Ascites: Difference between revisions

Latest revision as of 14:48, 2 August 2020

Differential Diagnosis

Hepatic
Cardiac
Neoplastic
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

@@ Line 1: / Line 1: @@
-== Management ==
+== Differential Diagnosis ==
+* Hepatic
-* Sodium restrict &lt; 88 mmol/day (5 g/day of salt)
+** [[Cirrhosis]]
-* Diuretics: spironolactone 100 mg po daily + furosemide 40 mg po daily
+** [[Alcoholic hepatitis]]
-** Titrate up every few days, to maximum of 400 mg / 160 mg
+** [[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 ==
-=== Refractory Ascites ===
+* Ultrasound or CT abdomen to look for fluid and any underlying lesions
-* Defined by urinary sodium excretion &lt;78 mmol/24h despite maximal tolerated diuretics
+* Diagnostic [[paracentesis]]
-** May be limited by diuretic effects
+** 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
-=== Spontaneous Bacterial Peritonitis ===
+=== Serum-Ascites Albumin Gradient ===
+* SAAG = serum albumin - ascites albumin
-* Diagnosed by ascitic fluid neutrophils &gt;250 or culture positive
+* SAAG ≥11 g/L suggests portal hypertension
-* Treat with ceftriaxone 2g q24h for 5-7 days
+* SAAG <11 g/L suggests a cause other than portal hypertension
+==Management==
-== Further Reading ==
+*Sodium restrict &lt; 88 mmol/day (5 g/day of salt)
-* [https://doi.org/10.1002/hep.26359 Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012]
+*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 &lt;78 mmol/24h despite maximal tolerated diuretics
+**May be limited by diuretic effects
+===Spontaneous Bacterial Peritonitis===
+*Diagnosed by ascitic fluid neutrophils &gt;250 or culture positive
+*Treat with ceftriaxone 2g q24h for 5-7 days
+==Further Reading==
+*[https://doi.org/10.1002/hep.26359 Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012]
 [[Category:Gastroenterology]]