Causes of ascites
Causative disorders
Cirrhosis
PHT-related disorder
Cardiac disease
Peritoneal carcinomatosis
Miscellaneous non-PHT disorders
Percentage
85%
8%
3%
2%
2%

Diagnosis of ascites
*
•
Ascites can be graded as
Grade 1 (mild) Detectable only by US
Grade 2 (moderate) Moderate abdominal distension
Grade 3 (large) Marked abdominal distension
* Moore KP et al. Hepatology 2003 ; 38 : 258 – 66.

Ascites grade 1
Detectable only by US

Pathogenesis of ascites in cirrhosis
PHT

Nitric oxide
Vasodilatation
Renal Na retention

Sympathetic activity

RAA system
Overfill of intravascular volume
Ascites formation

Indications for diagnostic paracentesis
•
Patients with new-onset ascites
•
Cirrhotic patients with ascites at admission
•
Cirrhotic patients with ascites & symptoms or signs of infection: fever, leukocytosis, abdominal pain
•
Cirrhotic patients with ascites & clinical condition deteriorating during hospitalization: renal function impairment, hepatic encephalopathy, GI bleeding

Needle-entry sites
Superior & inferior epigastric arteries run just lateral to the umbilicus towards mid-inguinal point & should be avoided
.

The Z-tract technique
Green (21 G) or blue (23 G) needle
Diagnostic purpose: 10- 20 ml of fluid ascites
Cytologic study: 50 ml of fluid ascites
Thomsen TW et al. N Engl J Med 2006 ; 355 : e21.

The angular insertion technique
Green (21 G) or blue (23 G) needle
Diagnostic purpose: 10- 20 ml of fluid ascites
Cytologic study: 50 ml of fluid ascites
.

MA
What are the contraindications & complications of paracentesis?

Complications of paracentesis
•
Abdominal hematomas
Up to 1 % of patients
Rarely serious or life threatening
•
Hemoperitoneum or bowel perforation
Rare (< 1/1000 procedures)
Serious complications
Guidelines on management of ascites in cirrhosis.
Gut 2006 ; 55 ; 1 – 12 .

Contraindications to paracentesis
•
Clinically evident fibrinolysis or DIC
Preclude paracentesis
•
Abnormal coagulation profile
Paracentesis not contraindicated
Majority of pts have prolonged PT & thrombocytopenia
No data to support the use of FFP before paracentesis
AASLD practice guidelines
Runyon BA. Hepatology 2004; 39: 841 – 856.

Ascitic Fluid Laboratory Data
Routine
Cell count *
Albumin
Total protein
Optional
Culture
Glucose
LDH
Amylase
Gram’s stain
Unusual
TB smear & culture
Cytology
TG
Bilirubin
Unhelpful pH
Lactate
Cholesterol
Fibronectin
* Automated counting can replace manual cell count
.

Serum Ascites Albumin Gradient (SAAG)

Albumin

Serum
– 
Albumin
(g/dL) (g/dL)

Ascites in the same day

Differential diagnosis according to SAAG
High Gradient
≥ 1.1 g/dL
Low Gradient
< 1.1 g/dL
.

Differential diagnosis of ascites according to SAAG
High Gradient
≥1.1 g/dL (11g/L)
Cirrhosis
Liver metastases
Low Gradient
<1.1 g/dL (11g/L)
Peritoneal carcinomatosis
Tuberculous peritonitis
Cardiac ascites
Portal-vein thrombosis
Budd–Chiari syndrome
Hypothyroid
Pancreatic ascites
Biliary ascites
Nephrotic syndrome
.
Serositis

What is the treatment?

Tapping ascitic fluid (1672)
German National Museum, Nürnberg, Germany

ND
What do you prescribe to this patient?
What are the side effects of these drugs?
How do you follow-up the patient?

