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Ascites

  • Ascites is free fluid within the abdominal cavity
  • Over 70% cases due to liver disease.

Aetiology

The main causes of ascites include the following conditions

  • Hepatic - cirrhosis, veno-occlusive disease
  • Cardiac - right ventricular failure, constrictive pericarditis
  • Renal - nephrotic syndrome, renal failure
  • Malignancy - ovarian, gastric, colorectal carcinoma
  • Infection - tuberculosis
  • Pancreatitis
  • Lymphatic - congenital anomaly, trauma
  • Malnutrition
  • Myxoedema

Investigation

A diagnostic peritoneal tap allows peritoneal fluid to be sent for:

  • Protein estimation
    • A transudate has a total protein < 30 g/l - cirrhosis, heart failure
    • An exudate has a total protein > 30 g/l - carcinomatosis, infection
  • Cytology
  • Bacteriology
  • Biochemistry - amylase, CEA

Pathophysiology

  • The normal peritoneal cavity contains ~100 ml of fluid
  • It is a transudate and has a 50% turnover per hour
  • It is produced by visceral capillaries
  • It is drained via diaphragmatic lymphatics
  • In cirrhotic ascites pathophysiology is complex
  • Results in sodium retention due to:
    • Portal hypertension
    • Altered systemic haemodynamics
    • Altered neurohumeral control
    • Altered renal function

Complications

  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome
  • Hepatic hydrothorax

Treatment of ascites in cirrhosis

  • Effective treatment is difficult
  • Medical measures include sodium restriction and diuretics
  • Spironolactone is usually drug of choice
  • In those with ascites refractory to medical therapy options include:
    • Repeated large-volume paracentesis
    • Peritoneovenous shunting
    • Portocaval shunting
    • Transjugular intrahepatic portosystemic shunting
    • Liver transplantation

Transjugular intrahepatic portosystemic shunting

  • Involves the creation of an intrahepatic portosystemic shunt
  • Hepatic vein is cannulated via the internal jugular vein
  • Intrahepatic portal vein punctured percutaneously
  • Guide wire passed from portal to hepatic vein
  • Stent is then passed along guide wire
  • Complications include encephalopathy and liver failure
  • Has improved survival compared with other technique

Bibliography

Gines P,  Cardenas A,  Arroyo V et al.  Management of cirrhosis and ascites.  N Eng J Med 2004;  350:  1646- 1654.

Howard E R,  Khawaja H T.  Management of ascites.  Curr Pract Surg 1992;  4:  245-250.

Jeffery J,  Murphy M J.  Ascitic fluid analysis:  the role of biochemistry and haematology.  Hosp Med 2001;  62:  282-286.

Rossle M,  Ochs A,  Gulberg V.   A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites.  N Eng J Med 2000;  342:  1701-1707.

Walsh K,  Alexander G.  Alcoholic liver disease.  Postgrad Med J 2000;  76:  280-286.

 

 
 

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