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Physicians's Approach to Ascites

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Physicians's Approach to Ascites Physicians's Approach to Ascites Dr. Gautam Bhandari Senior Consultant Physician Manidhari Hospital Jodhpur (Rajasthan) Dr. Shreyans D. Singhvi Smt. N.H.L Municipal Medical College, Ahmedabad Preksha T. Singh Smt. N.H.L Municipal Medical College, Ahmedabad ! Ascites word derived from Greek word 'Askitos' meaning bladder or bag ! Ascites is pathologic accumulation of fluid within peritoneal cavity Causes of Ascites Cause Percentage (%) Cirrhosis (with or without peritoneal infection) 85 Miscellaneous portal hypertension–related disorders 8 (including 5% with two causes) Cardiac disease 3 Peritoneal carcinomatosis 2 Miscellaneous non-portal hypertension–related disorders 2 ! But according to Indian Studies Cirrhosis is seen in 60.7% and there is higher incidence of non-hepatic causes. Causes of Ascites with Normal Peritoneum 1. Hepatic congestion 2. Liver disease Heart failure Cirrhosis Constrictive pericarditis Alcoholic hepatitis Tricuspid insufficiency Fulminant hepatic failure Budd-Chiari syndrome Massive hepatic metastases Veno-occlusive disease Hepatic fibrosis Acute fatty liver of pregnancy Causes of Ascites with Normal Peritoneum 3. Portal vein occlusion Hypoalbuminemina (SAAG < 1.1 g/dL) Miscellaneous conditions (SAAG < 1.1 g/dL) Nephrotic syndrome Chylous ascites Protein-losing enteropathy Pancreatic Ascites Bile Ascites Nephrogenic Ascites Urine Ascites Myxedema (SAAG ≥ 1.1 h/dL) Ovarian disease Diseased Peritoneum (SAAG < 1.1 g/dL)2 Infections Malignant conditions Other conditions •Bacterial peritonitis • Peritoneal carcinomatosis • Famillial Mediterranean •Tuberculous peritonitis fever • Primary mesothelioma •Fungal peritonitis • Vasculitis • Pseudomyxoma peritonei •HIV-associated peritonitis • Massive hepatic metastases • Garanulomatous • Hypatocellular carcinoma peritonitis • Eosinophilic peritonitis History ! History related to Alcohol, Injection-drug abuse, behaviour, jaundice, blood trunfusions, Accupuncture, tattos, ear piercing is vital for liver related diseases ! History related to malignancies of Breast, lung, colon and Pancreas i.e. massive weight loss or any lump. ! History related to Cardiac failure and renal diseases. Physical Examination ! Ascites (Fluid) need to be differentiate from Flatus, Fat, Fetus, Feces and Fatal Growth. ! Examine position of umbilicus. ! Ascites can be detected by : – shifting dullness (> 1500 ml) – Puddle's sign – Abdominal Ultrasound (> 100 ml) ! Look for the signs of liver failure like palmar erythema, spider Angioma, Gyneacomastia, Muscle wastings. ! Elevated JVP suggest Right sided Heart failure or constrictive pericarditis ! Large Tender liver suggest Ac. Alcoholic Hepatitis or Budd Chiari syndrome ! For Anasarca look for cardiac failure or Nephrotic syndrome ! Presence of large prominent Abdominal veins with cephalic flow suggest Portal Hypertension. ! Firm lymph node in Lt Supraclavicular region suggest intraabdominal Malignancy ! Spleenomegaly with other signs favour PHT ! Nodular liver suggest cirrhosis or malignancy ! Sister Marry Joseph Nodules suggest Peritoneal Carcinomatosis Abdominal Paracentesis ! Most Rapid, Bed side and cost effective method for establishing etiology of Ascites ! Paracentesis may be – – Diagnostic – Therapeutic Patient Position and Choice of Needle and Entry Site ! Large volume Ascites and thin Abdominal wall – supine position, preferably Left lower quadrant between umbilicus and Ant Superior iliac Spine. ! Lesser fluid – Lateral decubitus position (midline or Right or Left lower quadrant. ! Minimal fluid – with Ultrasound guidance Ascitic Fluid Analysis Gross Appearance ! Colour and opacity depends on the protein/Lipid concentration and Neutrophil counts. ! Routinely Ascitic fluid must be sent for : – Albumin – Total proteins – Cell