AscitesMatthewJohnsonM.D.

•  Themostcommoncomplicationofportalhypertension•  50%ofpatientswhohavecompensatedcirrhosisdevelopascitesby10years

•  Survivalafterascitesdevelops:•  1-year:85%•  5-year:60%•  6-monthmediansurvivalforrefractoryascitesis50%

CausesofAscites•  Cirrhosis:80-85%•  EtOHHepatitis•  AcuteLiverfailure•  HeartFailure/CM:3%•  Cancer:10%•  Pancreatitis•  TBPeritonitits:2%•  NephroticSyndrome•  Renalfailure•  BuddChiari•  Myxedema•  Post-operativelymphaticleak

•  Biliary•  ForeignBody•  MassiveLiverMets•  Sinuoisoidalobstructionsyndrome

•  Hemoperitoneum•  ChylousAscites•  Proteinlosingenteropathy•  HDassociatedascites:1%•  Pancreaticdisease:1%•  Mixed:5%

History•  Riskfactorsforliverdisease•  Lifetimebodyweight(NASH/NAFLD)•  Diabetes(NASH/NAFLD)•  Heartfailure•  Renaldisease•  TB•  Thyroiddisease

PhysicalExam•  ShiftingDullness•  85%Sens,56%spec.•  Minimumofabout1L-1.5L

•  JVD•  ElevatedincardiaccausesandpulmonaryHTN

•  Patientswithcirrhosisandascitesalmostalwayshavestigmata•  Palmarerythema(blotchyonhypothenareminence)•  Spiderangioma(neck,shoulders,upperchest)

Paracentesis•  Whatlandmarksshouldoneuse?•  Whatstructuresdowewanttoavoid?

TIPSforPara•  Nodatatosupportcutoffofcoagulationparametersafterwhichtonotperformaparacentesis•  In1100largevolumeparasnocomplications

•  Plateletcountaslowat19,000•  INRashighas8.7(75%>1.5and26.5%>2)

•  RoutineuseofFFPorplasmaorplateletsbeforeparacentesisisnotrecommended

Colloidreplacement•  Afterlargevolumepara(>5liters)•  Give6-8gofalbuminperliterremoved•  Meta-analysisof1,225patients

•  Reductioninmortalityof0.64(95%CI:0.41-0.98)

Asciticfluidanalysis•  Appearance:•  Normal:translucentyellow•  Turbid:98%sens,23%specforSBP•  Milky:chylousascites•  Pink/Bloody:traumatictap,malignancy

TeststoSend•  Routine:•  Cellcountwithdifferential•  Totalprotein•  AlbuminforSAAG

•  Basedonsuspicion:•  Gramstain•  Cultureinbloodculturebottlesatbedside!•  Glucose:lowininfection•  LDH(ratioofascitic:serum:0.4incirrhosis,approach1inSBP)•  Amylase:pancreaticascitesvs.bowelperforation

•  Ascitic:serum>0.4

Moretests…•  Unusual:•  Triglyceride:sendifwhite;>200mg/dL•  Bilirubin:if>serumsuggestbowel/biliaryperforation•  Cytology:Sensmayapproach96.7%ifthreesamplessentfrom3differentparacentesis•  50ccofsamplehandcarriedtolab•  Positiveonlywithcarcinomatosis

•  TB:sensitivityofsmearapproaches0%•  Sensitivityoffluidculture~50%•  PCRoffluidorlaparoscopywithbiopsypreferred•  Culturemayapproach83%senswith1literoffluid•  ADA:falselylowincirrhosissonotmuchuseinUSA

•  CA-125nothelpfulinddxforascites–increaseswithascites

•  Whatarethetwomaincategoriesofascites?

HighSAAG•  ≥1.1:PortalHTNwith97%percentaccuracy•  EtOHHepatitis•  Cardiaccauses(heartfailure,constrictivepericarditis)•  MassiveLiverMets•  AcuteLiverfailure•  BuddChiari•  PortalVeinthrombosis•  Cirrhosis(Asciticfluidprotein<2.5)•  Myxedema•  TBwithcirrhosis•  Sinusoidalobstructivesyndrome•  PulmonaryHTN•  Idiopathicportalfibrosis

LowSAAG•  <1.1•  Nephroticsyndrome(lowtotalprotein<2.5g/dL)•  Malnutrition•  Proteinlosingenteropathy•  Carcinomatosis•  Infection(TB,fungal)•  Pancreatitis•  Serositis•  Biliary•  ForeignBody•  Peritonealdialysis•  ESRD(hightotalproteinbetween3-6g/dL)

FirstLineTreatment•  FirstLine:•  EtOHcessation•  SodiumRestriction(2000mg[88mEq]/day)

•  WanturinaryNaexcretion>78mmol/day•  10-15%ofpatientshavenatriuresisgreaterthanthisatbaseline•  SpotUrineNa/Kratio>1andshouldloseweight•  If>1andnotlosingweight:toomuchsaltindiet

•  Fluidrestrictionnotneededinmostpatients•  IfserumNa<120-125,reasonabletorestrict

FirstLineTherapycontinued•  Diuretics:•  Spironolactone100mgPOdaily(max400mg)•  +/-Furosemide40mgPOdaily(max160mg)•  Singledosinghelpswithcompliance•  Up-titratedosesevery3-5days

