Ascitis es la acumulación patológica de fluido en la cavidad peritoneal, la causa más común es la cirrosis hepática.

1. Ascitis
DEFINITION
Ascites refers to a pathologic accumulation of
fluid in the peritoneal cavity, most commonly
caused by liver cirrhosis.
SYNONYMS
Fluid in peritoneal cavity
Hydroperitoneum
Hydroperitonia
Hydrops abdominis
EPIDEMIOLOGY & DEMOGRAPHICS
Ascites is the most common complication of cirrhosis
and signifies decompensation of chronic
liver disease. Ascites occurs in 60% of individuals
with cirrhosis within ten years of diagnosis.
Cirrhosis is the cause of 75% of cases of ascites.
Other causes include intraperitoneal malignancy,
heart failure, tuberculosis, pancreatitis, nephrotic
syndrome, and Budd-Chiari syndrome.

2. CLINICAL PRESENTATION
Important information to elicit within history:
1. History of viral hepatitis
2. Alcoholism
3. Intravenous drug use, intranasal cocaine use
4. Sexual history (i.e., men who have sex with men)
5. History of transfusions, tattoos, piercings, imprisonment
6. Symptoms suggestive of peritoneal malignancy (e.g., weight loss, pain, palpable masses,
rectal/vaginal bleeding)
7. Other liver disease symptoms (e.g., increasing abdominal girth, jaundice, pruritis,
confusion, pedal edema)
8. Cardiac symptoms (e.g., pedal edema, shortness of breath, orthopnea, chest pains)

3. Important physical exam findings:
1. Bulging flanks (can be present in obesity)
2. Flank dullness to percussion
3. Fluid wave on abdominal exam
4. Lower extremity edema
5. Shifting dullness on abdominal exam
6. Physical signs associated with liver cirrhosis: spider angiomas,
jaundice, loss of body hair, skeletal muscle wasting (sarcopenia),
Dupuytren’s contracture, bruising, palmar erythema, gynecomastia,
testicular atrophy, rectal varices, and caput medusae

4. ETIOLOGY:
Pathophysiology of
ascites

5. Diagnóstico:
LABORATORY TESTS
• Initial evaluation should always include:
1. Diagnostic paracentesis. Laboratory tests on this fluid should include a cell count, cytology, albumin, total protein,
culture, and Gram stain. A serum-ascites albumin gradient (SAAG) should be calculated in all patients.
a. If the SAAG is greater than 1.1, the cause of ascites can be attributed to portal hypertension.
b. If SAAG is less than 1.1, a non-portal hypertension etiology of ascites must be sought. Optional tests on
paracentesis fluid include amylase, LDH, acid-fast bacilli, and glucose levels.
c. Causes of ascites in the normal or diseased peritoneum by SAAG are summarized in Table 1.
d. Fig. 2 illustrates an algorithm for the approach to the differential diagnosis of ascites.
2. AST, ALT, total and direct bilirubin, albumin, alkaline phosphatase, GGTP
3. CBC, coagulation studies
4. Electrolytes, BUN, creatinine
IMAGING STUDIES
• Abdominal ultrasound (Fig. 3) is the most sensitive measure for detecting ascitic fluid; a CT or MRI scan is a viable
alternative. Doppler studies of portal and hepatic veins should be added to rule out vascular etiology.
• Endoscopy of the upper GI tract to evaluate for esophageal varices if ascites is secondary to portal hypertension.

7. Diagnóstico:
LABORATORY TESTS
• Initial evaluation should always include:
1. Diagnostic paracentesis. Laboratory tests on this fluid should include a cell count, cytology, albumin, total protein,
culture, and Gram stain. A serum-ascites albumin gradient (SAAG) should be calculated in all patients.
a. If the SAAG is greater than 1.1, the cause of ascites can be attributed to portal hypertension.
b. If SAAG is less than 1.1, a non-portal hypertension etiology of ascites must be sought. Optional tests on
paracentesis fluid include amylase, LDH, acid-fast bacilli, and glucose levels.
c. Causes of ascites in the normal or diseased peritoneum by SAAG are summarized in Table 1.
d. Fig. 2 illustrates an algorithm for the approach to the differential diagnosis of ascites.
2. AST, ALT, total and direct bilirubin, albumin, alkaline phosphatase, GGTP
3. CBC, coagulation studies
4. Electrolytes, BUN, creatinine
IMAGING STUDIES
• Abdominal ultrasound (Fig. 3) is the most sensitive measure for detecting ascitic fluid; a CT or MRI scan is a viable
alternative. Doppler studies of portal and hepatic veins should be added to rule out vascular etiology.
• Endoscopy of the upper GI tract to evaluate for esophageal varices if ascites is secondary to portal hypertension.

