Diagnosis and evaluation of patients with ascites

INTRODUCTION
The most common cause in the United States is cirrhosis, which accounts for approximately 80 percent of cases Ascites is the most common complication of cirrhosis Such patients usually respond to diuretics and sodium restriction

History
obese abdomen can masquerade as ascites onset of symptoms ( fluid usually accumulates rapidly, early satiety and shortness of breath) Risk factors for liver disease Alcohol (80 grams ethanol/d 10-20 yrs) Alcoholic hepatitis causes ascites with or without cirrhosis Nonalcoholic steatohepatitis (obesity, diabetes, and hyperlipidemia)

 Viral hepatitis :HCV:transfusions before 1990, needle sharing, substance use including cocaine snorting, tattoos, acupuncture, and emigration from Japan or Southeast Asia) HBV(transfusion before 1971, persons born in hyperendemic areas (these include Africa, Southeast Asia including China, Korea, Indonesia and the Philippines, the Middle East except Israel, South and Western Pacific islands, the interior Amazon River basin, and certain parts of the Caribbean (Haiti and the Dominican Republic)), men who have sex with men, injection drug users, those on dialysis, HIV infection, family, household, and sexual contacts of HBV-infected persons

new onset ascites in cirrhosis

progression of the underlying liver disease superimposed acute liver injury (such as alcoholic or viral hepatitis) development of hepatocellular carcinoma These causes may worsening ascites noncompliance should also be considered

causes
Patients with ascites who lack risk factors for or evidence of Cirrhosis (based upon history, physical findings, and laboratory and imaging tests) should be questioned about : Cancer Heart failure Tuberculosis Hemodialysis (called nephrogenic ascites) Pancreatitis Rare causes

Rare causes of ascites 1

Infectious
Amebiasis Ascariasis Brucellosis Chlamydia peritonitis Complications related to HIV infection Pelvic inflammatory disease Pseudomembranous colitis Salmonellosis Whipple's disease

Rare causes of ascites 2

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 Operative lymphatic tear or ureteral injury
Ovarian hyperstimulation syndrome POEMS syndrome Systemic lupus erythematosus Ventriculoperitoneal shunt

Ascites due to more than >1 cause

5% cirrhosis + tuberculosis peritoneal carcinomatosis heart failure diabetic nephropathy

Physical examination
stigmata of cirrhosis ( vascular spiders, palmar erythema, and abdominal wall collaterals) Jaundice muscle wasting leukonychia (white nails) Parotid enlargement (alcohol, not cirrhosis ) The liver and spleen may be palpable The most helpful physical finding in confirming the presence of ascites is flank dullness shifting dullness

 Jugular Venous Pressure JVP& Cirrhosis: Heart failure Constrictive pericarditis Alcoholics cardiomyopathy Hepatopulmonary syn

An umbilical nodule ( Sister Mary Joseph nodule) cancer A fine needle aspiration of the nodule can provide a rapid tissue diagnosis Gastric or colon cancer, hepatocellular carcinoma, or lymphoma can cause ascites accompanied by an umbilical nodule

DIAGNOSIS
The diagnosis of ascites is established with a combination of a physical examination and an imaging test (usually ultrasonography) The absence of flank dullness was the most accurate predictor against the presence of ascites; the probability of ascites being present was less than 10 percent in such patients 1500 mL of fluid had to be present for flank dullness to be detected Ultrasonography can be helpful when the physical examination is not definitive

Grading: International Ascites Club

Grade 1 mild ascites detectable only by ultrasound examination Grade 2 moderate ascites manifested by moderate symmetrical distension of the abdomen Grade 3 large or gross ascites with marked abdominal distension
Older system 1+ is minimal and barely detectable 2+ is moderate 3+ is massive but not tense 4+ is massive and tense

ABDOMINAL PARACENTESIS
Abdominal paracentesis with appropriate ascitic fluid analysis is the most efficient way to confirm the presence of ascites, diagnose its cause, and determine if the fluid is infected The technique of paracentesis An ultrasound study demonstrated that a left lower quadrant tap site is superior to a midline site; the abdominal wall is relatively thinner in the left lower quadrant while the depth of fluid is greater Risk of large hematoma after abdominal paracentesis is only about 1 percent The risk of hemoperitoneum or iatrogenic infection is only about 1 per 1000 patients with clinically evident fibrinolysis or disseminated intravascular coagulation should not undergo paracentesis

Indications for abdominal paracentesis in a patient with ascites

Appearance
Clear : Uncomplicated ascites in the setting of cirrhosis is usually translucent yellow; it can be water clear if the bilirubin is normal and the protein concentration is very low Turbid or cloudy: Spontaneously infected fluid is frequently turbid or cloudy Opalescent: A substantial minority of samples in the setting of cirrhosis are "opalescent" and have a slightly elevated triglyceride concentration , This peculiarity does not seem to have clinical significance except to explain the opalescence, which can be misinterpreted as "pus."

