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Ascites - Approach

 

  • Symptoms: weight gain, lower extremity edema (negative LR 0.1)

 

  • Pathophysiology:
    • Elevated hydrostatic pressures (SAAG >1.1)
      • Normal JVP: cirrhosis (80%), alcoholic hepatitis, IVC obstruction, Budd-Chiari, portal vein thrombosis
      • Elevated JVP: heart failure, constrictive pericarditis, pulmonary hypertension
    • SAAG <1.1
      • Decreased oncotic pressure (ascitic total protein <2.5 g/dL): protein losing enteropathy, nephrotic syndrome, malnutrition
      • Increased permeability (ascitic total protein >2.5 g/dL): malignancy (8%), infection (TB, secondary peritonitis), serositis, pancreatitis
  • Diagnosis
    • Physical exam: shifting dullness (LR 2.7) and fluid wave (LR 6.0) are most helpful maneuvers
    • Gold standard for diagnosis is ultrasound, which can detect as little as 100cc
    • Paracentesis, with following:
      • Cell count: >250 PMN/mm3 indicates spontaneous bacterial peritonitis
      • Serum albumin ascites gradient (Serum albumin less ascitic albumin
      • Total protein: when SAAG is >1.1, protein >2.5 mg/dL suggests cardiac ascites, <1 mg/dL increases risk of SBP
    • o    When considering TB:
      • AFB smear very insensitive
      • AFB culture: 75% sensitive when one liter cultured
      • Adenosine deaminase not useful (falsely depressed in cirrhosis)
      • Often requires peritoneoscopy and biopsy
    • When considering malignancy:
      • Cytology: 50cc typically sufficient if coordinated with lab for prompt processing (sensitivity increases from 83% to 97% if send 3 samples)

(Christopher Woo MD, 5/10/11)