Counts ! Serum albumin must be measured simultaneously ! If infection is Suspected, Gram Staining and culture are needed. Table : Ascitic Fluid Laboratory Tests (based upon cost effective analysis) Routine Optional Unusual Unhelpful • Cell count • Amylase • Bilirubin • Cholesterol • Albumin • Culture in blood • Cytology • Fibronectin • Total culture bottles • TB smear, culture, • Lactate protein • Glucose and PCR test • pH • Gram stain • TG • LDH LDH - lactate dehydrogenase; PCR - polymerase chain reaction; TB - tuberculosis; TG - triglyceride HCC – hepatocellular carcinoma; SBP – spontaneous bacterial peritonitis TB – tuberculosis Serum Ascites–Albumin Gradient SAAG ! SAAG helps to differentiate Ascites caused by PHT from Non- PHT ! SAAG = S. Albumin – Ascitic fluid Albumin ! SAAG is based on Oncotic Hydrostatic pressure and does not very with Diuretic therapy. ! SAAG > 1.1 gm/dL reflects the presence of PHT and indicates that Ascites is due to increased pressure in Hepatic Sinusoids. ! SAAG < 1.1 gm/dL indicates that Ascites is NOT related to PHT Table : Classification of Ascites by the Serum- Ascites Albumin Gradient High gradient ≥1.1 g/dL (11 g/L) Low gradient <1.1 g/dL (11 g/L) • Alcoholic hepatitis • Biliary ascites • Budd–Chiari syndrome • Bowel obstruction or infarction • Cardiac ascites • Nephrotic syndrome • Cirrhosis • Fatty liver of pregnancy • Pancreatic ascites • Fulminant hepatic failure • Peritoneal carcinomatosis • Massive liver metastases • Postoperative lymphatic leak • “Mixed” ascites • Serositis in connective tissue diseases • Myxedema • Portal vein thrombosis • Tuberculous peritonitis • Sinusoidal obstruction syndrome Ascitic Fluid Proteins ! For high SAAG Ascitic fluid protein can further give clue to etiology of Ascites. ! An Ascitic fluid protein level of > 2.5 gm/dL indicates that Hepatic Sinusoids are Normal and are allowing passage of Proteins into Ascitic fluid ! An Ascitic fluid protein of < 2.5 gm/dL indicate that Hepatic Sinusoids have been damaged an scarred and no longer allow passage of proteins. Aigorithm for the Diagnosis of Ascites according to the Serum-Ascites Albumin Gradient (SAAG) Cell Counts PMN – polymorphonuclear neutrophils SBP – spontaneous bacterial peritonitis WBC – White blood cell Other Parameters in Ascitic Fluid Examination ! Adenosine Deaminase levels when elevated (> 45 units/litre). Suggest tubercular cause with 90% sensitivity Tubercular Ascites is important common cause of Ascitic in India. ! Glucose concentration of Ascitic fluid is similar to that of serum, but in cases of secondary Bacterial Peritonitis or late SBP Glucose concentration of Ascitic fluid drop very low or zero. ! LDH of Ascitic fluid in uncomplicated cirrtiotic Ascites is Half of S-LDH levels; but Ascitic fluid LDH rises both in Sec. Bacterial Peritonitis and late SBP. Other Parameters in Ascitic Fluid Examination ! Amylase of Ascitic fluid is half of S. Amylase But in case of Acute Pancreatitis and intestinal perforation, Ascitic fluid Amylase in markedly elevated (> 2000 units/litre) ! Cytologic Exam – Useful to defect malignancy esp. in cases of peritoneal carcinomatosis. ! Triglyceride levels of Ascitic are measured when it is milky in appearance, elevated levels suggest Chylous Ascites (> 200 mg/dL) ! Bilurubin measured when Ascitic fluid in dark brown (> 6 mg/ dL), Increased levels suggest biliary or Proximal Small Intestinal perforation into Ascitic fluid. SBP v/s Secondary Bacterial Peritonitis Conclusion ! Paracentesis and Calculation of SAAG differentiates Portal Hypertensive causes of Ascites from others. ! Among the High Gradient Ascites (SAAG > 1.1 gm/lit) Cardiac and liver related causes are important. ! Low gradient Ascites (SAAG < 1.1 gm/lit) is commonly caused by tuberculosis and peritoneal carcinomatosis. ! A systemic approach is mandatory to reach correct diagnosis for cause of Ascites.
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