Presentation on theme: "Dr Intekhab Alam MANAGEMENT OF ASCITES by Professor of Medicine Department of Medicine Postgraduate Medical Institute, Lady Reading Hospital, Peshawar."— Presentation transcript:
14 Etiology Cirrhosis (75%) Malignancy (10%) Cardiac (3%) TB (2%) Most common cause of ascitesMost common complication of cirrhosisOther causes occur more frequently in cirrhoticsMalignancy (10%)Cardiac (3%)TB (2%)Pancreatic Ascites(1%)Various othersHepatology 38:258-66
15 Pathophysiology of ascites in CLD: Splanchnic HTN due to outflow obstructionIncreased vasodilatation (NO)This sequesters volume in the abdomenDecreases systemic fillingDecreases systemic BPActivates antinatriuretic factorsCombination of increased splanchnic BP with vasodilatation leads to capillary leakLymph return can only keep up for sometime then ascites develops.
16 Physical Examination Bulging Flanks Flank Dullness Shifting Dullness Fluid WavePuddle signApproximately 1.5 L must be present before flank dullness is detected. If no flank dullness is present, the patient has less than 10% chance of having ascites.JAMA 1992; 267:
17 Bulging FlanksOccur when weight of ascites is sufficient to push the flanks outwardsDifficult to distinguish from obesitySensitivity-72-93%Pooled data 81%Specificity-44-70%Pooled data 59%JAMA 1992; 267:
18 Flank Dullness Similar to bulging flanks, although uses percussion Typically bowel will float to the top and ascitic fluid sinks to the bottomSensitivity-80-94%Most sensitive testPooled data 84%Specificity-29-69%69% outlying valuePooled data 59%JAMA 1992; 267:
19 Shifting Dullness Find the point where flank dullness occurs Mark it Roll the patient away from the examinerRepeat percussion and ensure that the point moves to the dependent sideSensitivity-60-83%Pooled data 77%Specificity-56-90%Pooled data 72%JAMA 1992; 267:
20 Fluid Wave (fluid thrill) Medial edges of both hands down midlineTap flank firmly and feel for an impulse on the other sideSensitivity-50-80%Pooled data 62%Specificity-82-92%Most specific testPooled data 90%JAMA 1992; 267:
21 Puddle Sign Have patient prone 3-5 minutes then rise to crawling Place the diaphragm of the stethoscope over the most dependent area of the abdomenFlick a finger until sound detectedNo longer recommendedFormerly used for high sensitivitySensitivity-43-55%Pooled data 45%Specificity-51-83%Pooled data 73%JAMA 1992; 267:
22 International Ascites Club Grading Grade 1Mild, only detectable by U/SGrade 2Moderate, symmetrical distensionGrade 3Gross or large with marked distensionLarge typically means painful/uncomfortableRefractory Ascites (5-10%)Can not be mobilized or early recurrence refractory to medical managementNEJM 350:Hepatology 2003; 38:
23 Diagnosing AscitesUltrasound is the most sensitive test for ascites (100mL detection)Have to use caution as small or even moderate ascites may be difficult to tap (even when marked)Ensure mark is appropriateGo with patient to U/S (ideal)If not possible, in order specify location where you want to place your needleImage from
24 Paracentesis: General Tips Do NOT do paracentesis to see if ascites present, should know beforeIf unclear need U/SEnsure patient has voidedFFP/Platelet transfusion if indicatedEnsure landmarksGet Quick-Tap kit, plastic catheter does not work as well as the metal one.Picture from
25 Paracentesis:Site: 5cm cephalic & 5 cm medial to ASIS in the left lower quadrant of the abdomen has been shown to be the ideal site with larger pool of fluid.Complications: (1% of patients) Abdominal wall hematomas. Hemoperitoneum or bowel entry.Contraindications: Clinically evident fibrinolysis or DIC.
