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(Created page with "==Treatment== #Salt restriction ##Effective in about 15% of patients #Diuretics ##Spironolactone ###Starting dose = 100mg/day PO (max 400mg/day) ###40% of patients will respond ...")
 
 
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==Treatment==
==Background==
#Salt restriction
[[File:Scheme body cavities-en.png|thumb|Lateral view showing abdominopelvic cavity.]]
##Effective in about 15% of patients
*Abnormal buildup of peritoneal fluid
#Diuretics
*Most commonly caused by portal hypertension
##Spironolactone
*Ascites fluid can become infected (spontaneous bacterial peritonitis), carrying a mortality rate between 30%-90%<ref>Sundaram V, Manne V, Al-Osaimi AM. Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers. Saudi J Gastroenterol. 2014;20(5):279-287. doi:10.4103/1319-3767.141686</ref>
###Starting dose = 100mg/day PO (max 400mg/day)
###40% of patients will respond
##Furosemide
###40 mg/day PO (max 160 mg/day)
###Ratio of 100:40 with spironolactone (reduces risks of potassium prob)


===Causes===
*[[Cirrhosis]] 81%<ref>Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.</ref>
*Malignancy 10%
*[[Heart failure]] 3%
*[[Tuberculosis]] 2%
*Other 4%


==Clinical Features==
[[File:Hepaticfailure.jpg|thumb||[[Ascites]] secondary to [[cirrhosis]].]]
*[[Abdominal distention]] +/- discomfort
*Fluid wave
*+/- [[SOB]] if massive amount


==Differential Diagnosis==
{{DDX abdominal distention}}
{{Hepatomegaly DDX}}


==Water restriction==
==Evaluation==
==Paracentesis==
[[File:Auscities.png|thumb|Ascites appearance on ultrasound]]
==Liver transplantation==
[[File:Ascites Alerhand.gif|thumbnail|POCUS showing ascites<ref>http://www.thepocusatlas.com/bowel/</ref>]]
{{main|liver transplantation}}
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]]
Ascites that is refractory to medical therapy is considered an indication for [[liver transplantation]]. In the United States, the [[Model for End-Stage Liver Disease|MELD score]] ([http://www.unos.org/resources/meldPeldCalculator.asp online calculator])<ref name="pmid2682175">{{cite journal |author=Cosby RL, Yee B, Schrier RW |title=New classification with prognostic value in cirrhotic patients |journal=Mineral and electrolyte metabolism |volume=15 |issue=5 |pages=261–6 |year=1989 |pmid=2682175 |doi=}}</ref> is used to prioritize patients for transplantation.
''Ascites in females with no other reason for it = gynecologic neoplasm until proven otherwise (ovarian cancer)''


==Shunting==
===Workup===
*CBC
*Chem 7
*PT/PTT
*[[LFTs]] + lipase
*[[FAST]]
 
====Ascites Fluid Workup====
*Cell count and differential
*Albumin
*Total protein
*Only if suspicious:<ref name=Runyon2012>Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.</ref>
**[[Gram stain]]
**Glucose
**LDH
**Amylase
**AFB smear and culture
**Cytology
**Triglyceride
 
{{Ascites Evaluation}}
 
==Management==
*Salt restriction
**Effective in about 15% of patients
*[[Diuretics]]
**[[Spironolactone]]
***Starting dose = 100mg/day PO (max 400mg/day)
***40% of patients will respond
**[[Furosemide]]
***40mg/day PO (max 160mg/day)
***Ratio of 100:40 with spironolactone (reduces risks of potassium prob)
*Water restriction
*[[Paracentesis]]
*Consider liver transplantation and shunting
 
==Disposition==
*Frequently outpatient, once [[SBP]] is ruled out, if a known reason for ascites and sufficiently therapeutically drained
 
==Complications==
*[[SBP]]
*[[Hepatorenal syndrome]]
*[[Pleural effusion]]
 
==See Also==
*[[Jaundice]]
*[[Paracentesis]]
*[[SBP]]
*[[Cirrhosis]]
*[[Acute hepatic failure]]
 
==References==
<references/>
[[Category:GI]]
[[Category:Symptoms]]

Revisión actual - 22:20 7 feb 2024

Background

Lateral view showing abdominopelvic cavity.
  • Abnormal buildup of peritoneal fluid
  • Most commonly caused by portal hypertension
  • Ascites fluid can become infected (spontaneous bacterial peritonitis), carrying a mortality rate between 30%-90%[1]

Causes

Clinical Features

Ascites secondary to cirrhosis.

Differential Diagnosis

Abdominal distention

Hepatic Dysfunction

Infectious

Neoplastic

Metabolic

Biliary

  • Biliary cirrhosis

Drugs

Miscellaneous

Evaluation

Ascites appearance on ultrasound
POCUS showing ascites[4]
Liver cirrhosis with ascites on CT

Ascites in females with no other reason for it = gynecologic neoplasm until proven otherwise (ovarian cancer)

Workup

Ascites Fluid Workup

  • Cell count and differential
  • Albumin
  • Total protein
  • Only if suspicious:[5]
    • Gram stain
    • Glucose
    • LDH
    • Amylase
    • AFB smear and culture
    • Cytology
    • Triglyceride

Ascites Diagnosis

The differential diagnosis of ascites is often clarified by the calculation of the serum albumin to ascites gradient (SAAG).^

^SAAG = (serum albumin in g/dL) − (ascitic albumin in g/dL)

Management

  • Salt restriction
    • Effective in about 15% of patients
  • Diuretics
    • Spironolactone
      • Starting dose = 100mg/day PO (max 400mg/day)
      • 40% of patients will respond
    • Furosemide
      • 40mg/day PO (max 160mg/day)
      • Ratio of 100:40 with spironolactone (reduces risks of potassium prob)
  • Water restriction
  • Paracentesis
  • Consider liver transplantation and shunting

Disposition

  • Frequently outpatient, once SBP is ruled out, if a known reason for ascites and sufficiently therapeutically drained

Complications

See Also

References

  1. ↑ Sundaram V, Manne V, Al-Osaimi AM. Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers. Saudi J Gastroenterol. 2014;20(5):279-287. doi:10.4103/1319-3767.141686
  2. ↑ Runyon BA. Care of patients with ascites. N Eng J Med. 1994; 330: 337-342.
  3. ↑ Tintanelli's
  4. ↑ http://www.thepocusatlas.com/bowel/
  5. ↑ Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
  6. ↑ Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
  7. ↑ Runyon BA. Cardiac ascites: a characterization. J Clin Gastro. 1998; 10(4): 410-412.
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