1. Ascites The Aim Is To Approach The Patient With Ascites In Terms Of :
DEFINITION ;
CAUSES ;
CLINICAL FEATURES ;
INVESTIGATIONS ;
MANAGEMENT ;
COMPLICATIONS ;
MCQs.

2. ASCITES
IT IS THE CONDITION OF PATHOLOGICAL ACCUMULATION OF FLUID IN ABDOMINAL CAVITY

3. CAUSES Can Be Broadly Classified On The Basis Of : Normal peritoneum
Diseased peritoneum

4. CAUSES NORMAL PERITONEUM Portal hypertension Congestive Heart Failure
Constrictive Pericarditis
Tricuspid Insufficiency
Budd-Chiari Syndrome
Liver Cirrhosis
Alcoholic Hepatitis
Fulminant Hepatic Failure
Massive Hepatic Metastases

5. CAUSES NORMAL PERITONEUM Hypoalbuminemia Nephrotic Syndrome
Protein-losing Enteropathy
Severe Malnutrition with Anasarca

6. CAUSES NORMAL PERITONEUM Miscellaneous conditions Chylous ascites
Pancreatic ascites
Nephrogenic ascites
Meig’s syndrome

7. CAUSES DISEASED PERITONEUM Infections Tuberculous Peritonitis
Bacterial Peritonitis
Fungal Peritonitis
HIV associated peritonitis

8. CAUSES DISEASED PERITONEUM Malignant conditions
Peritoneum Carcinomatosis
Hepatocellula Carcinoma
Primary Mesothelioma
Pseudomyxoma Peritonei

9. DISEASED PERITONEUM CAUSES Other rare conditions
Granulomatous Peritonitis
Vasculitis

10. PRESENTING COMPLAINTS
CLINICAL FEATURES
PRESENTING COMPLAINTS
Abdominal Distension
Diffuse Abdominal Pain
Bloated Feeling of Abdomen
Dyspnoea and Orthopnea (due to elevation of daipharagm)
Indigestion and Heart burn (due to inc intra abdominal pressure)

11. CLINICAL FEATURES PHYSICAL EXAMINATION Abdominal Distension
Fullness of Flanks
Umbilicus Flat and Everted
Diverticulation of Recti Muscles
Distended Abdominal Veins
Shifting dullness (esp. when >1000ml of fluid)
Fluid Thrill
Puddle Sign

12. CLINICAL FEATURES PHYSICAL EXAMINATION
SIGNS RELATED TO SECONDARY EFFECTS OF ASCITES
Scrotal Edema
Pleural effusion (due to defect in the diaphragm and fluid pass into the pleural space)
Edema
Cardiac apex is shifted upward due to raised diaphragm)
Distended neck veins due to inc rt atrial pressure)

13. CLINICAL FEATURES PHYSICAL EXAMINATION
SIGNS RELATED TO THE CAUSE OF ASCITES
LIVER DISEASE:
Jaundice,Anemia,Palmar erythema,Spider angiomas,Hepatosplenomegaly,
CARDIAC DISEASE:
Elevated JVP
MALIGNANCY:
SISTER MARY JOSEPH NODUE in umblicus(peritoneal carcinomatosis like gastric, pancreatic and hepatic malignancies)
VIRCHOW NODE (rt supraclavicular lymph node due to upper abdominal malignancy)
NEPHROTIC SYNDROME:
Edema or Anasarca

14. STAGING Stage 1+ is detectable only after careful examination.
Can Be Semi Quantified Into:
Stage 1+ is detectable only after careful examination.
Stage 2+ is easily detectable but of relatively small volume.
Stage 3+ is obvious ascites but not tense ascites.
Stage 4+ is tense ascites.

15. INVESTIGATIONS

16. INVESTIGATIONS
Includes:
Imaging studies
Lab studies
Laparoscopy

17. INVESTIGATIONS IMAGING STUDIES CHEST AND ABDOMINAL PLAIN FILMS
Detects ascites if >500ml fluid
Elevated diaphragm
Pleural effusion (hepatic hydrothorax)
Diffuse abdominal haziness
USG ABDOMEN
can detect as small as 5ml fluid
can identify the cause like liver cirrhosis
CT SCAN:
can identify the cause like malignancies

18. INVESTIGATIONS LAB STUDIES Ascitic Fluid should be analyzed for
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
Ascitic Fluid should be analyzed for
APPEARANCE
CELL COUNT
TOTAL PROTEINS
SAAG(SERUM ASCITIC ALBUMIN GRADIENT)
CYTOLOGY
CULTURE
MISCELLENOUS
BASELINE INVESTIGATIONS LIKE BLOOD CP,LFTS,PT APTT

19. INVESTIGATIONS LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
APPEARANCE
TRANSPARENT AND TINGED: NORMAL
STRAW COLORED: CIRRHOSIS
HEAMORRHGIC: MALIGNANCY
CLOUDY: INFECTION
BILE STAINED: BILIARY CONTAMINATION
CHYLOUS: LYMPHATIC OBSTRUCTION

20. INVESTIGATIONS LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
CELL COUNT
WBCS <500/mm3 and NEUTROPHILS<250/mm3: NORMAL
NEUTROPHILS>250/microL: suggests SBP
LYMPHOCYTES PREDOMINANCE: ABDOMINAL TB OR MALIGNANCY

