APPROACH TO ASCITESDR RUSHIKESH KUTE RUSHIKESH KUTE
NIRMAL HOSPITAL PVT LTD SURATNIRMAL HOSPITAL PVT LTD SURAT
Definition
-Ascites is of greek derivation(askos) which refers to bag or sack
-The word describes pathological fluid accumulation in peritoneal cavity
Background
• Peritoneum
• Portal HTN
• Impaired drainage in lymphatic system
• Hypoalbuminemia
Pathophysiology
• Under filling theory primarily there is inappropriate
sequestration of fluid within the splanchnic vascular bed as a consequence of portal hypertension (PHT) that produces decrease in effective circulating blood volume. This activates the plasma rennin, aldosterone, and sympathetic nervous system, resulting in renal sodium and water retention
Overflow theory
primary abnormality is inappropriate
renal retention of sodium and water in the absence of volume depletion. Basis of this theory is that patients with cirrhosis have intravascular hypervolemia rather than hypovolemia
Peripheral arterial vasodilatation
• The major factor of ascites formation is splanchnic vasodilation.
• Cirrhosis causes increased hepatic resistance to portal flow that results in PHT and shunting of blood to the syst emiccirculation.
• Local production of vasodilators, mainly nitric oxide due to PHT results in splnchnic and peripheral arterial vasodilatation. This leads to decrease in effective arterial blood volume (EABV)
Pathogenic mechanism• Increased hydrostatic pressure
• Decreased colloid osmotic pressure
• Increased permeability of peritoneal capillaries
• Leakage of fluid into peritoneal cavity
• Misc.
Etiology
• Neonatal ascites/congenital ascites1.Associated with hydrops > -cardiovascular rhythm dist. cardiac malformn. -hematological isoimmune hemolytic dis. homo alpha thal.
2. Isolated ascites
- chylous
congenital anomaly of lymphatic channels
-biliary
spontaneous perforn of biliary tree
- pancreatic duct anomaly
-chromosomal
turner synd
trisomy 13,18,21
-infections
TORCH
syphillis
-renal
nephrosis
PUV
-pulmonary diaphragmatic hernia-gastrointestinal atresia-maternal condn toxemia diabetes-placenta/cord cord compression chorangioma
-misc wilms tumour neuroblastoma-storage dis. mucopolysachharadosis 8-skeletal abn. osteogenesis imperfecta achondrogenesis
-cirrhosis
alpha antitrypsin def.
-liver failure
neonatal hemochromatosis
-unknown
2.Isolated asictes - chlylous congenital anomaly of lymphatics - biliary spontaneous perforation of biliary tree - pancraetic duct anomaly3. Peritonitis - chemical bile,meconium - bacterial
Etiology In Children1.Associated with portal hypertension -extrahepatic venous obstruction misc -intrahepatic biliary tract dis. hepatocellular dis. toxins misc -others
Etiology of acute ascites
-Venous obstruction
-Peritonitis
-Fulminant hepatic failure
Etiology in ref to normal /diseased peritoneum
Normal- portal HTN liver dis. hypoalbuminemia miscDiseased- infections malignancy others
Presentation
• Abdominal distension
• Increasing wt
• Respiratory embarras.
• Pedal oedema
Risk factors
• Chronic viral hepatitis
• Intravenous drug use
• Sexual promiscuity
• Transfusions
• Tattos
• Habitation or origination from endemic hepatitis
Examination• Flank dullness 90% sensitive
• Increased abdominal girth and wt loss
• Puddle sign
• Shifting dullness
• Fluid thrill
• Peritoneal tap
Monitoring
• Abdominal girth and weight
-jugular venous distension
-heart murmur/signs of CHF
-signs of pulmonary oedema
-skin changes
-asterixis/anasarca
-virchows node
• Grading
1.Mild
Puddle sign/usg
2.Moderate
Shifting dullness/no thrill
3.Tense
Fluid thrill/resp. difficulty
• Staging
1+ careful examin
2+ easily detectable
3+ obvious but no tense
4+ tense ascites
Confirm >cause >complications• Blood tests > Complete blood counts
Complete urine examination
LFT
Clotting screen
Imaging studies
• Chest and abdominal films
-elevation of diaphragm
-nonspecific signs
-hellmer sign
-obliteration of hepatic angle
-dogs ear/mickey mouse sign
-med displacement of cecum & ascending colon & lat displacement of properitoneal line
• USG
-site for paracentesis
-100ml fluid
-uncomplicated ascites
homogenous ,freely mobile, anechioc collection in peritoneal cavity,deep acoustic enhancement
-massive ascites
small bowel loops-polycyclic,lollypop like arcuate app.
