| Chronic liver disease
| Alkaline phosphatase (ALP)
| Liver Function Tests
| Ascites Assessment and Management
| Budd-Chiari syndrome
| Autoimmune Hepatitis
| Primary Biliary Cirrhosis
| Primary Sclerosing Cholangitis
| Wilson disease
| Hereditary Haemochromatosis
| Alpha-1 Antitrypsin (AAT) deficiency
| Non alcoholic steatohepatitis (NASH)
| Spontaneous Bacterial Peritonitis
| Alcoholism and Alcoholic Liver Disease
The serum-ascites albumin gradient or gap (SAAG) is a calculation used to determine the cause of ascites. The SAAG may be a better discriminant than the older method of classifying ascites fluid as a transudate versus exudate. A SAAG = 11 g/L suggests ascites is due to portal hypertension
- Ascites is due to the collection of free fluid in the peritoneal space.
- Commonly associated with liver cirrhosis and malignancy.
- Activation of RAA system causing sodium and water retention
- Portal hypertension
- Abdomen is distended and there is central resonance due to bowel loops floating to the top of the fluid and leaving fluid dullness in flanks
- If the patient rolls on onto their from the supine position the gas-filled bowel loops again float on top of the fluid and the area that was dull and at the highest point becomes resonant.
- Ascites may be seen with any intra-abdominal pathology and with low albumin e.g. kwashiorkor
- Protein levels: a useful test is to measure the difference in the protein level in Ascitic fluid compared with plasma.
- Gram stain and culture for Bacteria and TB in selected cases
- Cell count : Causes of a neutrophil count > 250 /ml is diagnostic of spontaneous bacterial peritonitis
- Glucose: A low glucose is seen with TB/Malignancy and a high amylase with pancreatitis.
- Cytology : Malignant cells
- Amylase : suggests related to pancreatitis
- USS: Can detect ascites. Clinically needs 500 mls to be detected and 1.5 L for reliable clinical detection
- Serum Albumin - Ascitic albumin) of > 11 g/l
- Transudate as the Ascitic albumin is low
- Portal hypertension, Cirrhosis, Alcoholic hepatitis
- Hepatocellular carcinoma, Budd-Chiari syndrome
- RV failure, Constrictive pericarditis, Myxoedema
- Meig's syndrome (ovarian tumour, ascites, hydrothorax)
- Serum Albumin - Ascitic albumin) of < 11 g/L
- Exudate as Ascitic albumin higher
- Malignancy, Tuberculosis, Pancreatitis
- Hypothyroidism, Nephrotic syndrome
- Bed rest, salt restriction, daily weights and measure U&E
- Therapeutic paracentesis is the first-line treatment for
patients with large or refractory ascites.
- Paracentesis of < 5 litres of uncomplicated ascites should be followed by plasma expansion with a
synthetic plasma expander and does not require
volume expansion with albumin.
- Large volume paracentesis should be performed in a single session with volume expansion being given once
paracentesis is complete, preferably using 8 g of 20% Albumin for each litre of ascites removed (ie. 100 ml of 20% albumin per 3 L ascites)
- Close observation is needed. Sodium restriction to 2 g/day.
- Hold diuretics if intravascular low volume. May eventually need Spironolactone 50-400 mg /day or Furosemide 20-160 mg /day
- TIPS: TIPS can be used for the treatment of refractory ascites
requiring frequent therapeutic paracentesis or hepatic
hydrothorax with appropriate assessment of risk
- Transplant should be considered where useful in patients
with cirrhotic ascites
- Patients with ascites and previous SBP should be on prophylactic antibiotics e.g. norfloxacin or Ciprofloxacin