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Ascites

more about Ascites




Normal

Abnormal
  • Ascites refers to the abnormal (pathologic) build up of fluid in the peritoneal (abdominal) cavity.  Normally there should be almost no fluid here (i.e., surrounding the intestines and organs such as the liver and spleen).
  • Ascites occurs because of one of four general problems: 1) there is a disease in the peritoneal cavity that is producing excessive fluid (e.g., infections or cancer); 2) there is fluid back up from the liver or large blood vessels into the peritoneal cavity -- known as portal hypertension; 3) low protein state in the body; and 4) miscellaneous.

  • Increased abdominal girth

  • Disease in the peritoneal cavity
    1. Malignant conditions (cancer) -- peritoneal carcinomatosis, hepatocellular carcinoma ("liver cancer"), cancer metastasized to the liver, psuedomyxoma peritonei, and Mesothelioma
    2. Infections -- bacterial peritonitis, fungal peritonitis, Tuberculosis peritonitis, HIV-associated peritonitis
    3. Others -- vasculitis, granulomatous peritonitis, familial Mediterranean fever, and eosinophilic peritonitis
  • Portal hypertension
    1. Liver diseases -- cirrhosis, Alcoholic Hepatitis, massive hepatic metastases, fulminant hepatic (liver) failure, fatty liver of pregnancy, hepatic fibrosis
    2. Hepatic (liver) congestion -- congestive Heart Failure, Budd-Chiari syndrome, tricuspid insufficiency, constrictive Pericarditis, and veno-occlusive disease
    3. Portal vein occlusion
  • Low protein (albumin) conditions

- Severe Malnutrition with anasarca, protein-losing enteropathy (body loses protein from the gastrointestinal tract), and Nephrotic Syndrome (a kidney condition)

  • Miscellaneous

- Pancreatic ascites, ovarian disease, Myxedema (thyroid disease), chylous ascites, bile ascites, urine ascites, nephrogenic ascites


  • Examination:
    1. Abdominal cavity checked for peritoneal fluid (check for shifting dullness), liver examined to see if it is enlarged or tender
    2. Neck -- check for jugular venous distention
    3. Heart -- check for tricuspid murmur or signs of heart disease
    4. Lungs -- examine for signs of fluid (Heart Failure)
    5. Skin -- may show cutaneous spider angiomas (spider vein clusters), palmar erythema (redness to palms of the hands), Dupuytren's Contracture, or large veins on the abdomen.
    6. Asterixis may be present (a tremor produced by pushing the hand backwards at a 90 degree angle to the wrist)
    7. Generalized edema -- swelling throughout the body
    8. Examine all lymph nodes carefully for enlargement
  • Testing:
    1. Ultrasound will determine if ascites is truly present.
    2. Paracentesis -- a needle is placed steriley in the abdomen and fluid is drawn off.  Small amounts of fluid may be drawn off to help diagnose the cause of the ascites (larger volumes to help relieve pressure).  Tests that the fluid may be sent for include cell count, albumin level, total protein, glucose, LDH, Amylase, Bilirubin, triglyceride level, gram stain and culture, AFB (stain and culture for Tuberculosis), fungal stain and cultures, and cytology (cytology means the fluid is checked for the presence of cancer cells).
    3. Albumin level significance -- the albumin level is very helpful in determining the cause of the ascites.  The albumin level in the peritoneal fluid is subtracted from the level in the blood.  If this number (known as the serum-ascites albumin gradient) is greater than 1.1, then the cause is usually in the general category of portal hypertension (see above); if less than 1.1, it is generally one of the other causes.
    4. CT scan -- can check for cancer or blood clots in the hepatic or portal veins.
    5. Doppler Ultrasound can detect blood clots in the hepatic or portal veins.
    6. Laproscopy -- surgery in which only a small incision is made through which a scope with a camera is passed in order to directly visualize the abdominal cavity and possibly biopsy tissue.

  • Large volume paracentesis (fluid removal) may be performed for symptomatic relief.  Fluid should be removed slowly to prevent secondary circulatory hypovolemia.
  • Identify and treat the underlying cause.  See individual disease sections for specific treatments.
  • Diuretic induced diuresis.





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