ND
Recommendation
Low sodium diet
Dietary salt should be restricted to a no-added salt diet of 90 mmol salt/day (5.2 g salt/day) by adopting a no-added salt diet & avoidance of pre-prepared foodstuffs

Diuretics treatment in cirrhotic ascites
Oral route – Single morning dose
Progressive Schedule Combined Schedule
SP *
100

200

300

400 mg/d
SP 100 mg/d
+ FUR 40 mg/d
40
Progressive increase every 3-5 days
SP 400 mg/d + FUR**

80

120

160 mg/d
SP 200

300

400 mg/d
+ FUR 80

120

160 mg/d
*SP
**FUR
Spironolactone
Furosemide

Follow-up of patients on diuretics – 1
•
Weight loss
Massive edema
Resolved edema
No limit to daily weight loss

0.5 kg / day
•
Weight loss less than desired
24-hour urine sodium
> 78 mmol/24h & no weight loss: patient not compliant
< 78 mmol/24h & no weight loss: increased diuretics
“spot” urine NA/K>1 = 24-hour urine Na>78 mmol/24h

Follow-up of patients on diuretics – 2
•
Body weight
•
Blood pressure
•
Pulse
•
Electrolytes
•
Urea
•
Creatinine
Every 2 – 4 weeks
Every few months thereafter

Side effects of diuretics
•
Spironolactone
Men
 libido, impotence, gynecomastia
Women Menstrual irregularity
•
Hydro-electrolytes disturbances
Hypovolemia: hypotension – renal insufficiency
Hyponatremia
Hypo or hyperkalemia
Hepatic encephalopathy

Water restriction
•
Not necessary in most cirrhotic patients with ascites
•
Cirrhotic patients have symptoms from hyponatremia if Na < 110 mmol/L or if very rapid decline in Na
•
Water restriction indicated in patients who are clinically euvolaemic withs severe hyponatraemia & not taking diuretics with normal creatinine
•
Avoid increasing serum sodium > 12 mmol/l per day
ND

Bed rest in cirrhotic ascites
•
Upright posture associated with activation of RAA system, reduction in GFR & sodium excretion, & decreased response to diuretics
•
Bed rest
 muscle atrophy & other complications
•
No clinical studies to demonstrate efficacy of bed rest

Recommendation
Bed rest
Bed rest is NOT necessary for the treatment of cirrhotic ascites

OH
How do you treat the tense ascites in this patient?

RA
Is this a refractory ascites?
How do you treat refractory ascites?

Refractory ascites (

10 %)
•
Diuretic resistant ascites
Unresponsive to LSD (< 88 mmol/day)
& High-dose diuretics
SP 400 mg & FUR 160 mg/d for at least
1 week
•
Diuretic intractable ascites
D iuretic induced complications Encephalopathy
Creatinine > 2.0 g/dL
Na < 125 mmol/L
K > 6 or < 3 mmol/L
International ascites club
Arroyo V et al. Hepatology 1996 ; 23 : 164 – 76.

Treatment of refractory ascites
•
Therapeutic paracentesis is the first line treatment:
< 5 L: Colloid - No need for albumin
> 5 L: Albumin after paracentesis (8g/l)
•
TIPS should be considered in refractory ascites
•
LT referral should be considered in refractory ascites
•
Peritoneovenous shunt should be considered in patients who are not candidates for paracentesis, TIPS, or LT
ND

Refractory Ascites
LT evaluation
LVP + Albumin
Na restricted diet (90 mEq/d)
Fluid restriction if Na < 130 mEq/L
Repeated LVP + albumin
1 st Step
Maintenance
Treatment
Preserved liver function?
Loculated ascites?
Paracentesis more frequent than 2-3 /month?
No
Continue LVP + Albumin
Yes
Consider TIPS
Clin Gastroenterol Hepatol 2005 ; 3 : 1187 – 1191.

Treatment of refractory ascites
•
Serial therapeutic paracentesis
•
TIPS
•
Liver transplantation
•
Peritoneovenous shunt: LeVeen – Denver

I s
TIPS for refractory ascites practice guidelines
Runyon BA. Hepatology 2004; 39: 841 – 856.

Albumin in cirrhotic ascites
•
Large paracentesis > 5 L
8 g albumin/liter of ascites removed
(100 ml of 20% albumin / 3 L ascites)
•
SBP with renal impairement
First six hours 1.5 g albumin / kg bw
Day 3 1g albumin / kg bw
•
HRS-I
First day 1 g / kg bw (maximum 100 g)
Following days 20 – 40 g / day

Prognosis of ascites in cirrhotic patients
•
Ascites 50 % survival at 2 years
•
Refractory ascites 50% survival at 6 months
25% survival at 1 year
•
SBP
•
HRS-2
•
HRS-1
30 - 50% survival at 1 year
40% survival at 6 months
< 5% survival at 6 months
Referral to liver transplantation unit