RefractoryAscites•  Fluidoverloadunresponsivetodietandhighdosediuretic•  Recursrapidlyaftertherapeuticparacentesis

•  DiureticResistance/Failure•  Uncontrolled/recurrentencephalopathy•  Creatinine>2•  Sodium<120•  Potassium>6

SecondLineTherapies•  Midodrineifhypotensive

•  IncreaseBPandincreasedurineoutput•  SerialTherapeuticPara•  If>8-10LremovedmorefrequentlythanQ2weeks(notdietcompliant)

•  TIPS•  Peritoneovenousshuntbyexperiencedsurgeon•  Drainsperitonealfluidintotheinternaljugularvein

•  Evaluatefortransplant

MedicationstoAvoid(2ndLine)•  ACEinhibitors•  ARBs•  Beta-blockers•  151patientswithdiureticresistantascites

•  Independentpredictorsofincreasedmortality:•  ChildsC,hyponatremia,beta-blockeruse•  Studynotrandomized

•  NSAIDS:causerenalvasoconstriction•  Lessensresponsetodiurectics•  DecreaseurinaryNaexcretionandcauseazotemia

TIPS•  Transjugularintrahepaticportosystemicstent-shunt•  Decreaseascites/varices•  Increaseencephalopathy

•  Criteria:•  Diureticresistant•  IntolerantofPara•  ChildsAorB•  MELD<18•  <65yearsold•  EF>60%•  NospontaneousHE

SBP•  Symptoms:fever,abdominalpain,unexplainedencephalopathy,acidosis,azotemia,hypotension,hypothermia,leukocytosis

•  Top3organisms:•  E.Coli,Klebsiellapneumoniae,S.Pneumo

•  PMN≥250•  SecondarySBP(Bowelperforation,periappendicealabsces)•  LDH>ULNforserum,Glucose<50,TP>1,multiorganism,•  Perforation:CEA>5;AlkPhos>240

Cultures•  Isolationofbacteriamaximizedif:•  Fluidculturesinoculatedinbloodculturebottlesatbedside•  Nopriorantibiotics•  NootherexplanationforincreasePMNsuchas:

•  Hemorrhagicascites•  Carcinomatosis•  Pancreatitis•  PeritonealTB

SBPTreatment•  IV3rdGenerationCephalosporinx5days•  Ceftriaxone2gIVQ24H•  Cefotaxime2gIVQ8H(moststudiesusethis)

•  PCNAllergy:Levaquin(notifFQasprophylaxis)•  Albumin:•  IfCr>1,BUN>30orTB>4•  1.5g/kgonD1within6hours•  1g/kgonD3

•  Decreaseinhospitalmortalityfrom29to10%(126patients)•  MorerecentstudyonlygiveAlbifCr>1,BUN>30,TB>4•  Only38‘episodes’from28patients

OralTreatment?•  Ofloxacin400mgPOBIDx8daysequaltoparenteralcefotaxime•  Withoutvomiting,shock,GradeIIHE,orCr>3•  Nopriorexposetoquinolones•  Only61%metstudyinclusioncriteria

•  Cipro200mgIVQ12x2daysthen500mgPOQ12for5days

WhentorepeatParaforSBP?•  Minimalimprovementinsymptoms•  PMN<250thenstop•  Greaterthanpre-treatment:thinksurgicalproblem•  Elevatedbutlessthanpre-treatment:continuetxfor48hoursandrepeatparaagain

SBPProphylaxis•  1.PriorhistoryofSBP•  2.Anyinpt.withtotalasciticprotein<1(US)or1.5(EU)•  BactrimDS,Cipro500mg,orNorfloxacin400mgdaily

•  3.Asciticprotein<1.5andanyoneofthefollowing•  BUN≥25•  Na<130•  Cr≥1.2•  Tbili≥3•  ChildsPugh≥9

•  4.GIbleed•  ChildsA:BactrimDSorCiproBIDx7days•  ChildsB/C:Ceftriaxone1gIVdaily

ProphylacticAntibiotics•  Norfloxacin400mg/d(UnavailableinUSA)•  BactrimDS1tabPOdaily•  Cipro500mgPOdaily

Tipstoavoidreadmission•  Apptwithin7daysofdischarge

HepatorenalSyndrome•  Cirrhosiswithascites•  Cr≥1.5•  Noimprovementwith48hoursofdaily1g/kgalbuminanddiureticwithdrawal

•  Noproteinuriaorhematuria•  Absenceofshock•  Nonephrotoxicdrugs

HRS•  Type1:rapidprogression(<2weeks)•  Type2:slowprogression•  Diagnosisofexclusion

•  Urinaryneutrophilgelatinase-associatedlipocalin:•  20ng/mLcreatinineinnormalcontrols,•  20ng/mLinpre-renalazotemia,•  50ng/mLinchronickidneydisease,•  105ng/mLinhepatorenalsyndrome,•  325ng/mLinacutekidneyinjury

HRSTreatment

•  HD•  Octreotide:decreaseportalpressure•  Midodrine:alphaagonist:increaseBP•  Albumin:restorevolume

HepaticHydrothorax•  Nochesttubes•  Transudativeeffusion•  Narestrictionanddiuretics

•  Thora:•  Asciteswithlowerprotein

•  AvoidPEGtubes