Ascites resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Steven Bellm, M.D. [2]

Ascites resident survival guide Microchapters
Overview
Classification/Causes
Diagnosis
Treatment
Do's
Dont's

Overview

Accumulation of fluid within the peritoneal cavity results in ascites. Most important for a successful treatment of ascites is an accurate diagnosis of its cause. Most common causes are portal hypertension, malignancy and heart failure. The diagnosis is made with a combination of physical examination and abdominal imaging. The next step is typically a paracentesis to evaluate the ascitic fluid for causes.[1]

Classification/Causes

Ascites can be classified based on the underlying causes. Common causes are:[1]

 
 
 
 
 
 
 
Causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Portal hypertension:

❑  Cirrhosis
❑  Alcoholic hepatitis
❑  Acute liver failure
❑  Hepatic veno-occlusive disease (eg, Budd-Chiari syndrome)
❑  Heart failure
❑  Constrictive pericarditis

❑  Hemodialysis-associated ascites (nephrogenic ascites)
Hypoalbuminemia:

❑  Nephrotic syndrome
❑  Protein-losing enteropathy

❑  Severe malnutrition
 
 
Peritoneal disease:

❑  Malignant ascites
❑  Infectious peritonitis
❑  Eosinophilic gastroenteritis
❑  Starch granulomatous peritonitis

❑  Peritoneal dialysis
 
Other etiologies:

❑  Chylous ascites
❑  Pancreatic ascites (eg, from a disrupted pancreatic duct)
❑  Myxedema

❑  Hemoperitoneum
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

 
 
 
 
 
 
 
History and symptoms:

❑  Hints for etiology (i.e. cirrhosis, malignancy)?

❑  Abdominal distension/abdominal discomfort?

❑  Duration and onset of illness/ symptoms?

❑  Severity and triggers?

❑  Weight loss/weight gain/early satiety?

❑  Presence of peripheral edema, anasarca?

❑  Problems with breathing at night/ sleep?

❑  Fever, abdominal tenderness, and altered mental status?

❑  Diarrhea and steatorrhea, malnutrition, nausea, enlarged lymph nodes

❑  Medical history

❑  Prior hospitalizations?
❑  Medication?
 
 
 
 
 
 
 
Physical examination:

❑  Vital signs:

❑  Pulse (strength and regularity)
❑  Blood pressure
❑  Respiratory rate

❑  General appearance:

❑  BMI(weight loss/weight gain)
❑  Peripheral edema
❑  JVD

❑  Heart:

❑  Murmur
❑  Carotid and peripheral pulses

❑  Lungs:

❑  Rales?
❑  Pleural effusion?

❑  Abdomen:

❑  Hepatomegaly
❑  pulsatile liver and/or ascites (volume overload)
❑  Flank dullness
 
 
 
 
 
 
 
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Treatment

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hidden

Do's

Dont's

References

  1. 1.0 1.1 1.2 Runyon BA, AASLD (2013). "Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012". Hepatology. 57 (4): 1651–3. doi:10.1002/hep.26359. PMID 23463403.