 Milky : triglyceride concentration>than serum and >200 mg/dL (2.26 mmol/L) and often > than 1000 mg/dL "chylous ascites" Malignancy is the most common cause of chylous ascites cirrhosis caused 10 times as malignancy Approximately 1 out of 200 patients (0.5 percent) with cirrhosis has chylous ascites in the absence of cancer

 Pink or bloody : Pink fluid usually has RBC >10,000/mm3 Frankly bloody fluid has RBC= tens of thousands per mm3 The white cell count and neutrophil count should be corrected in bloody samples Bloody: "traumatic tap Dif.Dig: Cirrhosis leakage of blood from a punctured collateral Malignancy (22%) HCC(50%)

ASCITIC FLUID TESTS

Is the fluid infected? Is portal hypertension (PHT) present? Cell count and differential : single most helpful test performed on ascitic fluid Antibiotic treatment should be considered in any patient with a polymorphonuclear count 250/mm3 Serum-to-ascites albumin gradient >1/1 =PH

Classification of ascites by the serum albumin-ascites gradient

Cultures: new onset ascites admitted with ascites who deteriorate with fever, abdominal pain, azotemia, acidosis, or confusion

blood culture bottles at the bedside

 Protein - exudate 2.5 or 3 g/Dl less than 1 g/dL have a high risk of SBP PMN 250 cells/mm3 and meets two out of the following three criteria Total protein >1 g/dL Glucose <50 mg/dL (2.8 mmol/L) LDH greater than the upper limit of normal for serum = unlikely to have SBP and warrant immediate evaluation to determine if gut perforation into ascites has occurred

 Glucose is similar to serum unless glucose is being consumed in the peritoneal cavity by WBC or bacteria ,Malignant cells Lactate dehydrogenase - ascitic fluid/serum (AF/S) ratio of LDH is approximately 0.4 in uncomplicated cirrhotic ascites In SBP, the ascitic fluid LDH level rises such that the mean ratio approaches 1.0 If the LDH ratio is more than 1.0, LDH is being produced in or released into the peritoneal cavity; usually because of infection or tumor

 Gram stain - Gram stain of uncentrifuged fluid is positive in only 7 percent (R/O perforation ) Amylase 40 IU/L ,0.4 pancreatitis or gut perforation (Pancreatitis 2000,0.6) Triglycerides milky ,Chylous ascites triglyceride content greater than 200 mg/dL (2.26 mmol/L) and usually greater than 1000 mg/dL (11.3 mmol/L) Bilirubin brown ascites. Bilirub >serum suggests bowel or biliary perforation

Tests performed on ascitic fluid

Routine tests
Cell count and differential Albumin concentration Total protein concentration Culture in blood culture bottles

Unusual tests
Tuberculosis smear and culture Cytology Triglyceride concentration Bilirubin concentration

Optional tests
Glucose concentration LDH concentration Gram stain Amylase concentration

Useless tests
PH Lactate Fibronectin Cholesterol

Tests for tuberculous peritonitis

Direct smear -only 0 to 2 percent sensitivity Culture When one liter of fluid is cultured, sensitivity for Mycobacteria supposedly reaches 62 to 83 percent Peritoneoscopy Peritoneoscopy with biopsy culture = 100 percent sensitivity for detecting tuberculous Cell count Tuberculous peritonitis can mimic the culture-negative variant of SBP, but mononuclear cells usually predominate in tuberculosis.

Tests for tuberculous peritonitis

Adenosine deaminase Adenosine deaminase is a purine-degrading enzyme that is necessary for the maturation and differentiation of lymphoid cells Adenosine deaminase activity of ascitic fluid has been proposed as a useful non-culture method of detecting tuberculous peritonitis; however, patients with cirrhosis and tuberculous peritonitis usually have falsely low values

 Cytology peritoneal carcinoma= 100% malignancy-related ascites = massive liver metastases, chylous ascites due to lymphoma, or hepatocellular carcinoma overall sensitivity of cytology smears for the detection of malignant ascites is 58 to 75 percent Carcinoembryonic antigen (CEA) in ascitic fluid has been proposed as a helpful test in detecting malignancy-related ascites?