ASCITES

Reading Assignment
Erjan Fikri

Deffinition: an accumulation of serous fluid within the peritoneal cavity.

In pediatric, ascites may be due to:

Bile (A601)
Chiloud (A605)
billiary tract disorders (A605)
portal hypertension (A605)
posterior ureal valve (A785)
pancreatic (A644)

Causes of childhood ascites:

Serous ascites;
Cirrhosis
Nephrosis
Right sided hearth failure
Budd-Chiari syndrome
Post operative (venous pressure shunt, peritoneal dialysis )

Biliary ascites;
Neonatal bile duct perforation
Hepatitis
Cystic fibrosis
Chylous ascites;
Malrotation with volvulus
Lymphangioma
Small bowel obstruction
Trauma

Urinary ascites;
Posterior urethral valves
Bladder perforation
Ureterocele

Pancreatic ascites;
Acute pancreatitis
Pancreatic pseudocyst

Ovarian ascites;
Cyst (torsion, rupture)
Tumors

Malignant ascites;

Classic physical signs: bulging flanks, shifting dullness, fluid wave.

Patients with ascites are at increased risk for spontaneous bacterial peritonitis.
Chylous ascites can result from obstruction or injury to the intraabdominal portion of
the lymphatic system:
lymphangiomatosis
congenital malformations
tumors
enlarged lymph nodes
previous abdominal surgery or trauma
Loss of serum proteins oncotic pressure peripheral edema anasarca.

Dx depends on paracentesis:
Macroscopic: serous - milky
Fluid analysis:
high cell count (predominant lymphocyt)
high protein content
elevated triglyceride level
Serum hypoalbuminemia & lymphopenia

Treatment:
Diet regulations:
high protein - low fat diet
med chain triglyceride supplement (absorbed directly into portal
circulation)
Parenteral alimentation to decrease lymph flow to facilitate sealing of
leak.

Laparotomy was indicated:

particularly in cases secondary to trauma or previous surgery.
to search for the site of the leak.
if a trial of dietary management has been unsuccessful after 4-6 weeks
Ascites secondary to parenchymal liver disease
Ascites conjunction with palmar erythema & abdominal wall collateral vein.
Parenchymal liver disease (cirrhosis hepatis) vasopressin,
rennin-aldosteron & sympathetic nervous system are activated renal vasoconstriction
sodium&water retention fluid weeps from the congested hepatic sinusoid
ascites.
Treatment: dietary sodium restriction
diuretic (furosemide alone or in combination with spironolacton)

Refractory ascites: unresponsive to sodium-restricted diet and high-dose diuretic

treatment
Refractoriness may be manifested by
minimal weight loss despite diuretic
diuretic complications
development of tense ascites alter renal blood flow & systemic
hemodynamic

Treatment:
Porto caval shunt ( >< oprative hemorragic & portosystemic
encephalopathy )
Serial therapeutic paracentesis + iv albumin infusion
Peritoneovenous shunt
Transjugular intrahepatic portosystemic shunt (tips), portal vein - hepatic
vein
 Liver transplantation.