26 Gross Appearance of Ascitic Fluid ColorAppearanceTranslucent or yellowNormal / sterileBrownHyperbilirubinemiaGB or biliary perforationCloudy or turbidInfectionPink or blood tingedMild TraumaGrossly bloodyMalignancyAbdominal traumaMilky ("chylous")CirrhosisThoracic duct injuryLymphoma
27 Diagnostic Studies Recommended Studies If clinically appropriate AlbuminProteinCell countLooking for PMNsCulturesIf clinically appropriateGlucoseLDHAmylaseRBC countTB smear/cultureCytologyTriglyceridesPolys > 250 infection
28 Diagnostic Studies SAAG > 1.1 SAAG < 1.1 1. Check serumand fluid albuminSAAG > 1.1SAAG < 1.1Hepatic Sinusoid sourcePeritoneum source2. Check AscitesProteinAscites Protein <2.5Ascites Protein >2.5Ascites Protein >2.5Capillarized sinusoidPeritoneal lymphNormal sinusoid3. DifferentialDiagnosisCirrhosisLate Budd-ChiariCardiac ascitesEarly Budd-ChiariVeno-occlusive diseaseMalignancyTuberculosisThe SAAG does not need to be repeated after the initial measurement.Note: Exceptions exist: may have mixed featuresAdapted from
29 Ascitic fluid analysis: If the PMN count is >250 cells/mm3, another specimen is injected into blood culture bottles at bedside. Bacterial growth occurs in about 80% of specimens with count of >250 cells/mm3. In a "bloody" sample that contains a high concentration of RBC, the PMN count must be corrected: One PMN is subtracted from the absolute PMN count for every 250 red cells/mm3 in the sample. The results must be available within 1 hour, so that important diagnostic and therapeutic decisions can be made. A Gram stain is of particular low yield unless free gut perforation, is suspected.
30 Based on clinical judgment, additional testing can be performed Cytology ,smear & culture for mycobacteria.Cytology : in peritoneal carcinomatosis (sensitivity increased by centrifuging large volume).Elevated bilirubin level suggest biliary or gut perforation.LDH >225mU/L, glucose <50mg/dL, total protein >1g/dL and multiple organisms on gram stain suggest secondary bacterial peritonitis.High level of TG's confirms chylous ascites.Elevated amylase level suggest pancreatitis or gut perforation.
31 Prognosis Poor outcomes Refractory ascites SBP HRS MELD (Model for end-stage liver disease) is not specifically validated for patients with ascitesNEJM 350:
32 PrognosisAny person with ascites due to cirrhosis needs transplant evaluationIf MELD is <15 can stop thereAverage US wait time 500dAverage wait less in some other countries120 days in UK180 days in SpainIf admitted for ascites 40% chance of dying within 2 yearsImproves to 70-80% 5 year survival after transplantCirrhosis is the 12th leading cause of death in the USADig Dis 2005; 23:30-38Hepatology 2003; 38:
34 Treatment Grade 2 Bed rest Sodium and water restriction Diuretics Diuretics work better supinestudied bemetanideGFR lower standing as wellSodium and water restrictionDiureticsBr Med J. 1986;292:1351-3Hepatology 2003; 38:
35 Treatment Grade 3 Paracentesis is the treatment of choice Shown to have fewer complications than diuresisFaster responseAfter this would do Grade 2 treatment optionsHepatology 2003; 38:
36 Treatment Refractory ascites Paracentesis with colloid infusion TIPS Choice between these is controversialIf repeated paracentesis is contraindicated,TIPS not an option then consider porto-venous shuntPVS shown inferior to repeat paracentesis in NEJM studyHepatology 2003; 38:
37 Sodium RestrictionNo survival benefit related to ascites shown, does have benefit in GIB mortality50mm restriction is equivalent to 120mm (approx. 2g/day)Tighter restriction had faster resolutionHigher incidence of renal dysfunction and hyponatremiaHepatology 2003; 38:
38 Diuretics Spironolactone Can use potassium sparing diuretics start per dayTitrate to max of 400 per day in severe hyper-aldoCan use potassium sparing diureticsAmiloride inferior to canrenoate (anti-mineralocorticoid)No other comparison trials, but spironolactone accepted as first lineUse second line if spironolactone not possible 2/2 complications (ie gynecomastia)Hepatology 2003; 38:
