ASCITES
Background:
Most common of all the complications of portal hypertension
Diagnosis requires:
Clinical suspicion based on physical exam (shifting dullness, bulging flanks)
Although often related to portal hypertension, must also rule out other causes such as carcinomatosis (Ovarian Ca, disseminated Adenocarcinoma) Infection (TB peritonitis) CHF (right sided heart failure), Nephrogenic ascites
Paracentesis needs to be performed
Send fluid for cell count each time fluid is tapped.
Consider assessing fluid for Albumin, Protein, Amylase, cytology, Glucose, or LDH particularly the first time the patient undergoes diagnostic paracentesis, or, if there is a change in the patients clinical status
Calculate Serum Albumen to Ascites Albumen gradient (Serum Albumen – Ascites Albumen) on the first tap or if there is a change in patient status
Gradient > 1.1 g/dl indicative of portal hypertension as the cause of ascites
Gradient < 1.1 g/dl may indicate alternative cause of ascites
Treatment: (general guidelines)
Fluid restriction ( < 2 L per day)
Sodium restriction ( < 2,000 mg per day)
Diuretics
Spironolactone (begin with 75 mg q day, may increase up to 400 mg/day
Watch out for Hyperkalemia, painful gynecomastia
Furosemide (begin with 20 mg every other day, may require daily doses, maximum 160 mg/day)
Watch for hypokalemia, hypnatremia, hypomagnesemia, increased creatinine
Consider adding Zaroxolyn 5 mg po qd if above not working
Similar side effects as Furosemide
May be associated with significant hypokalemia
Refractory ascites indicates above therapy not working. Consider:
Hospitalize, Intravenous Albumen (50 gm 25%) followed 20 minutes later by Intravenous Lasix. Continue Aldactone
Large volume paracentesis with Albumen replacement particularly if patient with renal insufficiency or lack of peripheral edema (50 gm 25 % Albumen per each 2 liters Ascites removed)
TIPS ( as a bridge to Transplant)
Peritoneo-venous shunt – Denver Shunt (may be of limited sustained benefit)
Transplant
Background:
Defined as an increase in peritoneal WBC with infection that occurs in the absence of identifiable intra-abdominal pathology such as Cholecystitis, Diverticulitis, intra-abdominal abscess
Ascites polymorphonuclear cell count > 250 cells/cc
Must have a high index of suspicion as many patients with SBP do not have overt signs of infection (i.e. fever, peripheral leukocytosis, abdominal pain)
Must rule out SBP in any patient with Ascites who develops any evidence of decompensation, i.e., encephalopathy, refractory ascites, renal insufficiency
Variations of SBP
Culture positive neutrocytic ascites = positive culture from fluid with elevated neutrophil count
ONE bug (usually gm negative, e-coli, enterococcus, but may see pneumococcus). If > 1 bug = primary, not spontaneous peritonitis
Culture negative neutrocytic ascites = same as above but ascites cultures are negative
Most common
Culture positive non-neutrocytic ascites
If culture grows gram positive (such as Diptheroid or other skin contaminant and low ascites fluid WBC, this is a contaminant)
If culture grows gram negative and WBC is low, consider this early SBP
Treatment:
For the Board exam- Cefotaxime 2 gm IV q 8 hrs if not Penicillin allergic
In real life- consider Zosyn 3.375 mg IV q 6 or Unasyn 1.5-3 gm IV q 6 (watch creatinine for adjustments) as this may be better coverage
May treat IV for 5 days and switch to a Quinolone po (Levoquin 500 mg po qd) for a total of 10 days
Consider:
Liver transplantation evaluation in any patient with SBP as there is a high likelihood of recurrence
May use prophylactic therapy (an oral Quinalone such as Norfloxacin 400 mg/q week) to prevent SBP in patients with a low ascites protein count, or a previous history of SBP
Use Intravenous antibiotics in any patient with cirrhosis (particularly if they have ascites) if admitted with UGI bleeding due to the increased risk of sepsis and SBP in these patients