Ascites is abnormal collection of free fluid in the peritoneal cavity. The term ascites is from greek origin askos meaning bag or bladder.

Diagnostic features of Ascites:
1.Uniform distension of abdomen 2.Flanks full (500ml) Shifting dullness (1000ml) Fluid thrill =massive ascites Other associated features: Everted umbilicus, umbilical hernia, Divarication of recti, Inguinal or epigastric hernia Note:Absence of shifting dullness or fluid thrill or absence of both does not exclude the presence of ascites.

Dullness in ascites
Moderate Ascites- Flanks are dull Large ascites (500ml)- Horse shoe shaped dullness Flanks and hypogastric regions are dull Massive Ascites- Whole of the abdomen is dull except for a small area over the umbilical region. Puddles sign: to detect small volume of ascetic fluid 100ml. Method to elicit: Patient is put in knee elbow position, keeping the diaphragm of stethoscope over the most dependent part of abdomen, flick on the flank repeatedly and lightly. Diaphragm of stethoscope is moved gradually to the other flank.A change in the intensity and character of the note indicates fluid. Shifting dullness: to be elicitable requires minimum of 1000 ml of free fluid Fluid thrill _elicitable in massive ascites Mechanism of shifting dullness: The ascitic fluid will flow to the most dependent portion of the abdomen, the air filled intestine will float on top of this liquid. The technique of shifting dullness makes use of this relationship to detect the presence of ascitic fluid.

Symptoms of ascites
Increasing abdominal girth. Shortness of breath because of elevation of diaphragm-dypnea /orthopnea Reflux esophagitis causing heartburn Secondary effects of ascites:

Hypoprotenemia.amo ebic filarial 4.U.IVC obstruction: When massive ascites presses on IVC-can lead to pedal edema 3.Chronic peritonitisTB.2 1.spontaneous bacterial peritonitis 3.. 2 Renal Nephrotic syndrome. ..super imposed Hepatoma to be suspected. y USG can detect as little as 100 ml of fluid in peritoneum y In ovarian masses characteristically flanks are resonant y Ascites developing in stable chronic cirrhosis.Endocrinehypothyroidism(rare) GENERAL 1.CCF.metastatis liver Systemic disease 1. Cardiac constrictive pericarditis. 2.peritoneal) Cardiac failure TB abdomen LEARNING POINTS : y Ascites is a sign of decompesated liver y 500ml of fluid should be present before before flank dullness is detected.Malnutrition.Hepatic vein occlusion(Budd-chiarri syndrome/veno occlusive diseases 4 IVC obstruction - Disease of peritoneum 1.G. y Difficult to make out dulness in obese abdomen-diagnose by USG. 5.Pancreatic-pancreatitis.polyserositis 5.lymphatic obstruction.atrial pressure following tense ascites raising the diaphragm CAUSES OF ASCITES Diseases of portal tract 1Portal vein thrombosis 2..System-Meig's 5 .dialysis 3.portal hyper tension (cirrhotic/non cirrhotic) 3. y Malignancy related ascites-painful ------ .fungal.hepatocell ularCa.Protein losing enteropathy 4.Distended neck veins Elevated Rt.Acute peritonitispyogenic 2.. Malignant peritonitis-peritoneal carcinamotis.Familial meditteranian fever Above the level of hepatic vein COMMON CAUSES OF ASCITES Hepatic cirrhosis Malignant diseases (hepatic. 3.Pleural effusion Rt side: due to defect in diaphragm allowing ascetic fluid to pass into pleural space 2.parasitic. 4.

