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Evaluation of Ascites
Andrew MaclennanMorning Report
July 24, 2009
Pathophysiology of Ascites
From: Robbins Basic Pathology
Causes of AscitesCause Frequency
Cirrhosis 81%
Cancer 10%
Heart Failure 3%
Tuberculosis 2%
Dialysis 1%
Pancreatic Disease 1%
Other 2%
Source: UpToDate
Rare Causes of AscitesCategory
Infectious diseases Amebiasis, Ascariasis, Brucellosis, Chlamydia peritonitis, Complications related to HIV infection, Pelvic inflammatory disease, Pseudomembranous colitis, Salmonellosis, Whipple's disease
Hematologic Amyloidosis, Castleman's syndrome, Extramedullary hematopoiesis, Hemophagocytic syndrome, Histiocytosis X, Leukemia, Lymphoma, Mastocytosis, Multiple myeloma
Miscellaneous Abdominal pregnancy, Crohn's disease, Endometriosis, Gaucher's disease, Lymphangioleiomyomatosis, Myxedema, Nephrotic syndrome, lymphatic tear or ureteral injury. Ovarian hyperstimulation
Imaging
• Ultrasound with Dopplers– Easily confirms ascites– May see nodularity of cirrhosis– Evaluate patency of vasculature– No radiation, contrast
• CT / MRI – Evaluation for malignancy
Tests on Ascitic FluidRoutine Optional Unusual
Cell count and differential Glucose concentration Tuberculosis smear and culture, adenosine deaminase
Albumin concentration LDH concentration Cytology
Total protein concentration Gram stain Triglyceride concentration
Culture in blood culture bottles
Amylase concentration Bilirubin concentration
Cell Count, differential and culture
• Is ascites infected?– Greater than 250 PMN = SBP
• If ascites is bloody ( > 50,000 RBC/mm3), correct by subtracting 1 PMN / 250 RBC
• Is ascites bloody?– 5% of pts w/ cirrhosis - spontaneous or s/p traumatic
tap. • Non-traumatic associated with malignancy
– 20% of malignant ascites– 10% of peritoneal carcinomatosis
Serum to Ascites Albumin Gradient
• Is portal hypertension present? • 97% accurate
SAAG > 1.1 g/dL Portal HTN SAAG < 1.1 g/dL Other causes
The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20.
Serum to Ascites Albumin GradientSAAG > 1.1 g/dL SAAG < 1.1 g/dL
Cirrhosis Peritoneal carcinomatosis
Alcoholic hepatitis Peritoneal tuberculosis
CHF Pancreatitis
Massive hepatic metastases Serositis
Budd Chiari Syndrome Nephrotic syndrome
Congestive heart failure/constrictive pericarditis
Total Protein
• Exudate ( > 2.5 g/dL) or Transudate?– Supplanted by SAAG
• Is there gut perforation? (vs SBP)– Total protein >1 g/dL – Glucose <50 mg/dL (2.8 mmol/L) – LDH greater than serum ULN
Glucose and LDH
• Consistent with infection or malignancy?– Infection and cancer consume glucoselow
• LDH is a larger molecule than glucose, enters ascitic fluid with difficulty.– Ascitis/Serum LDH ratio
• ~ 0.4 in cirrhotic ascites• Approaches 1.0 in SBP• >1.0, usually infection or tumor
Other tests• Amylase
– Uncomplicated cirrhotic ascites • About 40 IU/L. The AF/S ratio is about 0.4
– Pancreatic ascites• About 2000 IU/L. The AF/S ratio is about 6
• Triglycerides — run on milky fluid. – Chylous ascites - TG > 200 mg/dL, usually 1000
mg/dL
• Bilirubin — run on brown ascites. – Biliary perforation – AF Bili > serum Bili
Tests for TB
• Smear – extremely insensitive• Culture – 62-83% when large volumes
cultured• Cell count – mononuclear cell predominance• Adenosine deaminase –
– Enzyme involved in lymphoid maturation– Falsely low in pts with both cirrhosis and TB
Cytology
• “almost 100%” with peritoneal carcinomatosis have positive cytology
• Malignant ascites from massive hepatic mets, HCC, lymphoma are usually negative
• Overall sensitivity for detection of malignancy-related ascites is 58 to 75 %
Not helpful
• “Some tests of ascitic fluid appear to be useless. These include pH, lactate, and ‘humoral tests of malignancy’ such as fibronectin, cholesterol, and many others”
Biopsy
Cirrhosis Fatty Liver
http://library.med.utah.edu/WebPath/LIVEHTML/LIVERIDX.html#2
Causes of Cirrhosis Cause Testing
Alcoholic liver disease History, AST / ALT > 2
Chronic hepatitis C Hep C Ab, Viral load
Primary biliary cirrhosis Antimitochondrial antibodies
Primary sclerosing cholangitis Contrast cholangiography , ANA, Anti smooth muscle Ab, ANCA
Autoimmune hepatitis Type 1: ANA, ANCA antismooth muscle Ab Type 2: anti-LKM-1
Chronic hepatitis B Hepatitis B serologies
Hemochromatosis Ferritin, genetic testing
Wilson’s disease Ceruloplasmin
Alpha-1-antitrypsin deficiency Serum AAT
Nonalcoholic fatty liver disease Hx of DM or metabolic syndrome
Malignant Ascites
• Definition: abnormal accumulation of fluid in the peritoneal cavity as a consequence of cancer.
• Commonly caused by cancers of:– Breast, bronchus, ovary, stomach, pancreas, colon
• 20% of cases have tumors of unknown primary
• Survival poor – usually less than 3 monthsBecker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597
Malignant Ascites: Pathophysiology
• Obstruction of lymphatics by tumor– Prevents absorption of fluid and protein
• Alteration in vascular permeability– Hormonal mechanisms (VEGF, IL2, TNF alpha)
• Decreased circulating blood volume– Activates RAAS leading to Na retention
Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597
Pathophysiology of Malignant Ascites
http://www.fresenius.de/internet/fag/com/faginpub.nsf/Content/Pressemappe+ASCO+2007
Management of Malignant Ascites
• Therapeutic paracentesis– Removing up to 5L appears safe – No good data on role of volume expanders
• Diuretics– Equivocal evidence of efficacy– May be helpful for portal HTN– Less/minimally useful when no portal HTN
• Drainage Catheters• Peritoneovenous shunts
Peritoneovenous Shunt
Denver Shunt(Similar to LaVeen Shunt)
Contraindications•Protein > 4.5 g/l (occlusion)•Loculated ascites•Coagulopathy•Advanced renal/cardiac disease•GI malignancy
Complications•Infection•Hematogenous spread of mets•DIC•Pulmonary edema•Pulmonary emboli
Transjugular intrahepatic portosystemic shunt (TIPS)
References1. Up to Date2. Ascites and renal dysfunction in liver disease, Second edition. Edited by Pere Ginès,
Vicente Arroyo, Juan Rodés, and Robert W. Schrier. Malden, Mass., Blackwell, 2005.
3. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20.
4. Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597
5. Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis, and management. Arch Intern Med. Vol 161. Dec 10/24, 2001.
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