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1. ASCITES
1
MOST PATIENTS
HAVE CIRRHOSIS
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2. Hepatocellular carcinoma
2
 When to suspect?
Sudden
development of
ascites in a stable cirrhotic
patient
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3. Constrictive pericarditis
3
Tuberculosis
One
of the few curable
causes of ascites
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4. Tuberculous peritonitis
4
Very important cause
Curable
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5. Peritoneal carcinomatosis
5
 Protein rich fluid by tumor cells lining
the peritoneum

ECF enters the peritoneal cavity to maintain oncotic
balance
 Tuberculosis

Also causes production of protein rich fluid
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6. Sister Mary Joseph's nodule
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Hard periumbilical nodule
Metastatic
Pelvic
disease
or gastrointestinal
primary tumor
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10. Virchow's node
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Supraclavicular
adenopathy
GI malignancy
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14. IVC blockage
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Large veins
Back
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15. Portal hypertension
15
 First pathogenetic abnormality in
ascites formation in cirrhosis
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16. Obstruction of hepatic lymphatics
16
Cause exudation of
hepatic lymph from the
surface
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17. Increased hepatic lymph
17
 Normal physiology
 Lymph
 To
produced in the hepatic sinusoids
systemic circulation by the thoracic duct
 When sinusoidal pressures rise
 Lymph
spills over from the surface of the
liver to the peritoneal cavity
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18. PATHOGENESIS OF ASCITES
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 Splanchnic vasodilatation

Chief factor contributing to ascites
 Increased hydrostatic pressure within the
splanchnic capillary bed
 Exudation of lymph from the surface of the
cirrhotic liver
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19. Kidneys
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 Increased sodium and water reabsorption
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20. Hypoalbuminemia
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 Reduced plasma oncotic pressure
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22. PRECIPITATING FACTORS
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1. Excessive salt intake
2. Failure to take drugs
3. Peritoneal infection
4. Worsening of liver disease
5. Hepatocellular carcinoma
6. Portal vein thrombosis
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23. USS
23
 Best test to detect even small amount
of ascites
 Can detect as little as 100 mL of fluid
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26. Morrison’s pouch
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
Earliest fluid collection

Hepato-renal pouch
 POD
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28. More than 500 to 1000 mL
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Shifting
dullness
 Fluid thrill
Not very useful
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29. No flank dullness
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Ascites
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unlikely

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33. Paracentesis
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 Final confirmation of ascites
 Best method for diagnosing the
cause
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34. Routine tests on ascitic fluid
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1. Cell count
2. Albumin
3. Total protein
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35. Optional
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4. Culture
5. Glucose
6. Gram’s stain
7. Amylase
8. Cytology
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36. Cell count
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Single most helpful
ascitic fluid test
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37. WBC count
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 Uncomplicated cirrhotic ascites
 < 500 WBCs/mm3 in
 Absolute neutrophil count
 < 250/mm3 in uncomplicated cirrhotic ascitic fluid
 Empiric antibiotic treatment
 Based on absolute neutrophil count rather than the
culture
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38. Spontaneous bacterial peritonitis
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 Most common cause of an elevated
ascitic WBC count

PMN > 70% of the total WBC count
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39. Elevated ascitic WBC count – other causes
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Tuberculous peritonitis
2. Peritoneal carcinomatosis
Predominance of lymphocytes
1.
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40. SAAG
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 Serum ascites albumin gradient

Serum albumin in g/dL minus ascites albumin in g/dL
 To differentiate cirrhotic ascites from
other causes of ascites

Better than total protein content in the ascitic fluid
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41. High SAAG (> 1.1 g/dL)
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 Uncomplicated cirrhotic ascites
 Serum albumin concentration
At
least 1 g/dL higher than that of the
ascitic fluid albumin concentration.
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42. SAAG - indirect but accurate index of portal
pressure
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 1.1 g/dL or more
 Portal hypertension
Accuracy
97%
 < 1.1 g/dL
 No portal hypertension
Accuracy
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97%

