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Ascites
By R.Gnanaraj
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DefinitionDefinition• From greek derivation askhos which
refers to a ‘bag’ or ‘sack’.• Pathologic fluid accumulation in the
peritoneal cavity.
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Causes of ascitesCauses of ascites• Hepatic• Renal• Cardiac• Infectious• GI • Neoplasm• Gynecological• Pancreatic• miscellaneous
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Causes of ascitesCauses of ascites• Ascites in newborn is classified as 1.associated with hydrops 2.isolated ascites 3.ascites due to peritonitis
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Associated with hydropsAssociated with hydrops1.CVS(20%)- heart block auricular tachycardia hypoplastic left heart ebstein disease2.Hematological (10%)-isoimmune hemolytic disease homozygous alpha thalassemia3.Chromosomal(10%)-turner syndrome trisomy 13,18,214.Infection(10%)-TORCH group syphilis5.Pulmonary(5%)-diaphramatic hernia
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Contd…Contd…6.Gastrointestinal(5%)-atresia7.Renal(5%)-nephrosis8.Maternal conditions(5%)-Toxemia, Diabetes9.Miscellaneous(5%)- Wilm’s tumors Neuroblastoma10.Liver-Cirrhosis Alpha-1 antitrypsin deficency Neonatal hemochromatosis11.Placenta or cord-Cord compression Chorangioma12.Unknown(20%)
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• Isolated ascites-Chylous ascites Obstructive uropathy Biliary ascites• Ascites due to peritonitis Bacterial Chemical
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Causes of ascites in childrenCauses of ascites in children• Extrahepatic-Venous obstruction CHF AV fistula• Intrahepatic-Biliary tract disease Hepatocellular disease Toxins Schistosomiasis• Other causes-TB Nephrotic syndrome Pancreatitis Chlamydial infection Rheumatoid arthritis
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Causes of acute ascitesCauses of acute ascites• Venous obstruction• Peritonitis• Fulminant hepatic failure
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PathophysiologyPathophysiology
•Underfill theory•Overflow theory•Peripheral vasodilation theory
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Clinical featuresClinical features• Distension of abdomen• Abdominal pain• Respiratory distress
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Signs of ascites Signs of ascites • 5 classic physical signs Bulging flanks Flank dullness Shifting dullness Fluid wave Puddle sign
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Look for…Look for…• Triad of PHT• Umbilical herniation• Pedal edema & anasarca • Hepatojugular reflux & dilated veins
with flow upwards• Fever & abdominal pain with
guarding & rigidity• Evidence of malignancy
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Investigations Investigations • Blood – cell counts,viral markers• Urine analysis• LFT• Mantoux test• Renal & cardiac evaluation• Ascitic fluid analysis• USG, CT scan , MRI
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Grading of ascites Grading of ascites • Mild - only seen in USG or puddle
sign• Moderate – shifting dullness present• Severe – fluid thrill present
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Abdominal paracentesisAbdominal paracentesis• Position• Site• Technique – ‘Z’ tract
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Ascitic fluid analysisAscitic fluid analysis• Colour • Cell count• Protein• Culture• SAAG• LDH• Amylase• TG, bilirubin
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Serum ascites albumin Serum ascites albumin gradient(SAAG)gradient(SAAG)
• Ratio >1.1 portal hypertension• Ratio <1.1 peritoneal pathology -TB -SBP -Malignancy
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Exudative & transudative Exudative & transudative causescauses
• Exudative(<1.1) 1.Peritonitis 2.IVC obstruction 3.Malignancy 4.Pancreatitis 5. Chylous
ascites 6.Hemorrhagic
• Transudative(>1.1) 1.Nephritic
syndrome 2.Hypoproteinemia 3.CCF 4.End stage liver
cell failure 5.Protein losing
enteropathy
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Complications Complications • Spontaneous bacterial peritonitis• Hernias• Respiratory distress
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Management Management • Depends on the SAAG Low albumin gradient ascites High albumin gradient ascites
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Low albumin gradient Low albumin gradient ascitesascites
• Does not respond to salt restriction & diuretics• Treatment depends on the cause TB peritonitis- ATT Pancreatic ascites- endoscopic stenting somatostatin therapy surgery Chlamydial-tetracycline Nephrotic & lupus ascites-steroids Malignancy-chemotherapy surgery
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High albumin gradient High albumin gradient ascitesascites
• Bed rest• Diet restriction• Diuretics• Beta blockers
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Diet restrictionDiet restriction• Sodium restriction upto 5 mEq/day (1-4 yrs)
upto 20mEq/day (4-11 yrs) upto 30mEq/day (>12 yrs)
• No fluid restriction
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Diuretics Diuretics • Potassium sparing diuretics• Loop diuretics• Thiazides
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SpironolactoneSpironolactone
• Starting Dose - 1-2mg/kg/day• Gradually increased upto
6mg/kg/day• Onset – 2-4days• Side effects – hyperkalemia metabolic acidosis gynecomastia• Others – triamterene,amiloride
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Loop diureticsLoop diuretics• Furosemide,bumetanide,ethacrynic acid• Starting Dose - 1-2mg/kg/day• Gradually increased upto 6mg/kg/day• Onset – 2-4days• Side effects – hypokalemia hyperchloremic acidosis ototoxicity
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Thiazide diureticsThiazide diuretics• Hydrochlorthiazide indicated when
diuresis on high doses are inadequate.
• Dose – 2-3mg/kg/day• Side effects-hypokalemia hyperglycemia hyperuricemia
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Duration of diureticsDuration of diuretics• Treatment – till ascites is cured• Maintenance – in case of cirrhosis for
months to years.
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Beta blockers Beta blockers • Causes increased natriuresis by 1.lowering of portal pressure 2.inhibition of renin secretion
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Refractory ascitesRefractory ascites• Fluid overload unresponsiveness to
salt restriction & high dose diuretic• Causes-infection malignancy TB liver cell failure renal causes
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Treatment for refractory Treatment for refractory ascites ascites
• Paracentesis• LeVcen shunt (peritoneal venous
shunt)• Orthotropic liver transplantation
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Paracentesis Paracentesis • LVP - 200-400ml/kg/day slowly over
4-6hrs • Simultaneous infusion of 6g of 20%
albumin for every liter of fluid removed.
• Mechanism-paracentesis decreases systemic venous congestion, increases GFR & renal plasma flow
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Chylous ascitesChylous ascites• Causes• Anomaly of lymphatics• cirrhosis• trauma• Tumor• Rheumatoid arthritis• Infections
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Clinical featuresClinical features• Abdominal distension• Poor weight gain• Loose stools• Anasarca
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Management Management • Fluid analysis-white in colour Increased protein Increased TG Decreased gamma globulin Lymphocytosis• Treatment 1.diet- low fat diet with MC TG High protein diet 2.paracentesis 3.surgery
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Reference OP Ghai Nelson IAP Pediatricks
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Thank you