Section 9 Section Editor: Jyotirmoy Pal Clinical Medicine 113. Approach to Ascites 119. Anatomic Localization of Classical Neurological Veerendra Singh Symptoms 114. Approach to Acute-on-Chronic Liver Failure Uddalak Chakraborty, Avik Mukherjee, Jyotirmoy Pal Anshuman Elhence, Abhinav Anand, Shalimar 120. Clinical Signs of Diaphragm Dysfunction 115. Approach to a Patient with Chronic Dyspnea of Atanu Chandra, Aritra Kumar Ray, Arkapravo Hati Undetermined Etiology 121. Approach to Chest Pain in Emergency Manish Kumar, Krishna Kumar, DP Singh Partha Sarkar, Adrija Chatterjee 116. “Choice versus Chance”: Mathematics behind 122. Approach to a Case of Anemia Clinical Decision-making Manoj Kumar Srivastava Alladi Mohan, Alladi Vikramchandra 123. Approach to Aphasia 117. Approach to Syncope in Emergency Room Jyotirmoy Pal, Tarun Kumar Paria, Purbasha Biswas, Prasanta Kumar Bhattacharya Manisankar Bhattarcharya 118. Nailing the Diagnosis through Nail Changes Bidita Khandelwal, Pradeep Balasubramanian MU-113 (Sec-9).indd 705 02-02-2021 18:14:12 MU-113 (Sec-9).indd 706 02-02-2021 18:14:12 CHAPTER 113 Approach to Ascites Veerendra Singh Abstract Ascites, the collection of fluid in the peritoneal cavity, can originate from hepatic, malignant, cardiac, renal, and infectious diseases. Cirrhosis, tuberculosis, and malignancy are the most common causes in Indian patients. Ultrasonography and paracentesis with ascetic fluid examination are the modalities used to establish the etiology. Sodium restriction and diuretics are mainstay of treatment of ascites due to cirrhosis. Ascites due to other causes requires specific treatment. For refractory ascites large volume paracentesis along with infusion of albumin is used. Liver transplantation is the gold standard therapy. Despite the advances in modern medicine, development of ascites is associated with poor prognosis and high mortality. Introduction Ascites Due to Cirrhosis Commonly presenting with abdominal swelling, ascites Portal hypertension and renal salt and water retention are is a pathological fluid collection in the peritoneal cavity. the key mechanisms of ascites in cirrhosis. Ascites denotes The common causes of ascites are cirrhosis, tuberculosis, the transition from a compensated to a decompensated malignancy, cardiac failure, pancreatitis, and nephrotic stage of cirrhosis. Initially ascites is uncomplicated, not syndrome. The management depends on the etiology of infected, and responds well to diuretics.1 As disease ascites from hepatic to extrahepatic causes and on the progresses, ascites ceases to respond to diuretics stage of ascites from uncomplicated to refractory stage. (refractory ascites) and renal dysfunction supervenes (hepatorenal syndrome). Causes of Ascites Uncomplicated ascites is subdivided into three grades: Various causes of ascites are shown in Table 1. In India, mild, moderate, and massive ascites. Refractory ascites has 2 cirrhosis of liver is most common cause of ascites followed two subtypes: diuretic-resistant and diuretic-intractable. by tuberculosis versus malignancy in developed countries. Sometimes more than one condition may coexist with Complications of Cirrhosis significant management implications. Alcoholic patients can have cirrhosis with cardiomyopathy, tuberculosis, Spontaneous Bacterial Peritonitis or malignancy. For management, perspective ascites is Spontaneous bacterial peritonitis (SBP), a lethal grouped under two heads: ascites due to cirrhosis or due complication, results from ascitic fluid infection in to causes other than cirrhosis. absence of an intra-abdominal infective focus. MU-113 (Sec-9).indd 707 02-02-2021 18:14:12 708 SECTION 9 Clinical Medicine TABLE 1 Causes of ascites Portal hypertension Infections Miscellaneous z Cirrhosis liver z Bacterial peritonitits z Pancreatitis z Alcoholic hepatitis z Tubercular peritonitis z Hypoalbuminemia z Hepatic congestion z HIV associated periotonitis z Nephrotic syndrome — Congestive cardiac failure Malignancies z Lymphatic leakage — Constrictive pericarditis z Peritoneal carcinomatosis z Myxoedema — Hepatic venous outflow obstruction z Primary mesothelioma z SLE z Portal vein thrombosis z Hepatocellular carcinoma z Non-cirrhotic portal hypertension z Metastatic liver disease z Pseudomyxoma peritonei Hepatic Hydrothorax Evaluation and Diagnosis Pleural effusion develops in approximately 5–10% Clinical Assessment of patients with cirrhosis due to transdiaphragmatic Ascites may be asymptomatic or may just produce an movement of fluid from peritoneal cavity to pleural space.3 increase in abdominal girth described as tightness of cloths Patients usually have minimal ascites. Pleural effusion is or belt. Massive ascites produces abdominal discomfort, right sided in 85%, left sided in 13%, and