43. Accuracy > 97%
43
 Even with
 Ascitic
fluid infection
 Diuresis
 Paracentesis
 IV albumin
 Varying causes of liver disease
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44. High SAAG
44
 Does not confirm cirrhosis
Indicates
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portal hypertension

45. Typical of cirrhosis
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4.
SAAG >1.1 g/dL
WBC count < 500 cells/mm3
Predominant lymphocytes
Specific gravity less than 1016
5.
Urine Na low
1.
2.
3.
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46. High gradient (transudative) ascites
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 Right heart failure
Another
common cause
 Nephrotic syndrome
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47. HIGH GRADIENT ≥1.1 g/DL
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 Cardiac


TR
Constrictive pericarditis
 Alcoholic hepatitis
 Massive liver metastases
 Fulminant hepatic failure
 Budd-Chiari syndrome
 Portal vein thrombosis
 Myxedema
 Meigs' syndrome
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48. LOW GRADIENT <1.1 g/DL
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 Peritonitis

TB, Bacterial
 Peritoneal carcinomatosis
 Pancreatic ascites
 Bowel obstruction or infarction
 Biliary ascites
 Postoperative lymphatic leak
 Serositis in connective tissue diseases
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49. Blood-stained ascitic fluid
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 Traumatic tap
 Frequently
clots
 Tuberculous peritonitis
 Hepatoma
 Peritoneal secondaries
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50. Peritonitis
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 Bacterial
 Polymorphonuclear cells predominate
 Gram's stain may be positive
 TB
 Predominant lymphocytes
 Diagnosis
 Granulomas on peritoneal biopsy
 AFB
 Difficult to recover from ascitic fluid
 May take 4 to 6 weeks
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51. CHYLOUS ASCITES
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 Lymphatic obstruction
 Trauma
 Tumor
 TB
 Filariasis
 Cirrhosis
 Nephrotic syndrome
 Congenital abnormalities
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52. Salt restriction
52
 Most important treatment of
cirrhotic ascites
 Normal diet contains

5 to 15 grams of sodium chloride
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53. Spironolactone plus furosemide produce a diuresis
in most patients
53
 If sodium restriction alone does not
cause diuresis and weight loss
 Spironolactone

Drug of choice
 Furosemide
 Risk
of excessive diuresis
 Hypokalemia
Precipitate
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encephalopathy

54. Fluid intake
54
 Restricted only if there is
dilutional hyponatremia
 High
levels of antidiuretic hormone
Diagnosis
Serum
sodium < 130 mEq/L in the
presence of ascites
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55. Large-volume paracentesis
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Treatment of choice for
large-volume ascites
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56. LARGE VOLUME PARACENTESIS
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 Tense ascites
 Respiratory distress
 Poor response to medical
therapy
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59. Hepatorenal syndrome
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 Renal failure
 Profound vasoconstriction in the
renal circulation
Due
to excessive activity of endogenous
vasoactive substances
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60. Hemodynamic hallmark
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 Systemic vasodilation
 Renal vasoconstriction
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61. Clinical hallmarks
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Worsening azotemia
Hyponatremia
Progressive oliguria
Hypotension
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62. Treatment
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 Vasoconstrictor drugs
 Norepinephrine, midodrine,
terlipressin or alpha-adrenergic
agents
 In combination with albumin
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63. Liver transplantation
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Most effective treatment for
hepatorenal syndrome
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64. SBP
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 No obvious primary source of
infection
 Contrast-enhanced CT
To
exclude an intra-abdominal
source for infection
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65. Cefotaxime and an aminoglycoside
65
90 %
Monomicrobial
Enteric GNB
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66. What is the diagnosis
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 A 30-year-old male is admitted with mild
abdominal swelling, fever, and loss of weight.
Ascitic fluid shows the following changes.
Macroscopic appearance - hemorrhagic.
Proteins = 3 grams/dl. SAAG = < 1.1 g/dl.
Cells = WBCs in plenty. 70% of cells are
lymphocytes. Few mesothelial cells are also
present. He occasionally takes alcohol. What
is the most probable diagnosis?
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67. Answer
67
 TB
 Predominant
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lymphocytes