Ascities overview
- 1. Ascites ‘’abnormal collection of fluid in the peritoneal cavity, a common complication of portal hpt secondary to cirrhosis’’ Na+ & H20 retention, due to peripheral arterial vasodilation particularly the splanchnic circulation. This reduces BP and activates the rennin-angiotensin system and sympathetic nervous supply increased H20 and Na+ retention Local hydrostatic pressure increase due to portal hpt, which increase lymph production in the hepatic and splanchnic areas. Transudation of the fluid ascites Hypoalbuminaemia due to decreased liver synthesis, resulting in a low plasma oncotic pressure 2° hyperaldosteronism with reduced catabolism of the salt-retaining hormone. Spironolactone (aldosterone antagonist) used as Tx. Causes: Portal Hpt: Cirrhosis CCF Constrictive Pericarditis Budd-Chiari Syndrome IVC obstruction Hypoalbuminaemia: Nephrotic Syndrome Protein losing enteropathy Neoplasms: Peritoneal carcinomatosis Pseudomyxoma Miscellaneous: Pancreatic ascites Nephrogenic – ass with dialysis Myxoedema Meigs’s syndrome Clinical Features: Abdo distension Fluid thrill Shifting Dullness Tense ascites can cause; pain, difficulty breathing, eversion of the umbilicus, hernias & scrotal odeama. If rapid onset think Ca, GI bleeding, infection, portal venous thrombosis
- 2. What is the Ascites made of? Look at serum: asites albumin gradient shows oncotic pressures and correlates with portal venous pressures Management: Dietary Na+ restriction (1-1.5g/day) Diuretics – spironlactone Stop alcohol Monitor renal and liver function Potential complications – encephalopathy, hypokaleamia, hyponatreamia, hypochloraemic alkalosis and azotaemia. If tense ascites paracentesis If no response serial therapeutic paracentesis, peritoneovenous shunt, transjugular intrahepatic portosystemic shut & liver transplant. Transudate : low protein ( <30 g/L) Exudate : high protein High gradient >11g/l - (ass with portal hpt) Cirrhosis Alcoholic Hepatitis Cardiac Ascites Fulminant hepatic failure Budd-Chiari Portal vein thrombosis Veno-occlusive disease Low gradient <11g/l Peritoneal carcinomatosis TB Pancreatic Ascites Biliary Ascites Nephrotic Syndrome