Ascites, Emergency Medicine

Basics

Description

Pathologic accumulation of serous fluid in the peritoneal cavity
Portal hypertension (>12 mm Hg) starts fluid retention.
Avid sodium retention state
Retained sodium and water increases plasma volume.
Water excretion becomes impaired.
Increased release of antidiuretic hormone (ADH)
Urinary sodium retention, increased total body sodium, and dilutional hyponatremia
Degree of hyponatremia correlates with disease severity; prognostic factor.
Decreased plasma oncotic pressure from hypoalbuminemia
Peritoneal irritation owing to infection, inflammation, or malignancy

Etiology

Parenchymal liver disease:
- Cirrhosis and alcoholic hepatitis:
  - 80% of adult patients
- Fulminant hepatic failure
Hepatic congestion:
- CHF
- Constrictive pericarditis
- Veno-occlusive disease and Budd-Chiari syndrome
Malignancies:
- Peritoneal carcinomatosis
- Hepatocellular carcinoma or metastatic disease
Infections:
- TB, fungal, or bacterial peritonitis
Hypoalbuminemic states:
- Nephrotic syndrome
- Malnutrition; albumin <2.0 g/dL
Other conditions:
- Pancreatic ascites
- Biliary ascites
- Nephrogenous ascites
- Ovarian tumors
- Chylous ascites from lymphatic leak
- Connective tissue disease
- Myxedema
- Granulomatous peritonitis

Most pediatric cases owing to: á

Malignancy (Burkitt lymphoma, rhabdomyosarcoma)
Nephrotic syndrome
Malnutrition

Diagnosis

Signs and Symptoms

Abdominal distention, discomfort
Weight gain; sometimes weight loss
Dyspnea
Orthopnea
Edema
Abdominal hernias
Muscle wasting
Shifting dullness, flank fullness, fluid wave, puddle sign
Signs and symptoms of underlying disease
Stigmata of chronic liver disease

History

Risk factors for liver disease
Description of onset of symptoms:
- Distinguishes ascites from obesity
- Patients less tolerant of rapid accumulation of ascitic fluid
New-onset ascites in known cirrhotic signifies 1 of the following:
- Progressive liver disease
- Superimposed acute liver injury (alcohol, viral hepatitis)
- Hepatocellular carcinoma

Physical Exam

Detection difficult in obese patients
Flank dullness is a prominent physical finding:
- 500 mL for flank dullness
- Fluid wave
- Shifting dullness

Essential Workup

Search for liver disease, CHF, TB, malignancy, and other systemic disorders.
Abdominal paracentesis:
- Necessary for:
  - New ascites
  - Worsening encephalopathy
  - Fever
  - Abdominal pain/tenderness
Determine if fluid infected or presence of portal hypertension
Test ascitic fluid for:
- Cell count and differential:
  - Most helpful to determine infection quickly
  - Order on every specimen
- Albumin
- Protein
- Gram stain
- Culture twice in blood culture bottles with 10 mL of fluid
- Lactate dehydrogenase (LDH)
- Glucose
- TB culture
- Amylase
- Triglyceride
- Cytology
- Bilirubin
- Carcinoembryonic antigen
Spontaneous bacterial peritonitis (SBP):
- Ascitic fluid infection without an intra-abdominal surgically treatable source
- Fever, abdominal pain/tenderness, altered mentation
- Polymorphonuclear neutrophils (PMNs) >250 cells/mm3
- Ascitic fluid protein <1 g/dL
- Low concentration of opsonins
Secondary bacterial peritonitis:
- Bacterial peritonitis from a surgically treatable intra-abdominal source
- Gut perforation or intra-abdominal abscess (i.e., perinephric abscess)
- PMNs >250 cells/mm3 with multiple micro-organisms on Gram stain + 2 of the following found with secondary bacterial peritonitis:
  - Total protein >1 g/dL
  - Glucose <50 mg/dL
  - LDH greater than the upper limit of normal for serum

Diagnosis Tests & Interpretation

Lab

CBC
Basic chemistry
LFTs
PT, PTT, INR
Arterial blood gas (ABG) or pulse oximeter
Urinalysis
Urine sodium
Hepatitis panel
Amylase/lipase
╬▒-fetoprotein
TSH

Imaging

US:
- Confirm ascites, especially if <500 mL
- Evaluate liver, pancreas, spleen, and ovaries
- Guides paracentesis
Doppler study: Evaluate hepatic blood flow
CT scan
CXR: CHF, effusions, cavitary, or mass lesion
ECG

Diagnostic Procedures/Surgery

Peritoneoscopy: Ascites of unknown cause; especially TB
Paracentesis:
- Clinical diagnosis of SBP without paracentesis is inadequate.
- Safety of paracentesis:
  - 70% of ascitic patients have coagulopathy.
  - Benefits of a diagnostic paracentesis outweigh the risks.
  - Paracentesis is still indicated unless disseminated intravascular coagulation (DIC) is present.
  - Transfusion of plasma or platelets prior to paracentesis is not supported.

