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DR. SAI LAKSHMIKANTH BHARATHI
De Medicina
Aulus Cornelius Celsus
Roman
25 B.C to 50 A.D
Coined “ASCITES” ; askites – baglike
(Greek)
Definition
Pathogenesis & theories of ascites
formation
Approach
Differential Diagnosis
Management
Accumulation of fluid in the peritoneal
cavity
Hydroperitoneum
Hydraskos or abdominal dropsy
Similar to edema formation
I. Increased hydrostatic pressure
II. Reduction in colloid osmotic pressure
III. Disturbance of capillary permeability
IV. Insufficiency of lymphatic drainage
Portal hypertension
IVC obstruction
Anatomic disruption of Hepatic veins
Minimum albumin concentration – 2.5 to
3g/100ml
Decreased albumin production
Increased excretion of albumin
Hypoalbuminenia + Portal HTN- a pre-requisite for
ascites
Trauma
Inflammation
Immune mediated
Mesentric lymph adenopathy
Parasitic lymphatic obstruction
Underfill theory
Overflow theory
Lymph imbalance theory
Vasodilation theory
Primary
• Imbalance of Starling’s forces
• Reduced effective plasma volume
• Stimulation of Volume receptors,RAAS & sympathetic system
• Increased circulating ADH levels
• Increased Sodium reabsorbtion and reduced GFR
• Ascites formation
Lymphatic insufficiency secondary to portal HTN
Opening of Portosystemic shunts
Decreasing PVR
Formation or breakdown of
vasodilatory substances
Primary
• Liver damage
• Portal hypertension sends salt retaining signal
• Retention of Sodium
• Volume expansion
• Overflow from Intravascular volume
• Ascites formation
Do not explain in each case
Both theories not mutually exclusive
Doesn’t effectively explain the initial event
Contradicts “classical” theories
Extravasation from intravascular space
(Lymph Production)
Reflux into vascular system
(Lymphatic Drainage)
Obliteration of diaphragmatic lymphatics
Dilated lymphatic vessels – reduced flow
Limited lymph kinetics at the communion
of lymphatics and venous systems
• Portal Hypertension
• Peripheral vasodilation
• Plasma volume reduction
• Volume retention
• Salt retention
• Plasma volume expansion
• Ascites formation
Clinical features
Laboratory findings
Is the distension due to Ascites??
Acute or Chronic??
Possible etiological factors??
Grade of Ascites??
Manifest ascites – 1.5 to 2 liters
Puddle sign 100-150 ml
Shifting dullness 1-1.5 liters
Fluid thrill >2 liters
Colour
Cell count & Differential
Protein
Sugar(Glucose < 50g/dL – Bacterial infection)
LDH
Bacteriology-Culture & Gram Stain, TB
ADA
Clear and straw coloured
Turbid
Hemorrhagic
Chylous
Exudate ->1000/cu.mm; Transudate <
250cu.mm
PMN > 250/cu.mm – Bacterial
Lymphocytes >20% of Total Counts – TB
(also Ascitic:Blood Glucose <0.7)
SAAG – Serum albumin: Ascitic Albumin
>1.1 – Ascites secondary to Portal
Hypertension
<1.1 – Malignancy or Inflammation
Transudate Exudate
Protein <2.5g/L Protein >2.5g/L
Specific Gravity <1,015 Specific gravity >1,016
Gram stain
Culture – Aerobic and anaerobic
AFB staining
PCR for Tuberculosis
Ascites:serum <1.4 – portal hypertension
Absolute value >400 IU/L
Ferritin
Fibronectin
Cholesterol
α1- antitrypsin
Parameters Portal hypertension Infectious etiology malignancy
Clinical
features
Splenomegaly, spider
naevi, jaundice,
Dupytren’s
contracture
Fever, tenderness,
guarding..
Sister Mary Joseph
nodules,
Troisier’s sign
Loss of weight
SAAG
Protein
>1.1
<2.5g/dL
<1.1
>3g/dL
<1.1
>3g/dL
Cell count <250cells/cu.mm >1000cells/cu.mm >>1000cells/ cu.mm
Ascites:
Serum LDH
<1.4 >1.4 >>1.4
Color Clear Clear to turbid Clear, turbid,
hemorrhagic or
chylous
Portal hypertension
Infective etiology
Malignancy
Salt restriction
Diuretics
Beta blockers
Aldosterone antogonist
Paracentesis
Based on culture & sensitivity
Empirically, cefotaxime 2g IV q12h for min.
5 days
Alternatively, Oral ofloxacin 400mg q12h
ESBL antibiotics and aminoglycosides-
avoided
Norfloxacin daily;
At risk -ascitic fluid protein <1g/dL, UGI
bleed, previous SBP