Ascites

Causes of Ascites
Cause Frequency
Cirrhosis 81%
Cancer 10%
Heart Failure 3%
Tuberculosis 2%
Dialysis 1%
Pancreatic Disease 1%
Other 2%

Source: UpToDate
 Rare Causes of Ascites
Category
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,
 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 Fluid
Routine Optional Unusual
Cell count and Glucose Tuberculosis smear
differential concentration and culture,
adenosine deaminase
Albumin LDH concentration Cytology
concentration
Total protein Gram stain Triglyceride
concentration concentration
Culture in blood Amylase Bilirubin
culture bottles concentration 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
Gradient
SAAG > 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
Alcoholic liver disease
Chronic hepatitis C
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis
Chronic hepatitis B
Hemochromatosis
Wilsons disease
Alpha-1-antitrypsin deficiency
Nonalcoholic fatty liver disease
Testing
History, AST / ALT > 2
Hep C Ab, Viral load
Antimitochondrial antibodies
Contrast cholangiography , ANA,
Anti smooth muscle Ab, ANCA
Type 1: ANA, ANCA antismooth
muscle Ab Type 2: anti-LKM-1
Hepatitis B serologies
Ferritin, genetic testing
Ceruloplasmin
Serum AAT
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 months
Becker, 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/Pressemapp
 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

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
Denver Shunt
(Similar to LaVeen Shunt)
 Transjugular intrahepatic
portosystemic shunt (TIPS)
 References
1. Up to Date
2. Ascites and renal dysfunction in liver disease, Second edition. Edited by
Pere Gins, Vicente Arroyo, Juan Rods, 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.