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