definitions and classifications of ascites.

1. Dr Karrar Adil

2. Introduction :
 The peritoneal cavity normally contains
approximately 50–75 ml of fluid that serves to
lubricate the tissues that line the abdominal
wall and viscera.
 Ascites is defined as pathological collection of
fluid in the peritoneal cavity.
 In Western countries cirrhosis is the most
common cause (80%) of ascites.

3. International Ascites Club definitions
:
• Uncomplicated ascites :
Ascites that is not infected and which is not
associated with the development of the
hepatorenal syndrome (HRS).
• Refractory ascites :
Ascites that cannot be mobilised or the early
recurrence of which (ie, after therapeutic
paracentesis) cannot be satisfactorily prevented
by medical treatment. This includes two different
subgroups:

4.  Diuretic-resistant ascites :
Ascites that is refractory to dietary sodium
restriction and intensive diuretic treatment.
 Diuretic-intractable ascites :
Ascites that is refractory to treatment owing to
the development of diuretic-induced
complications that preclude the use of an
effective diuretic dosage.

5. Subtypes and variants :
 Chylous ascites : collection of lymph in the abdominal
cavity, which is characteristically triglyceride-rich and
has a milky appearance.
Etiology : malignancy, cirrhosis, lymphatic disorders
(lymphatic hyperplasia).
 Bloody ascites : ascitic fluid with RBC > 50,000 /mm3.
Etiology : may be spontaneous (e.g., due to peritoneal
carcinomatosis or a malignant mass eroding into vessels)
or iatrogenic (e.g., following paracentesis or biopsy).

6. Etiological classification :
Ascites may be classified according to etiology
into four groups include:
1. portal hypertension associated
2. hypoalbuminemia associated
3. peritoneal disease associated
4. other diseases associated.

7. 1- Portal hypertension :
 Cirrhosis (most common)
 Alcoholic hepatitis
 Acute liver failure
 Hepatic veno-occlusive disease
 Heart failure
 Constrictive pericarditis
 Hemodialysis-associated

8. 2- hypoalbuminemia :
 Nephrotic syndrome
 Protein-losing enteropathy
 Severe malnutrition
3- Peritoneal disease :
 Malignant ascites
 Infectious peritonitis
 Eosinophilic gastroenteritis
 Starch granulomatous peritonitis
 Peritoneal dialysis

9. 4- Other diseases :
 Chylous ascites
 Pancreatic ascites
 Myxedema
 Hemoperitoneum
 Urologic injury

10. (SAAG) based classification
:
Ascites is also classified based on the serum-
ascites albumin gradient (SAAG) into two
subtypes:
1. Transudate : SAAG > 1.1 g/dL
2. Exudate : SAAG < 1.1 g/dL

11. 1- Transudate (Protein <2.5 g/dl) (> 1.1 g/dL)
:
 Cirrhosis
 Fulminant hepatic failure
 Veno-occlusive disease
 Hepatic vein obstruction (i.e., Budd-Chiari syndrome)
 Congestive heart failure
 Nephrotic syndrome
 Protein-losing enteropathy
 Malnutrition
 Ovarian tumors
 Pancreatic ascites
 Biliary ascites
 Malignancy
 Trauma

12. 2- Exudate (Protein >2.5 g/dl) (< 1.1 g/dL) :
 Primary peritoneal mesothelioma
 Secondary peritoneal carcinomatosis
 Tuberculous peritonitis
 granulomatous peritonitis
 Fungal and parasitic infections (eg,
Candida, Schistosoma mansoni,
Entamoeba histolytica)
 Sarcoidosis
 Foreign bodies (cotton and wood
fibers, starch, barium)
 Systemic lupus erythematosus
 Henoch-Schönlein purpura
 Eosinophilic gastroenteritis
 Endometriosis
US of the abdomen
demonstrated ascites with
particulate debris in keeping
with an exudate (arrow)
(Case of peritoneal
carcinomatosis)

13. US of the right iliac fossa
demonstrates complex ascites
(arrow). Multiple septations are
noted throughout the fluid
suggestive of an exudate.
(granulomatous peritonitis)
US oblique section through the
RUQ showing peri-hepatic
transudative ascites (arrow).
Note the lobulated outline of the
liver secondary to cirrhosis (*).

14. International Ascites Club
classification :
classifies the severity of ascites as follows:
 Mild - Grade 1 :
only visible on ultrasound.
(Up to 150 ml amount required to demonstrate
sonologically).

15.  Moderate - Grade 2 :
(1500-2000 ml)
causes clinical dullness in
flanks with symmetrical
distension in the flanks.
Shifting dullness is elicited.

16.  Severe (gross) - Grade 3 :
(>2000 ml)
It causes marked abdominal
distension. Fluid thrill is
elicited.

17. Thank you …