21. INVESTIGATIONS LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
TOTAL PROTEINS
PROTEINS<2.5g/dl: TRANSUDATE
PROTEINS>2.5g/dl: EXUDATE

22. INVESTIGATIONS LAB STUDIES SAAG (Serum Ascitic Albumin Gradient)
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
SAAG (Serum Ascitic Albumin Gradient)
The Difference bw Serum Albumin and Ascitic fluid Albumin
Best single test to differentiate between ascites due to portal hypertension and non-portal hypertension
When saag >1.1g/dl: strongly suggest portal hypertension
When saag < 1.1g/dl: non portal hypertensive causes
Accuracy more than 97%

23. INVESTIGATIONS LAB STUDIES CYTOLOGY CULTURE AND GRAM STAIN
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
CYTOLOGY
58-75% HELPING FOR DETECTING MALIGNANT ASCITES
CULTURE AND GRAM STAIN
MORE IMPORTANT IN SBP

24. INVESTIGATIONS MISCELLENOUS LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS)
MISCELLENOUS
GLUCOSE: low in TB peritonitis
AMYLASE: HIGH IN PANCREATIC ASCITES
PH: <7 SUGGEST BACTERIAL INFECTION
RBCS: MORE THAN 50,000/microL SUGGESTS TB,MALIGNANCY OR TRAUMA

25. INVESTIGATIONS LAPROSCOPY IN SOME PATIENTS FOR DIRCET VISUALIZATION
TO TAKE BIOPSIES OF
LIVER
PERITONEUM
INTRA ABDOMINAL LYMPHNODES

26. MANAGEMENT
COMPRISES OF:
General care
Medical care
Surgical care

27. MANAGEMENT GENERAL CARE MONITORING OF DIETRY MODIFICATIONS BED REST:
INPUT OUT PUT
ABDOMINAL GIRTH
WEIGHT
DIETRY MODIFICATIONS
SODIUM RESTRICTION UPTO 1g/day
WATER RESTRICTION (If Serum Sodium Level Is <120mmol/L Hyponatremia)
BED REST:
Improves renal perfusion which leads to diuresis

28. MANAGEMENT MEDICAL CARE DIEURETICS
THE AIM OF THE THERAPY IS WT LOSS OF BODY WIGHT DAILY
300g-500g IF ONLY ASCITES
800g-1000g IF ASCITES AND EDEMA
DIEURETICS
MAINSTAY THERAPY FOR ASCITES
SPIRONOLACTONE mg/d PO qd or divided bid
FUROSEMIDE:20-80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states
AMILORIDE:5-20 mg PO qd
COMBINATION THERAPY:
SPIRONOLACTONE + FUROSEMIDE
FUROSEMIDE + AMILORIDE

29. MANAGEMENT MEDICAL CARE THERAPEUTIC PARACENTESIS
In patients with massive ascites (grade 3 or 4)
In ascites refractory to dieuretics
If cardio respiratory distress due to ascites
3-5litres can be removed with the replacement of salt free albumin.

30. MANAGEMENT MEDICAL CARE
TIPS(TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT)
Becoming standard of care in dieuretic resistant ascites

31. MANAGEMENT SURGICAL CARE LEE VEEN SHUNT: It is a peritoneovenous shunt
Alternative for medically intractable ascites
Improves Cardiac Out Put, renal Blood Flow, Glomerular Filtration Rate, Urinary Volume, And Sodium Excretion And Decreased Plasma Renin Activity And Plasma Aldosterone Concentration
Doesn’t Improve Patient’s Survival So With The Advent Of Tips It’s Becoming Obsolete

32. COMPLICATIONS THE MOST COMMON COMPLICATION IS:
SBP (Spontaneous Bacterial Peritonitis)

33. COMPLICATIONS
SBP
Most common bacteria is E. Coli.Bacteria are believed to gain access to peritoneum by hematogenous route.
Low ascitic fluid albumin (<1g/dl) predisposes SBP
Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Rebound Tenderness.
Ascitic Fluid analysis shows wbcs >500/mm3l and Eutrophil>250/mm3
Third generation Cephalosporins 2g tid started empirically for 5 days till c/s report is available.
Recurrence is common. Ciprofloxacin 750 mg once weekly can be given prophylacticaly.

34. MCQs.

35. Q. No 1 MCQs IF SAAG IS >1.1 THEN THE CAUSE WOULD BE ALL EXCEPT:
PORTAL HYPERTENSION
MYXEDEMA
NEPHROTIC SYNDROME
TUBERCULOUS PERITONITIS

36. Q. No 2 MCQs THE MOST EFFICACIOUS TREATMENT FOR REFRACTORY ASCITES IS
MAXIMUM DOSE OF DIEURETICS
THERAPEUTIC PARACENTESIS
TIPS
LEE VEEN SHUNT

37. Q. No 3 MCQs SBP IS MORE LIKELY WHEN WBCS >250/microL
NEUTROPHILS>250/microL
LYMPHOCYTES>500/microL
ALL OF THE ABOVE

38. THANK YOU