Ascites Disease

BASICS

DESCRIPTION

Effusion and accumulation of fluid in the abdominal cavity. Ascites may occur in any condition that causes generalized edema. In children, nephrotic syndrome and malignancy are the predominant causes. In adults, cirrhosis, heart failure, nephrotic syndrome and chronic peritonitis are most common.

System(s) affected: Hemic/Lymphatic/Immunologic, Cardiovascular, Gastrointestinal, Renal/Urologic
Genetics: N/A
Incidence/Prevalence in USA: Determined by etiology
Predominant age: Determined by etiology
Predominant sex: Determined by etiology

SIGNS AND SYMPTOMS

Abdominal pain
Abdominal discomfort
Abdominal distention
Tight clothing
Shortness of breath
Anorexia
Nausea
Early satiety
Pyrosis; heartburn
Flank pain
Weight gain
Weight gain
Abdominal fluid wave
Shifting dullness
Penile edema
Scrotal edema
Umbilical herniation
Pleural effusion
Rales
Tachycardia

CAUSES

Peritoneal infection and inflammation:
- Tuberculosis
- Fungus disease
- Chronic bacterial (foreign body, fistula)
- Ruptured viscus
- Granulomatous peritonitis
- Filariasis
Metabolic diseases
- Hypothyroidism
- Cirrhosis
- Prehepatic and posthepatic portal hypertension
- Myxedema
- Nephrogenous
- Marked hypoalbuminemia (< 2 gm/dL)
Heart and hepatic congestion
- Congestive heart failure
- Constrictive pericarditis
- Tricuspid stenosis or insufficiency
Traumatic
- Pancreatic fistula
- Biliary fistula
- Lymphatic fistula (chylous)
- Hemoperitoneum (trauma, ectopic pregnancy, tumor)
Malignancy
- Peritoneal seeding - ovarian, colon, pancreas and others
- Lymphatic obstruction - leukemia, lymphoma

RISK FACTORS

Those associated with possible causes

DIAGNOSIS

LABORATORY

Ascitic fluid (must be sampled in all new onset, or new to treatment cases) obtain in all:
- Culture through inoculating blood culture bottles
- Total cell count < 500 mm3
- PMN < 200 mm3
- Albumin in both serum and ascites calculate. Serum - ascites 1.1 gm indicates portal hypertension. Protein > 2.0 gm (some would suggest 2.5 gm) indicates exudate.
Of use in specific circumstances
- Lactate dehydrogenase < 200 IU/L
- Amylase
- Acid fast or fungal cultures
- Cytology
- Triglycerides (with a serum test)
In blood
- Creatinine < 1.4 mg/dL
- Electrolytes
In urine - sodium levels in a single sample:
- < 10 mEq/L (< 10 mmol/L) diuretic response unlikely
- > 10-70 mEq/L (> 10-70 mmol/L) diuretic response likely
- > 70 mEq/L(> 70 mmol/L) diuretics unnecessary

Drugs that may alter lab results: Refer to laboratory test reference Disorders that may alter lab results: Refer to laboratory test reference

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

Laparoscopy

IMAGING

Sonography or CT scan

DIAGNOSTIC PROCEDURES

Diagnostic paracentesis

TREATMENT

APPROPRIATE HEALTH CARE

May be outpatient or inpatient depending on physical condition

GENERAL MEASURES

For all patients
- Some sodium restriction required, must be most severe when urine sodium is very low
- Select a sodium restriction that patient can attain at home; treatment usually required 3-6 months
- Water restriction only necessary if sodium < 130 mEq/L
- Any persistent elevation of creatinine to > 2.5 mg/dL should lead to decreasing diuretic doses and therapeutic paracentesis
- Daily record of weight to monitor gains and losses
For ascites with edema
- Salt restriction and diuretics usually effective
- Maximum weight loss of 5 lbs/day
- Weekly electrolytes on serum during rapid weight loss
For ascites without edema
- Dietary restrictions and diuretics as above
- Maximum loss of 2 lbs/day
Refractory ascites - ascites that is increasing despite maximal doses of spironolactone (300 mg/day) and furosemide (160-200 mg/day) and dietary sodium restriction OR progressive rise in creatinine to >2.0.
- Start paracentesis up to 10 L/session. Replace albumin IV for all removals > 5L at rate of 10 gm albumin for each liter >5 L removed. Continue diuretics at half previous dose.

SURGICAL MEASURES

In chronic, refractory cases, consider peritoneovenous shunt or transjugular intrahepatic portal shunt (TIPS)

ACTIVITY

Bedrest of benefit in heart failure and when leg edema is prominent, otherwise of limited value.

DIET

Sodium restriction needed for several months; regulate on a diet that can be followed outside hospital

PATIENT EDUCATION

Diet restrictions

FOLLOW UP

PREVENTION/AVOIDANCE

Dependent upon etiology

POSSIBLE COMPLICATIONS

Overly aggressive diuresis may lead to hypokalemia, worsening hepatic encephalopathy, intravascular volume depletion, azotemia, and possibly to renal failure and death
Sympathetic pleural effusion
Other complications as may be associated with cause of ascites

EXPECTED COURSE AND PROGNOSIS

Ascites is rarely life-threatening. Conservative therapy usually successful.
Prognosis variable depending upon the underlying cause

MISCELLANEOUS

ASSOCIATED CONDITIONS

Listed in Causes

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

NSAID = Non-steroidal anti-inflammatory drug

Clinical Investigations

ROLE OF HOMOEOPATHY

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