesis is still indicated unless disseminated intravascular coagulation (DIC) is present.
    • Transfusion of plasma or platelets prior to paracentesis is not supported.

DIFFERENTIAL DIAGNOSIS

• 1 of the 5 "F" causes of abdominal swelling:
  • Fluid (including cysts)
  • Fat
  • Flatus
  • Fetus
  • Feces
  • Other: Organomegaly
• Serum-ascites albumin gradient (SAAG) = serum albumin – ascitic albumin:
  • Replaced ascitic fluid total protein in the differential diagnosis of ascites
  • SAAG ≥1.1 g/dL:
    • 97% accurate in predicting portal hypertension
    • Cirrhosis
    • Alcoholic hepatitis
    • Cardiac
    • Liver metastases
    • Fulminant hepatic failure
    • Portal vein thrombosis
    • Veno-occlusive disease
    • Myxedema
    • Budd—Chiari
    • Fatty liver of pregnancy
    • SBP
  • SAAG < 1.1 g/dL:
    • Peritoneal carcinomatosis
    • TB
    • Pancreatic ascites
    • Nephrotic syndrome
    • Bowel obstruction or infarction
    • Vasculitis
    • Postoperative lymphatic leak

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

Symptomatic hypotension:

• Airway, breathing, circulation (ABCs), IV 0.9 NS

INITIAL STABILIZATION/THERAPY

Sudden increase in abdominal girth, pain, or fever requires urgent evaluation for possible complicating factor such as:

• Infection
• Hepatoma
• Obstruction of hepatic outflow
• Decompensated liver function

ED TREATMENT/PROCEDURES

• Successful treatment depends on accurate diagnosis of underlying cause.
• Treat underlying cause.
• Minimize ascitic fluid and peripheral edema without causing intravascular volume depletion.
• Early detection of complications is necessary:
  • SBP:
    • High degree of suspicion
    • Low threshold for paracentesis
    • Prompt therapy
  • Tense ascites and hydrothorax:
    • Supplemental oxygen
    • Therapeutic paracentesis or thoracentesis for respiratory distress
  • Abdominal hernias:
    • Watch for incarceration, ulceration, or rupture.
    • Therapeutic paracentesis
    • Surgical consultation
  • Persistent leak at paracentesis site:
    • Remove more fluid.
    • Stomal barrier device
  • Meralgia paresthetica:
    • Owing to pressure on the lateral femoral cutaneous nerve
    • Relieve the pressure by paracentesis or diuresis.
• Large-volume paracentesis:
  • 5–10 L (100 mL/kg)
  • Performed safely in the ED with stable hemodynamics
  • Consider replacement with IV albumin (5–10 g/L fluid removed) if > 5 L removed.
  • Monitor the patient for 8 hr prior to discharge.
• Nonparacentesis reduction of ascites:
  • Strict sodium restriction:
    • < 2 g/day
    • Restrict water if serum sodium < 120–125 mEq/L
  • Spironolactone:
    • Works best for cirrhotic ascites
    • Alternatives: Amiloride or triamterene
  • Furosemide:
    • Works best for other causes of ascites
    • Add to spironolactone in cirrhotics at spironolactone/furosemide ratio of 100 mg/40 mg.
    • Add metolazone for less responsive cases.
  • Diuretic principles:
    • Administer diuretics as single morning dose.
    • Obtain spot-urine sodium to evaluate response.
    • Patients with urinary Na > 10 mEq/L are more responsive to diuretics.
    • Diuretic-induced weight loss should not exceed 2 lb/day in patients without edema and 5 lb/day in patients with edema.
    • Monitor electrolytes and renal function.
    • Avoid hypokalemia since hypokalemia enhances renal ammonia production, precipitating hepatic encephalopathy.
  • Refractory ascites:
    • Accounts for 10% of patients
    • Ensure compliance with diet and medications.
    • Treated with peritoneovenous shunt—transjugular intrahepatic portosystemic shunt
    • Liver transplantation
  • Avoid NSAIDs:
    • Diminish response to diuretics
    • Decrease renal plasma flow and GFR.
    • Cause sodium retention/reduces urinary Na excretion
  • Treat underlying cause of ascites owing to conditions other than cirrhosis:
    • TB, CHF

MEDICATION

First Line

• Albumin: 5–10 g/L of fluid removed if > 5 L removed
• Cefotaxime: 2 g IV q8h
• Spironolactone: 100–400 mg/d (peds: 1–6 mg/kg) PO in 2 divided doses per day
• Furosemide: 40–160 mg/d (peds: 1–3 mg/kg) PO

Second Line

• Amiloride: 5–20 mg/d PO
• Metolazone: 5 mg/d
• Triamterene: 100–300 mg/d PO in 2 divided doses per day

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Fulminant liver failure
• Hepatic encephalopathy
• SBP
• Hepatorenal syndrome
• GI bleeding
• Tense ascites not responding to ED treatment

Discharge Criteria

Patients responding to ED management

FOLLOW-UP RECOMMENDATIONS

• GI for all new cases
• Primary doctor or GI for previously established cases

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• New cases need full workup and GI consultation for management.
• SBP symptoms are frequently vague.
• Must have a high suspicion and low threshold for paracentesis when considering SBP
• Benefits of confirming SBP outweigh risks of bleeding in a coagulopathic patient undergoing paracentesis.
• US guidance is helpful when performing paracentesis in lower-volume ascites.

ICD9

• 789.5 Ascites
• 789.51 Malignant ascites
• 789.59 Other ascites

ICD10

• R18 Ascites
• R18.0 Malignant ascites
• R18.8 Other ascites

[Outline]

• ICD9
• ICD10

• Feldman M. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, PA: WB Saunders; 2010.
• Runyon BA; AASLD Practice Guidelines Committee. Management of Adult Patients with Ascites Due to Cirrhosis: An update. Hepatology. 2009; 49:2087–2107.
• Runyon B, Such J. Initial Therapy of Ascites in Patients with Cirrhosis. UpToDate, 2012.
• Corey K, Friedman L. Harrison's Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012.

See Also (Topic, Algorithm, Electronic Media Element)

Cirrhosis

Paul J. Allegretti

Keri Robertson