Ascites

Differential Diagnosis

• Hepatic
  • Cirrhosis
  • Alcoholic hepatitis
  • Acute liver failure
  • Budd-Chiari syndrome
  • Sinusoidal obstruction syndrome
  • Sarcoidosis
  • Polycystic liver disease
  • Nodular regenerative hyperplasia
• Cardiac
  • Heart failure
  • Constrictive pericarditis
  • Pulmonary hypertension
• Neoplastic
  • Hepatocellular carcinoma
  • Liver metastases
  • Peritoneal carcinomatosis
  • Malignant chylous ascites
• Infectious
  • Peritoneal tuberculosis
  • Secondary bacterial peritonitis
• Other
  • Nephrotic syndrome
  • Pacreatitis
  • Mixedema
  • Post-operative lymphatic leak

Investigations

• Ultrasound or CT abdomen to look for fluid and any underlying lesions
• Diagnostic paracentesis
  • Albumin and protein, to calculated serum-ascites albumin gradient
  • Cell count and differential (PMN≥250 suggests SBP)
  • Gram stain and culture
  • ± acid-fast stain and culture
  • ± CEA and ALP
  • ± cytology
  • ± CA-125

Serum-Ascites Albumin Gradient

• SAAG = serum albumin - ascites albumin
• SAAG ≥11 g/L suggests portal hypertension
• SAAG <11 g/L suggests a cause other than portal hypertension

Management

• Sodium restrict < 88 mmol/day (5 g/day of salt)
• Diuretics: spironolactone 100 mg po daily + furosemide 40 mg po daily
  • Titrate up every few days, to maximum of 400 mg / 160 mg

Refractory Ascites

• Defined by urinary sodium excretion <78 mmol/24h despite maximal tolerated diuretics
  • May be limited by diuretic effects

Spontaneous Bacterial Peritonitis

• Diagnosed by ascitic fluid neutrophils >250 or culture positive
• Treat with ceftriaxone 2g q24h for 5-7 days

Further Reading

• Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012