9. Ascites, ultrasound.
Ultrasound is useful for detection of
ascites. Simple fluids such as ascites
are excellent sound transmission
media, reflecting almost no sound
waves. As a consequence, they
appear quite hypoechoic (black) on
ultrasound. This view of the right
lower quadrant shows loops of
bowel surrounded by fluid. During
the ultrasound, the bowel loops
would be seen to undergo peristalsis
and drift back and forth in the ascitic
fluid with patient movement.
Ultrasound cannot distinguish the
composition of the fluid; ascites,
liquid blood, liquid bile, urine, and
infectious fluids have a similar
appearance, with a few exceptions.
Blood may coagulate and form
septations within the fluid
collection. Infectious fluids also
frequently form loculated fluid
collections that may be recognized
on ultrasound, although the exact
composition cannot be determined.

15. Gastrointestinal malignancies
Unfortunately, clinical symptoms appear most often at the late stages
of disease and therefore are associated with poor patient survival.
Some tumors induce diffuse dissemination of the tumor cells into the
peritoneal cavity.
The appearance of peritoneal carcinomatosis (PCA) is associated with
tumor progression and an unfavorable outcome (survival ranging from
weeks to months), with ascites and bowel obstruction as the main
symptoms.
Expression of MicroRNAs in the Ascites of Patients With Peritoneal Carcinomatosis and Peritonitis
Diagnostic
is based on imaging of PCA and
cytological evaluation of ascites
followed by an invasive approach such
as laparoscopy or laparotomy.
Computed tomography and magnetic
resonance imaging deliver the most
reliable results for the nodal type of
PCA and pre-dominantly in advanced
stages of disease.
cytology remains the gold standard that allows
for the definitive diagnosis with high specificity,
although the sensitivity is only approximately
40% to 60%

16. Expression of MicroRNAs in the Ascites of Patients With Peritoneal Carcinomatosis and Peritonitis
patients with cirrosis
and ascites may
develop spontaneous
bacterial peritonitis
(SBP), which occurs in
10% to 30% of cases.
limited progress in the
development of alternative
molecular-based methods for the
diagnosis of PCA and SBP.
MicroRNAs (miRNAs)
small, endogenous, non-coding RNA molecules
miRNA is a consequence of the complex
transcription and RNA processing.
During this process, miRNA binds to Argonaute proteins and
controls the gene expression as the RNA-induced silencing complex (RISC).
various body fluids such as blood, urine, feces,
cerebrospinal fluid, etc.

17. Department of Gastroenterology, Hepatology and Infectious Diseases
at Otto-von-Guericke-University
in Magdeburg,
Germany.
45 patients
The ascites samples (approximately 25 mL) were collected from patients with various conditions during
diagnostic or therapeutic paracentesis.
1. 15 patients with PCA (detection of neoplastic cells in cytology);
2. 15 patients with sponatenous and secondary bacterial peritonitis (SBP) (polymorphonuclear
leukocytes count [PMN] 250 cells/mm3 and/or positive bacterial culture); and
3. 15 patients with ascites due to portal hypertension without complications (no SBP/PCA) (negative
cytology, PMNs 250 cells/mm3 , and negative bacterial culture).

19. miRNAs en ascítis
Análisis por reacción de cadena de transcriptasa reversa y polimerasa en forma cuantitativa
The results of the current study demonstrate that miRNAs can be easily isolated from ascites samples.
Hipertensión portal
Sobre expresado
miR-21
miR-186
miR-222
miR-483
infraexpresado
miR-266
Peritonitis bact. Espont.
“Sobre expresado”
miR-223
Carcinomatosis peritoneal
^^ Sobre expresado
miR-21
miR-186

20. Gracias
Dankon