bilateral in 2% umbilical eversion, hernias, and breathlessness. Physical cases. examination is not significant in mild ascites. In moderate ascites, flank dullness and shifting dullness are sensitive Ascites due to Causes other findings. Massive ascites produces marked distension of than Cirrhosis abdomen. Signs of liver disease and portal hypertension should be sought. Hepatic, renal, and cardiac status In malignancy and tuberculosis tumor cells and tubercles should be assessed. lining the peritoneum produce protein rich fluid. Pancreatitis, heart failure, nephrotic syndrome, and Pathological Assessment hypothyroidism may cause ascites. Routine urine examination, complete blood counts, blood sugar, liver function tests, viral markers (HBV, HCV, Malignant Ascites and HIV), serum screatinine, NT-Pro BNP, and thyroid Malignant ascites occurs secondary to: function tests should be obtained. Peritoneal carcinomatosis: malignant infiltration of peritoneum Imaging Massive hepatic metastasis Ultrasound is the best modality to document the presence Profound desmoplastic response to infiltrating breast of ascites. It can provide information about cause of cancer ascites (fibrosis in cirrhosis, nodules in HCC, or liver Chemotherapy induced nodular regenerative hyper- metastasis). Fibroscan is a new modality to document plasia fibrosis of liver. Doppler sonography can detect portal Two-thirds cases of malignant ascites are caused by or hepatic vein thrombosis. Contrast enhanced CT, peritoneal carcinomatosis from adenocarcinomas of echocardiography, upper GI endoscopy, and colonoscopy pancreas, stomach, colon, ovary, uterus, lungs, or breast. may be ordered in select conditions. MRI using gadolinium The remaining are caused by hapatocellular carcinoma or scan can demonstrate enhancement of peritoneal lining in hepatic metastases. peritoneal carcinomatosis.4 MU-113 (Sec-9).indd 708 02-02-2021 18:14:12 Approach to Ascites CHAPTER 113 709 TABLE 2 Tests of ascitic fluid Diffrentiation of ascites based on hepatic venous TABLE 3 pressure gradient measurement Routine tests Additional tests Causes of ascites WHVP FHVP HVPG z Appearance z Gram stain and culture z Total protein z AFB smear, culture and Cirrhosis Increased Normal Increased z Serum ascites albumin adenosine deaminase activity Cardiac ascites Increased Increased Normal gradient (SAAG) z Glucose and lactate Malignant ascites Normal Normal Normal dehydrogenase z Cell count peritoneal tuberculosis z Amylase concentration FHVP, free hepatic venous pressure; HVPG, hepatic venous pressure z Cytology and carcinoembryonic gradient; WHVP, wedged hepatic venous pressure antigen level z Triglyceride level Serum-ascites Albumin Gradient Serum-ascites albumin gradient (SAAG) is the difference Abdominal Paracentesis between albumin concentration in the ascitic fluid and Once the presence of ascites has been confirmed, the that in the serum both collected at the same time. It etiology of ascites is best determined by paracentesis. is a very useful tool to establish the presence of portal Between 20–50 mL of ascitic fluid should be aspirated and hypertension. A SAAG value more than 1.1 g/dL reflects examined (Table 2). portal hypertension and indicates the ascites is due to increased pressure in the hepatic sinusoids. The SAAG has been found to be superior to the total protein Appearance concentration for the differential diagnosis of ascites.5 In ascites due to portal hypertension the fluid is clear and straw colored. Turbid fluid can result from infection Hepatic Venous Pressure Gradient or malignancy. Milky fluid, chylous ascites results from Hepatic venous pressure gradient (HVPG) is direct lymphatic disruption due to malignancy, trauma, and measure of hepatic sinusoidal pressure measured via a congenital abnormalities. Bloody ascites could be due catheter in right femoral or internal jugular vein. Portal to traumatic tap or malignant ascites. Blood in traumatic hypertension is defined as HVPG value more than 6 mm fluid clots but in malignant ascites does not clot. Hg (Table 3). Total Protein Laparoscopy Protein levels are useful in determining etiology of ascites. Laparoscopy offers the advantages of visual inspection Traditionally ascitic fluid is grouped into: of the peritoneal cavity and obtains targeted biopsies for Exudate with protein concentration more than histological studies. With the availability of new imaging 2.5 g/dL. techniques, the need for laparoscopy in determining the Transudate with protein concentration less than cause of ascites has decreased. 2.5 g/dL. Exudative ascites occurs secondary to peritoneal Diagnostic Developments processes (malignancy, tuberculosis) or post-hepatic New novel diagnostic markers such as leukocyte esterase sinusoidal hypertension