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home - Liver - Ascites - Ascites Written by Dr Sebastian Zeki
Knowledge


Defines the causes (both hepatic and non hepatic) of ascites and
has a clear understanding of their pathogenesis

Recognises how to define resistant and refractory ascites
Understands the management of patients with ascites (including fluid
restriction use of colloids diuretics) as well as the indications for and
the role of interventional procedures such as paracentesis TIPS

Knows the value of laboratory investigation of acites including
diagnosis of spontaneous bacterial peritonitis its prognosis and
treatment

Appreciates the evidence for the prophylactic use of albumin
infusions to reduce risk of hepatorenal syndrome

Understands the indications for alternative interventions (e g TIPS
surgical shunt peritoneal–venous shunt and transplantation) and the
criteria for appropriate referral

Skills
Can perform safely both diagnostic and large volume paracentesis
Behaviours
Can refer patients in a timely manner to specialist liver services
Understand the implications on quality of life as well as the nutritional
impact of resistant ascites

Shows ability to develop and sustain supportive relationships with
patients and their families

Ascites

Ascites Most common cirrhosis causes: NAFLD. Hep C. ETOH. Carcinomatosis with peritoneal seedlings. 10% over 10 years Death Death 50% at 2 years 15% SBP Refractory ascitesOccurs for 10% of ascites.Measure urinary sodium to check compliance.If more than 90mmol/day then not compliant. Diuretic resistant Diuretic intractable Death 50% at 6 months SA-AG >/=11g/l Cirrhosis Cardiac failure Nephrotic syndrome SA-AG <11g/l Malignancy Pancreatitis TB Ascites Pancreatic Ascites-The level of amylase in the ascitic fluid is > 1,000 IU/L-Ascitic fluid to serum amylase ratio is 6.0. Cirrhotic Death 20% is inpt Death at 1 yr50-70% Recurrence at 1 year=70%.Therefore consider for liver transplantation If Na=126-135 with normal creatinine-no action 121-125, normal creatine-stop diuretics 121-125, increase creatinine- stop diuretic and expand volume Less than 120-stop diuretic, saline, avoid increasing Na by > 12mmol/l/24 hours Cirrhotic Ascites treatment Sodium-restrict to 90mmol/day. Fluid-Role for fluid restriction unclear. Diuretics-Spironolactone (or Amiloride). Treat gynaecomastia with Tamoxifen 20mg once a day. Start frusemide at 40mg to 160mg per day once stopped Spiro. Stop fluid retention medications of NSAID's. Aim is to cause weight loss of around 0.5kg/day. Bloody Ascites This refers to ascitic fluid with a red blood cell count >50,000 mm3. The RBC count of ascitic fluid is usually < 1000 mm3. Ascitic fluid will be pink colored at a level of 10,000 RBC cells. The management of pancreatic ascites-Conservative medical treatment improves 1/3rd of patients.-Start TPN.-Treatment with somatostatin or octreotide together with diuretics and repeated paracentesis is beneficial for some patients.-Transpapillary pancreatic duct stenting can be attempted in patients with pancreatic ascites and evidence of ductal disruption by ERCP.-The stent can facilitate healing of ductal disruptions by partially occluding the leaking duct or bypassing the pancreatic sphincter, thereby decreasing the intrapancreatic duct pressure. 3-5 day lag Start at 100mg up to 400mg Therapeutic paracentesis.-Large volume. Give 20% HAS for every 3 litres removed at the end. Drain within 4-6 hours. Put stitch in if any leakage. TIPS Causes HE in 25%/worse outcome in child QC. And can precipitate CCF. Aetiology of bloody ascites HCC is a cause in 30%. No cause is found in 50%. It occurs in 5 % of patients with cirrhosis.- either spontaneously or, usually, due to a traumatic paracentesis. 20 % of malignant ascites samples are bloody- 50% of these are HCC’s. Of samples of peritoneal carcinomatosis, only about 10 % are bloody. Rapid on onset ascites causes:Decompensated cirrhosis.Malignancy.Vascular problems (Budd-Chiari/PV or splenic vein thrombosis). Evaluation of pancreatic ascites-In some cases the fluid is serosanguineous or opalescent.-The combination of a serum-albumin ascites gradient below 1.1 g/dL, a total protein level >3 gm/L, and elevated ascitic amylase is diagnostic of this condition.-An ERCP/ MRCP should be performed to localize the site of leakage and to perform endoscopic therapy (stenting of pancreatic duct) if possible. Causes of pancreatic ascitesThe most common is alcoholic chronic pancreatitis.Also occurs with pancreatic pseudocysts, and acute pancreatitis. Indications for surgery for pancreatic ascites.-Persistent or recurrent accumulation of ascites and/or sudden deterioration of clinical status.-When the pancreatic duct is dilated, the ideal procedure is a wide anastomosis between the ruptured duct and a Roux-en-Y jejunal loop.-Patients with a pseudocyst and a mature lining can undergo internal cyst drainage into a jejunal loop.-Distal pancreatic resection followed by duct ligation is an accept-able alternative if the pancreatic duct is of normal calibre or the abnormality is localized in the tail of the pancreas. Written by Dr Sebastian Zeki

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