kidney ‡Hernial orifices Percussion: ‡Shifting dullness.CT Abdomen 3. CONSTRICTIVE PERICARDITIS 3. ‡Skin streched and shiny. Palpation ‡Tenderness.colon .intra abdominal/on abdominal wall ‡site.pancratic. odema of skin.pancreatitis.abdominal pain-TB abdomen h/oDM-nephrotic ascites h/o connective tissue disease-polyserositis h/o hypothyroidism CLINICAL EXAMINATION General examination: look for Stigmata of liver disease-spider nevi. HEPATIC VENOUS OCCLUSION 5.TUBERCULOUS PERITONITIS 6. RESTRICTIVE CARDIOMYOPATHY 4. ‡position. ‡herniae(umbilical. Raised JVP. ‡Rigidity.tattoos. ‡dilated veins.USG ABDOMEN-Confirms ascites 2. ‡shape of umbilicus(smiling umbilicus).I NTRA ABDOMINAL TUMOR INVESTIGATIONS : 1.gall bladder.fluid thrill.pedal edema Virchow s node-rt supraclavicular region Firm umbilical nodule-Sister Mary Joseph s nodule Examination of abdomen Inspection: ‡contour of abdomen.spleen..infection h/o fever .gastric H/o abdominal pain-malignancy related ascites. ‡striae.breast . ‡bruit GRADING OF ASCITES GR1+: ONLY ON CAREFUL EXAM GR2: EASILY DETECTABLE BY SMALL VOLUME GR3: OBVIOUS ASCITES BUT NOT TENSE GR4: TENSE ASCITES ASCITES DISPROPOTIONATE TO EDEMA: CODITIONS CAUSING 1.surface edges ‡Direction of blood flow in distended veins ‡viscera-liver.Peritoneoscopy .size.palmar erythema.parenteral therapy.stomach.3 HISTORY IN ASCITES Chronic alcoholism Other Liver diseases risks-transfusion. CIRRHOSIS OF LIVER 2.epigastric) ‡Transmitted pulsation in ca.accupuncture h/o alcoholic cardiomyopathy h/o heart disease H/o cancer. ‡movements of abdominal wall.jaundice. ‡lump.anemia.puddles sign Auscul tation: ‡Hepatic rub.shape.

Biochemical analysis 3.ESR. Biochemical analysis Proteins >3gms/dl in exudates SAAB-Serum albumin minus ascetic fluid albumin Less than1.investigations for diagnosis of portal hypertension Differences between transudate and exudate Features Transudate Appearance Clear Specific gravity Proteins Serum ascetic fluid albumin gradient Total cell count Differential count Less than 1016 Less than30gms /L >1.1/dl high Polymorphs.lymphocytes/RBCs ASCITIC FLUID ANALYSIS: Points to note: 1.Liver biopsy-in cirrhosis/malignancy of liver 8. milky-chylus TGL->200mg /dl.Gross appearance 2.straw coloured More than1016 More than 30gms/Litre <1.hemorrhagic.Other routine: TC.Microbiological with cytology Gross appearance transudate exudate cloudy a.clears on adding ether d.Xray chest.1/dl low Mesothelial cells/lymphocytes Exudate Turbid.LAPROSCOPY and peritoneal biopsy if undiagnosed 4.DC. purulent if >50000 cells/mm3 c.Liver function tests 7.in 20% RBC and also malignant cells seen. Infection-raised polymorphs>5000/mm3 b.Deep yellow colour-If bilirubin increased bile stained also when there is bile duct perforation Blood stained fluid-RBC more than10 thousand/mm3 Cell count WBC >denotes inflammation/malignancy Mainly polymorphs-Bacterial infection/SBP In SBP->250cells/mm3 diagnostic But in surgical peritonitis>10 thosand cells/mm3 Lymphocyte predominance in TB peritonitis In malignancy cell type variable.Diagnostic PARACENTESIS 5.4 3.abdomen 6.1 in exudates .

ileus .5 More than 1.Bacterial peritonitis Signs of septicemia with ascites . or drugs.hypotension. differential diagnosis of causes of ascites 1. AFB-often negative Cytology for malignant cells Positive only if peritoneum is directly involved COMPLICATIONS OF ASCITES 1. encephalopathy Ascitic fluid PMN cell count->250/mm3 Culture positive-enterobacter.Cirrhosis of liver: .reduced or 0.Tuberculous peritonitis Doughy abdomen Matted omentum and loops of intestine Multiple palpable masses Confirmation: peritoneal biopsy shows tuberculous granuloma 3. Amylase-raised in pancreatic disease Normal 250-1000 somayagi units per day Bacterial tests Gram stain-in centrifuged specimens positive in severe infection only.1 in transudate SAAB is is more useful (diuresis can affect total ascetic protein concentration) Glucose.Hepato renal syndrome Progressive renal failure Spontaneous or precipitated by diuresis.viridans Treament-Cefatoxime 2. abdominal pain .Signs of liver cell failure signs of portal hypertension Ascitic fluid-transudate 2. SBP-not positive because count is low Culture if done specimen must be sent to the lab immeadiately.in infected ascites (Because it is consumed by bacteria and WBC) Low glucose but normal cell count means intestinal contents aspiration Enzymes-LDH normally less than 50% of serum value In bacterial infection LDH more than serum value It is produced by lysed WBCs. bleeding. S. ?due to altered renal hemodynamics Differential diagnosis for distension of abdomen Fluid/Fat/flatus/foetus/Tumor in the abdominal cavity. going for fever.pneumonia. paracentesis. Spontaneous bacterial peritonitis: Suspect In cirrhosis with ascites. strept.

