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Ascites, Emergency Medicine

Basics

Description

- Hepatic congestion: - CHF - Constrictive pericarditis - Veno-occlusive disease and Budd-Chiari syndrome

- 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

- 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

- US: - Confirm ascites, especially if <500 mL - Evaluate liver, pancreas, spleen, and ovaries - Guides paracentesis

- 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

- Tense ascites and hydrothorax: - Supplemental oxygen - Therapeutic paracentesis or thoracentesis for respiratory distress

- 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.

- Refractory ascites: - Accounts for 10% of patients - Ensure compliance with diet and medications. - Treated with peritoneovenous shunt-transjugular intrahepatic portosystemic shunt - Liver transplantation

  • 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:Fulminant hepatic failure
  • Hepatic congestion:CHFConstrictive pericarditisVeno-occlusive disease and Budd-Chiari syndrome
  • Malignancies:Peritoneal carcinomatosisHepatocellular carcinoma or metastatic disease
  • Infections:TB, fungal, or bacterial peritonitis
  • Hypoalbuminemic states:Nephrotic syndromeMalnutrition; albumin <2.0 g/dL
  • Other conditions:Pancreatic ascitesBiliary ascitesNephrogenous ascitesOvarian tumorsChylous ascites from lymphatic leakConnective tissue diseaseMyxedemaGranulomatous 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 obesityPatients less tolerant of rapid accumulation of ascitic fluid
  • New-onset ascites in known cirrhotic signifies 1 of the following:Progressive liver diseaseSuperimposed 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 dullnessFluid waveShifting dullness

Essential Workup

  • Search for liver disease, CHF, TB, malignancy, and other systemic disorders.
  • Abdominal paracentesis:Necessary for:New ascitesWorsening encephalopathyFeverAbdominal pain/tenderness
  • Determine if fluid infected or presence of portal hypertension
  • Test ascitic fluid for:Cell count and differential:Most helpful to determine infection quicklyOrder on every specimenAlbuminProteinGram stainCulture twice in blood culture bottles with 10 mL of fluidLactate dehydrogenase (LDH)GlucoseTB cultureAmylaseTriglycerideCytologyBilirubinCarcinoembryonic antigen
  • Spontaneous bacterial peritonitis (SBP):Ascitic fluid infection without an intra-abdominal surgically treatable sourceFever, abdominal pain/tenderness, altered mentationPolymorphonuclear neutrophils (PMNs) >250 cells/mm3Ascitic fluid protein <1 g/dLLow concentration of opsonins
  • Secondary bacterial peritonitis:Bacterial peritonitis from a surgically treatable intra-abdominal sourceGut 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/dLGlucose <50 mg/dLLDH 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 mLEvaluate liver, pancreas, spleen, and ovariesGuides 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)FatFlatusFetusFecesOther: Organomegaly
  • Serum-ascites albumin gradient (SAAG) = serum albumin - ascitic albumin:Replaced ascitic fluid total protein in the differential diagnosis of ascitesSAAG ≥1.1 g/dL:97% accurate in predicting portal hypertensionCirrhosisAlcoholic hepatitisCardiacLiver metastasesFulminant hepatic failurePortal vein thrombosisVeno-occlusive diseaseMyxedemaBudd-ChiariFatty liver of pregnancySBPSAAG <1.1 g/dL:Peritoneal carcinomatosisTBPancreatic ascitesNephrotic syndromeBowel obstruction or infarctionVasculitisPostoperative 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 suspicionLow threshold for paracentesisPrompt therapyTense ascites and hydrothorax:Supplemental oxygenTherapeutic paracentesis or thoracentesis for respiratory distressAbdominal hernias:Watch for incarceration, ulceration, or rupture.Therapeutic paracentesisSurgical consultationPersistent leak at paracentesis site:Remove more fluid.Stomal barrier deviceMeralgia paresthetica:Owing to pressure on the lateral femoral cutaneous nerveRelieve the pressure by paracentesis or diuresis.
  • Large-volume paracentesis:5-10 L (100 mL/kg)Performed safely in the ED with stable hemodynamicsConsider 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/dayRestrict water if serum sodium <120-125 mEq/LSpironolactone:Works best for cirrhotic ascitesAlternatives: Amiloride or triamtereneFurosemide:Works best for other causes of ascitesAdd 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 patientsEnsure compliance with diet and medications.Treated with peritoneovenous shunt-transjugular intrahepatic portosystemic shuntLiver transplantationAvoid NSAIDs:Diminish response to diureticsDecrease renal plasma flow and GFR.Cause sodium retention/reduces urinary Na excretionTreat underlying cause of ascites owing to conditions other than cirrhosis:

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.

See Also (Topic, Algorithm, Electronic Media Element)

Cirrhosis á

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)