-coarse internal echoes(blood)
-fine internal echoes(chyle)
-multiple septa(TB,pseudomyxoma peritonei)
-loculated /atypical fluid distribution
-matting or clumping bowel loops\
-thickening of interface betn fluid & adjacent structure
• Upper GI endoscopy
-oesophageal/fundal varices
CT/MRI
-rt perihepatic space,morrisons pouch,douglas pouch
-malignant ascites
prop fluid in lesser & greater sac
-benign ascites
fluid in greater sac
Abdominal paracentesis• Position• Site• Technique• Ascitic fluid analysis routine/optional tests total protein/gram stain albumin/AFB smear and culture cell count cytology amylase/LDH/glucoseComplications
• white cell count- <500 leukocytes/ml & <250 PMN L-NRed cell count- >50000/ml hemorrhagicGross- transluscent/yellow-N brown-hyperbili/GB perforatn cloudy/turbid-infection pink/blood tinged-mild trauma gross blood-malignanacy/trauma milky-cirrhosis/thor.duct injury/lymphoma
• Toatl protein
• Gram stain
• Cytology
• SAAG-sr albumin-ascitic fluid albumin portal/nonportal
• Culture
• LDH
• Triglycerides
• Amylase
• Bilirubin
Classification of ascitic fluid infection
Type PMN count
Cells/mm3
Bacterial culture
Spont bact
peritonitis
> 250 +
Culture negative
>250 _
monomicrobial <250 +
Polymicrobial <250 +
Sec.bact.peritonitis
>250 +
Types of ascitis acc to sr ascitis albumin gradient
High gradient >1.1g/dl Low gradient <1.1g/dl
Cirrhosis
Hepatitis
Fulminant hepatic failure
Cardiac ascitis
Portal vein thromb.
Veno-occlusive dis.
Myxedema
Massive liver metastasis
Tb peritonitis
Nephrotic syndrome
Pancreatic ascitis
Bowel obst/infarction
Biliary ascitis
Postop lymph leak
Serositis in CTD
Indication for admssion• For investigation• Not responsive• Diet limited to 88mmol of Na per day• Monitoring• Grade 3 ascitis • Susp bact peritonitis• Electrolyte imbalance• Hepatorenal syndrome• Hepatic encephalopathy• Refractory ascitis
Management 1.non drug –
bed rest
medical care
diet
fluid restriction
2.drugs
diuretics
b blockers
3.Diuretic resitance
therapeutic paracentesis
le veen or denver peritoneovenous shunt
liver transplantation
extracorporeal ultrafiltration with reinfusion
TIPSS
Surgical• TIPSS-
-hepatic vein and portal vein
-reduces pressure gradient betn portal and systemic
Peritoneovenous shunt
• A peritoneovenous shunt (also called Denver shunt) is a shunt which drains peritoneal fluid from the peritoneum into veins, usually the internal jugular vein or the superior vena cava
Portocaval shunt
• A portacaval shunt (or portal caval shunt) is a treatment for high blood pressure in the liver. A connection is made between the portal vein, which supplies 75% of the liver's blood, and the inferior vena cava, the vein that drains blood from the lower two-thirds of the body.
• Liver transplantation
• Follow up
• Spontaneous bacterial peritonitis
• Prevention
• Patient education
• Monitoring
• Prognosis
• Lows albumin gradient ascites
Refractory ascitis• Fluid load that is non responsive to
restriction of dietary sodium to 88mmol/day and maximal dose diuretic therapy in absence of ingestion of prostaglandin inhibitors(NSAID)
• Management
serial large volume paracentesis
100ml/kg at a time
iv albumin 6-8g/lit
Others
• ANP
• V2 receptor antagonist
• OPC-3126
• Niravoline
• FK352
• Chylous ascitis
• Pseudochylous ascitis
• Management
low fat,high protein,paracentesis
THANK YOU
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