ASCITES

Epidemiology: 80% of pts w/ ascites have cirrhosis. It is the most common of the three major complications of cirrhosis (hepatic encephalopathy, variceal bleeding are the other 2). 50% of cirrhotic pts die w/in 2 yrs of developing ascites.

Physical exam: 1,500 mL fluid must be present to detect shifting dullness. U/S can detect as little as 100 mL.

Paracentesis:

Complications: 1) abd wall hematoma (1%). Prophylactic FFP is NOT indicated, even with elevated INR. 2) hemoperitoneum or bowel perforation (1/1,000)

Analysis

BASIC SCREEN

1. cell count/differential: IF ANC >/= 250(SBP

2. albumin: Serum-Ascites-Albumin-Gradient (SAAG) = serum alb – ascites alb. IF >/= 1.1(portal HTN. IF < 1.1(no portal HTN (97% accuracy).

3. bacterial cx in BLD CX BTTLS: sensitivity of nml cx 50%, bld cx 80%

SECONDARY BP SCREEN: ANC >/= 250, multiple organisms on GS/cx, PLUS 2 of following…

1. LDH > assay

2. TP > 1 g/dL

3. glucose < 50 mg/dL

Treatment: depends on cause- IF no portal HTN, unlikely to respond to Na-restriction/diuretics

1. STOP EtOH (EtOH liver disease potentially more reversible)

2. Na restriction: 2g/day

3. diuretics: Single dose PO spironolactone and furosemide (ratio 100/40)

4. fluid restriction is NOT indicated unless serum Na < 120

FOR DIURETIC RESISTANT ASCITES

1. serial therapeutic paracenteses

2. liver trx

3. perito-neovenous shunt

Spontaneous Bacterial Peritonitis:

1. most common isolates- E coli, K pneumoniae, pneumococcus

2. IF PMN >/= 250 cells/mm3(empiric abx (cefotaxime 2g Q8)

3. IF PMN < 250 w/ T > 100, abd pain or tenderness(empiric abx

4. prophylaxis: consider short-term in-pt quinolone IF 1) low protein (< 1 g/dL) ascites, 2) variceal hemorrhage, 3) prior SBP.

Runyon BA. Hepatology. 27(1): 264-272