Approach to Ascites

Investigations and Management

Causes

Liver Cirrhotic portal HTN (84%) Rare Bile

non-
Chyle
Com TB Liver
mon Blood
non- Cancer
Urine
liver
Carcinomatosis Kidney

Non-hepatic causes of portal

Pancreatic
hypertension
Thyroid
Baseline Investigations
• CBC • 2D-echo: if indicated; ?cardiac aetiology of
– Inflammation: TC/DC, anaemia (normocytic?), reactive fluid; portopulmonary hypertension/heart
thrombocytosis vs reactive thrombocytopaenia
failure
– Liver disease: low platelets
– Hypersplenism: bi-/pancytopaenia • ECG
– Varices: Hb drop → bleeding? • Chest X-ray
• LFTs + GGT
• Distant cultures: blood, urine; if applicable:
• Viral hepatitis workup respiratory, pus
• PT/INR, aPTT
• RFTs/electrolytes: evaluation of renal involvement
(HRS?), baseline Cr and Na
Abdominal Imaging
• Ultrasound ± portal venous Doppler
– Fluid locations, loculations/septations, local collections, echoes
– Organ assessment: liver, spleen, kidney
– Flow in hepatic veins, portal vein, superior mesenteric/splenic veins
– Any collaterals?
– ±Fibroscan for monitoring of liver stiffness/attenuation parameter
• CECT abdomen—triple phase
– Clear visualisation of vascular flow and collaterals if any
– Pancreas
– Masses and nodes
Ascitic Fluid Aspiration
• Indications: • Contraindications:
– Diagnostic: – Absolute:
• New-onset ascites • Severe coagulopathy
• Ascites due to uncertain cause • Bowel distention (eg, 2° to intestinal obstruction)
• New onset constitutional symptoms in a patient • Abdominal skin infections
known to have ascites – Relative:
– Therapeutic: • Puncture site scars
• Alleviation of symptoms caused by • Large intrabdominal mass
– Tense ascites • Extensive abdominal wall venous engorgement
– Refractory ascites
– CTP grade B/C
Ascitic Fluid Aspiration
• Routine evaluation:
– Inspection
– Total count/differential count
– Ascitic fluid total protein
– Ascitic fluid albumin
– Culture/sensitivity (bedside inoculum)
– Cytology
• Secondary labs:
– Amylase: pancreatic ascites
– MTB AFB/Xpert ± mycobacterial culture
– Bilirubin concentration: biliary peritonitis
– Triglycerides: chylous ascites
Ascitic Fluid: Appearance
Gross Appearance Interpretation
Straw-coloured Normal
Turbid Infected
Milky/creamy with layering effect when chilled Chylous ascites
Dilute milky appearance with loss of colour on addition Pseudochylous ascites
of glacial acetic acid/ethylether

Blood clots/fibrin strands Traumatic tap

Pinkish/reddish appearance without clots Blood-stained fluid
Tea-coloured/very deeply coloured Pancreatic ascites
Greenish-brown fluid Biliary peritonitis
Serum-Ascites
Albumin Gradient High SAAG >1.1 Low SAAG <1.1
g/dl g/dl

• SAAG = [serum albumin] – [ascitic

albumin] High protein >2.5 Low protein <2.5 High protein >2.5 Low protein <2.5
g/dl g/dl g/dl g/dl
• Low SAAG: <1.1 g/dl
• High SAAG: >1.1 g/dl—high
Sn/NPV for elevated portal pressure Cirrhosis
Cardiac ascites Infection Nephrotic
Late Budd-Chiari syndrome
• Corrected SAAG if s. globulin >5 Early Budd-Chiari Massive liver mets Inflammation
Severe protein-
IVC obstruction Cancer
g/dl: 0.16 × measured SAAG × Amyloidosis losing enteropathy
Portal vein Blood dyscrasias Non-cirrhotic Protein-energy
(globulin + 2.5) thrombosis chylous ascites malnutrition
Cell Count and Culture
Monomicrobial Secondary
Spontaneous Bacterial Culture-Negative Polymicrobial
Criterion Non-Neutrocytic Bacterial
Peritonitis Neutrocytic Ascites Bacteriascites
Bacteriascites Peritonitis
Culture Monomicrobial Monomicrobial Negative Polymicrobial Polymicrobial
Polymorph Count
>250 <250 >500 <250 >250
(cells/mm3)

Evidence of No; antibiotic NOT

No; antibiotic
intrabdominal No given; NO reason for Yes Yes
given
infection? high counts

Risk factors: prev. h/o

SBP, asc. protein <1 g/dl, SBP in
Considerations UGI bleed, advanced CLD, resolution, Perforation? Perforation?
PPIs, UTI, s. TB >2.5 Treated SBP?
mg/dl
Management of Ascites
• Dietary: • Beta-blockers: nonselective > selective
– Initial salt restriction <2 g/day (<88 mEq/day) – Among nonselective blockers, carvedilol >
• May be adjusted based on urinary sodium excretion (intake to
match output)
propranolol
– Fluid restriction: to match output; further restriction only if – Midodrine: adjunct to maintain blood pressure
significant hyponatraemia (<120 mEq/l) while beta-blockers and diuretics decongest
• Diuresis splanchnic circulation
– Normokalaemic ratio of spironolactone-furosemide 100 • Monitor RFTs/electrolytes
mg:40 mg (eg, 50/20 mg BD)
– Monitor weight and abdominal girth; aim 0.5 kg/day loss or • Manage underlying condition
1 cm/day loss
– Contraindications: development of pre-renal injury,
encephalopathy, hyponatraemia, drastic drop in BP
Refractory Ascites
• Ascites not remitting despite maximum tolerated doses of diuretics
• Management: plan for liver transplantation
• Bridging management:
– Serial therapeutic paracentesis under albumin cover
• Albumin: dose 6-8 g per removed litre of fluid if removing >4 litres
– Transjugular intrahepatic portosystemic stent-shunt (TIPSS) procedure