Differential Diagnosis

1 of the 5 "F"Ł causes of abdominal swelling:
- Fluid (including cysts)
- Fat
- Flatus
- Fetus
- Feces
- Other: Organomegaly
Serum-ascites albumin gradient (SAAG) = serum albumin - ascitic albumin:
- Replaced ascitic fluid total protein in the differential diagnosis of ascites
- SAAG ≥1.1 g/dL:
  - 97% accurate in predicting portal hypertension
  - Cirrhosis
  - Alcoholic hepatitis
  - Cardiac
  - Liver metastases
  - Fulminant hepatic failure
  - Portal vein thrombosis
  - Veno-occlusive disease
  - Myxedema
  - Budd-Chiari
  - Fatty liver of pregnancy
  - SBP
- SAAG <1.1 g/dL:
  - Peritoneal carcinomatosis
  - TB
  - Pancreatic ascites
  - Nephrotic syndrome
  - Bowel obstruction or infarction
  - Vasculitis
  - Postoperative lymphatic leak

Treatment

Pre-Hospital

Symptomatic hypotension: á

Airway, breathing, circulation (ABCs), IV 0.9 NS

Initial Stabilization/Therapy

Sudden increase in abdominal girth, pain, or fever requires urgent evaluation for possible complicating factor such as: á

Infection
Hepatoma
Obstruction of hepatic outflow
Decompensated liver function

Ed Treatment/Procedures

Successful treatment depends on accurate diagnosis of underlying cause.
Treat underlying cause.
Minimize ascitic fluid and peripheral edema without causing intravascular volume depletion.
Early detection of complications is necessary:
- SBP:
  - High degree of suspicion
  - Low threshold for paracentesis
  - Prompt therapy
- Tense ascites and hydrothorax:
  - Supplemental oxygen
  - Therapeutic paracentesis or thoracentesis for respiratory distress
- Abdominal hernias:
  - Watch for incarceration, ulceration, or rupture.
  - Therapeutic paracentesis
  - Surgical consultation
- Persistent leak at paracentesis site:
  - Remove more fluid.
  - Stomal barrier device
- Meralgia paresthetica:
  - Owing to pressure on the lateral femoral cutaneous nerve
  - Relieve the pressure by paracentesis or diuresis.
Large-volume paracentesis:
- 5-10 L (100 mL/kg)
- Performed safely in the ED with stable hemodynamics
- Consider replacement with IV albumin (5-10 g/L fluid removed) if >5 L removed.
- Monitor the patient for 8 hr prior to discharge.
Nonparacentesis reduction of ascites:
- Strict sodium restriction:
  - <2 g/day
  - Restrict water if serum sodium <120-125 mEq/L
- Spironolactone:
  - Works best for cirrhotic ascites
  - Alternatives: Amiloride or triamterene
- Furosemide:
  - Works best for other causes of ascites
  - Add to spironolactone in cirrhotics at spironolactone/furosemide ratio of 100 mg/40 mg.
  - Add metolazone for less responsive cases.
- Diuretic principles:
  - Administer diuretics as single morning dose.
  - Obtain spot-urine sodium to evaluate response.
  - Patients with urinary Na >10 mEq/L are more responsive to diuretics.
  - Diuretic-induced weight loss should not exceed 2 lb/day in patients without edema and 5 lb/day in patients with edema.
  - Monitor electrolytes and renal function.
  - Avoid hypokalemia since hypokalemia enhances renal ammonia production, precipitating hepatic encephalopathy.
- Refractory ascites:
  - Accounts for 10% of patients
  - Ensure compliance with diet and medications.
  - Treated with peritoneovenous shunt-transjugular intrahepatic portosystemic shunt
  - Liver transplantation
- Avoid NSAIDs:
  - Diminish response to diuretics
  - Decrease renal plasma flow and GFR.
  - Cause sodium retention/reduces urinary Na excretion
- Treat underlying cause of ascites owing to conditions other than cirrhosis:
  - TB, CHF

Medication

First Line

Albumin: 5-10 g/L of fluid removed if >5 L removed
Cefotaxime: 2 g IV q8h
Spironolactone: 100-400 mg/d (peds: 1-6 mg/kg) PO in 2 divided doses per day
Furosemide: 40-160 mg/d (peds: 1-3 mg/kg) PO

Second Line

Amiloride: 5-20 mg/d PO
Metolazone: 5 mg/d
Triamterene: 100-300 mg/d PO in 2 divided doses per day

Follow-Up

Disposition

Admission Criteria

Fulminant liver failure
Hepatic encephalopathy
SBP
Hepatorenal syndrome
GI bleeding
Tense ascites not responding to ED treatment

Discharge Criteria
Patients responding to ED management á

Follow-Up Recommendations

GI for all new cases
Primary doctor or GI for previously established cases

Pearls and Pitfalls

New cases need full workup and GI consultation for management.
SBP symptoms are frequently vague.
Must have a high suspicion and low threshold for paracentesis when considering SBP
Benefits of confirming SBP outweigh risks of bleeding in a coagulopathic patient undergoing paracentesis.
US guidance is helpful when performing paracentesis in lower-volume ascites.

Additional Reading

Feldman áM. Sleisenger and Fordtrans Gastrointestinal and Liver Disease. 9th ed. Philadelphia, PA: WB Saunders; 2010.
Runyon áBA; AASLD Practice Guidelines Committee. Management of Adult Patients with Ascites Due to Cirrhosis: An update. Hepatology. 2009; 49:2087-2107.
Runyon áB, Such áJ. Initial Therapy of Ascites in Patients with Cirrhosis. UpToDate, 2012.
Corey K, Friedman L. Harrison's Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012.

Codes

ICD9

789.5 Ascites
789.51 Malignant ascites
789.59 Other ascites

ICD10

R18 Ascites
R18.0 Malignant ascites
R18.8 Other ascites

SNOMED

389026000 Ascites (disorder)
307311001 Infected ascites (disorder)
236005001 Malignant ascites (disorder)
236004002 Hepatic ascites (disorder)

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