SAAG of >1. Frusemide20-40mg in divided doses (may combine with spiranolactone) Amiloride10mg/day ±frusemide/thiazide 5.colon.splenomegaly.Diuretics indicated in Gross ascites.daily weight chart .Assessment of SAAG helps to determine if diuretics are likely to help.increase to maximum of 400mg/day. Sister Joseph nodules in umbilicus 5.Pancreatic ascites H/o acute abdominal pain radiating to the back In chronic pancreatitis fluid leaks from the pseudo pancreatic cyst Serum amylase raised Ascitic amylase>1000Iu/L Diagnosis:ERCP 6.before biopsy.Nephrotic syndrome Initial puffiness of face Massive protenuria Hypercholestrolemia MANAGEMENT 1. Treatment of the cause.1gm/dl is associated with portal hypertension .Fluid restriction -1500ml/day 3. Salt free Albumin infusion 8.Constrictive Pericarditis Pulsus paradoxus.scan or venogram Drugs used Spiranolactone25mg qid. KEY TAKE HOME MESSAGE 1. 2.ovary. 4.Paracentesis in severe distension causing respiratory distress 6.Hepatic vein thrombosis Large tender liver Absent hepatojugular reflux 9.Peritoneal shunt in intractable ascites 7.or other intra abdominal tumors.Malignant Ascites: Primary-stomach.Portal vein thrombosis Sudden rapid development of ascites.6 and a focus of infection like indwelling catheter.hemetemesis and melena 8.Salt restriction2gms per day most important initial step 4.IO chart.kussmauls sign Hepatomegaly with ascites Pericardial knock Calcific pericardium 7.tense ascites.

About diuretic therapy y Avoid postural hypotension or fatgue from diuretic tmt which is likely to produce falls . -400mg/day of spiranolactone and 160 mg/day of frusemide -while remaining compliant with low sodium diet of 50-mmolsodium per day .hepatic encephalopathy precluding the use of an effective diuretic dose. Spontaneous bacterial peritonitis 6. Portal or hepatic vein thrombosis 3. Large volume paracentesis Removal of 5 litre or more of ascetic fluid Total paracentesis removal of all ascetic fluid also can be done (20L or more) Complications of large volume paracentesis Electrolyte imbalance . Malnutrition 7. Diuretic intractable ascites Definition I. Infection 5.7 2. REFRACTORY ASCITES Types: I. Active inflammation 2.urine sodium of less than 50mmol/l is indicates refractory ascites II. Diueretic-intractable ascites Development of diuretic ±induced complication like severe electrolyte disturbance. Recent study shows single dose of 80 mg of IV frusemide and subsequent random . Diuretic resistant ascites Lack of response to high dose of diuretic i.raised serum creatinine Spplemental Albumin infusion required . Super imposed cardiac and renal disease.that is worse than having ascites 3. Abstinence from alcohol As a First step in treatment convince patients to abstain from alcohol Abstinence of few months greatly improves reversible component of ascites. Hepato toxic and nephrotoxic drugs Prognosis poor Treatment I.e. Renal impairement. GI bleed 4.and lack of response with weight loss of less than200gm/day This requires an observation period of weeks to ensure diuretic resistance. (put in simple terms patient who cannot tolerate diuretics because of side effects) Conditions contributing to refractory ascites 1. Hepatoma 8. Diuretic resistant ascites II. 9.

Recent research Aquaretics-Vasopressin receptor antagonist Promote excretion of electrolyte free water Useful in patients with ascites and hyponatremia Not yet approved by FDA ------------------ . Frequent TIPS occlusion demands careful follow up III. Peritonio venous shunt (Nearly Abandoned therapy ) A surgically inserted tube connects peritoneal cavity to superior vena cava Tube courses subcutaneously Allows only one way passage of ascetic fluid to SVC and so back into circulation Demerits Tecchnical problems like blockage of tube and others) IV.8 5gm albumin per each Litre above 5L tapped Alternative to albumin Terlipressin -avoids exposing patient to blood product II. TIPS (trans jugular intrahepatic porto systemic stent shunt) Effective in decreasing ascetic fluid reaccumulation A flexible metal prosthesis is used to connect a branch of hepatic vein to portal vein thus reducing sinusoidal pressure Demerit: increased risk of hepatic encephalopathy.

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