Ascites, also called hydroperitoneum or dropsy of the peritoneum, is the accumulation of serous fluids in the space between the tissues and organs of the abdominal (peritoneal) cavity. It can be a sign of serious health problems. It is often associated with cirrhosis or hepatitis, but may occur due to constrictive pericarditis, congestive heart failure, liver and ovarian cancer, pancreatitis, nephrotic syndrome, protein-losing enteropathy or portal vein thrombosis. The fluids can build up enough to cause pain and shortness of breath due to pressure on the diaphram.
The Serum-ascities albumin gradient (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for classifying ascites.A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive etiology.
Causes of high SAAG ("transudate") are:
- Cirrhosis - 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%)
- Heart failure - 3%
- Budd-Chiari syndrome or veno-occlusive disease
- Constrictive pericarditis
Causes of low SAAG ("exudate") are:
- Cancer (primary peritoneal carcinomatosis and metastasis) - 10%
- Tuberculosis - 2%
- Pancreatitis - 1%
- Nephrotic syndrome
Among patients with cirrhosis, 5% will have an additional etiology present. The most common second etiologies are spontaneous bacterial peritonitis, tuberculous peritonitis, and malignancy. Among patients who have malignancy, most have abnormal imaging.
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Ascitic fluid analysis
The serum-ascites albumin gradient (SAAG) is usually above 1.1 g/dl; however, even lower values usually are due to portal hypertension.
Testing for tuberculosis
Among patients with ascites, some patients will have underlying tuberculosis. will have an additional etiology present. The most common second etiologies are spontaneous bacterial peritonitis, tuberculous peritonitis, and malignancy. Some of these patients will have a positive purified protein derivative (PPD) test.
Among patients with ascites, some patients will have underlying malignancy. will have an additional etiology present. The most common second etiologies are spontaneous bacterial peritonitis, tuberculous peritonitis, and malignancy. Most patients with malignancy will have abnormal imaging.
In patients with mild ascites, therapy is usually as an outpatient. The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema and no more than 0.5 kg/day for patients with ascites alone. In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis.
Salt restriction is the initial treatment, which allows diuresis (production of urine) since the patient now has more fluid than salt concentration. Salt restriction is effective in about 15% of patients.
Since salt restriction is important in treatment, and aldosterone is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be beneficial. Spironolactone (or other distal-tubule diuretics such as triamterene or amiloride) block the aldosterone receptor in the collecting tubule. Their benefit was shown in a randomized controlled trial.
Diuretics for ascites should be dosed once per day. Generally, the starting dose is oral spironolactone 100 mg/day (max 400 mg/day). 40% of patients will respond to spironolactone. For nonresponders, a loop diuretic may also be added and generally, furosemide is added at a dose of 40 mg/day (max 160 mg/day), or alternatively (bumetanide or torasemide). The ratio of 100:40 reduces risks of potassium imbalance. Serum potassium level and renal function should be monitored closely while on these medications.
A preliminary randomized controlled trial suggests that hypertonic saline solution combined with high-dose furosemide may be an effective alternative to repeated paracentesis for hospitalized patients.
- Monitoring diuresis
Diuresis can be monitored by weighing the patient daily. The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema and no more than 0.5 kg/day for patients with ascites alone. If daily weights cannot be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs. A random urine sodium-to-potassium ratio of > 1 is 90% sensitive in predicting negative balance (> 78-mmol/day sodium excretion).
- Diuretic resistance
Diuretic resistance can be predicted by giving 80 mg intravenous furosemide after 3 days without diuretics and on an 80 mEq sodium/day diet. The urinary sodium excretion over 8 hours < 50 mEq/8 hours predicts resistance.
Water restriction is needed if hyponatremia < 130 mmol per liter develops.
In those with severe (tense) ascites, therapeutic paracentesis may be needed in addition to medical treatments listed above. As this may deplete serum albumin levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed.
In patients with resistant ascites, shunts mayhelp. Options are portacaval shunt, peritoneovenous shunt, and the transjugular intrahepatic portosystemic shunt (TIPSS). However, none of these shunts has been shown to extend life expectancy.
Ascites that is refractory to medical therapy is considered an indication for liver transplantation. In the United States, the MELD Score (online calculator) is used to prioritize patients for transplantation.
Spontaneous bacterial peritonitis
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