39 Diuretics Loop diuretics Lasix Initial dose per dayCan adjust up to 160mg per dayShould be used only as an adjunct to spironolactoneRisks of K depletion, hyperchloremic alkalosis, hyponatremia and hypovolemia with subsequent renal dysfunctionDig Dis 2005; 23:30-38Hepatology 2003; 38:
40 Assessing Diuretic Response Weight lossLose 0.5kg a day when no edemaLose 1kg a day when edema is presentAvoid renal failureResponse rate in up to 90% patients who do NOT have renal dysfunctionDig Dis 2005; 23:30-38Hepatology 2003; 38:
42 Paracentesis First used by the Ancient Greeks Decreased in the 1950s when diuretics were discoveredResurgence in 1980s after 1987 article found paracentesis with lower complications than diureticsMore effective than diuresisShorter hospital stayDig Dis 2005; 23:30-38
43 ParacentesisTotal volume paracentesis is as effective and as safe as sequential 3L paracentesisHemodynamicsRA pressure drops immediatelyPCWP takes 6h to decreaseHepatology 2003; 38:
44 Paracentesis Post paracentesis volume expansion Side effects and albuminwithout 30%with 16%Albumin prevents increased renin/aldo better than synthetic agentsHRS decreasesLess HyponatremiaNEJM 350:Hepatology 2003; 38:
45 Paracentesis-Complications Bleeding - can be fatalAscitic fluid leakPurse string sutureLie with puncture site upBowel perforationRenal impairmentHypotension/Cardiovascular collapse
46 TIPS Transjugular Intrahepatic Portosystemic Shunt Creates a conduit from the high pressure portal system to the lower pressure systemic circulation
47 TIPS Ascites can only form when portal pressure is >12 Response rates 51-79% in RCTDig Dis 2005; 23:30-38
48 TIPS - Benefits May improve nitrogen balance Will decrease portal pressure reducing GIB riskImproves hemodynamicsIncreased CO, RA pressure, PCWP and decreased SVR with increased Na excretionImproves response to diuresisNEJM 350:Hepatology 2003; 38:
49 TIPS - Risks Encephalopathy CHF - this is due to increased preload 30% those treatedTypically can improve with shunt revision or medical managementIncreased risk ifAge >60History of Encephalopathy100% mortality if refractory to TIPS occlusionCHF - this is due to increased preloadNEJM 350:Am J Gastro 2003;98:
50 TIPS - Complications Capsule perforation Stenosis 75% in 6-12 monthsDecreased risk with stents coated in polytetrafluoroethylene (PTFE)Increased cost relative to paracentesisNEJM 350:Radiology 1999;231:
51 TIPS v. Paracentesis Several studies (2 examples) Lebrec 1996 No ascites recurrence benefit in CP class C patients with worsened survivalCP class B showed decreased recurrenceSmall study (25 patients)SalernoShown to have survival improvement with multivariate analysis (only trend to improved survival without this)Non-blinded 3 center studyHad to have 4 taps in the last monthDecreased ascites recurrence HR 0.37 ( )66 patientsJ Hepatol 1996;25:135-44Hepatology 2004;40:
52 Cochrane Database No difference in mortality Decreased re-accumulation at 3 and 12 monthsIncreased PSE OR 2.11( )Surprisingly no difference:GIB, ARF, Infection or DICSome issues in differences between the studies, not all paracentesis had post-paracentesis albumin, differences in MELD/CP between studiesHepatology 2003; 38:
53 Reasons for TIPS over Paracentesis TIPS better ifLoculated ascitesPatient unwilling to have repeat tapsFrequent recurrencesAm J Gastro 2003;98:
55 Peritoneovenous Shunts Creates a communication between the peritoneal cavity and the systemic circulation by a veinUsed in only in limited cases currentlyUsed for palliation if TIPS and paracentesis are not available or contraindicatedHepatology 2003; 38:
56 Spontaneous Bacterial Peritonitis H/O Chronic Liver Disease.Fever and abdominal pain (66%)Signs of peritonitis uncommon (<50%)Neutrocytic ascites on diagnostic paracentesis.20-30% of pts with CLD develop SBP.Almost always monomicrobial.Anaerobes are not associated with SBP20% are asymptomatic.Typically due to translocationThis is why E. Coli is the most common
57 SBP: Diagnosis.Diagnosed with >250 polys or > 50-70% of the total cell count.Ascitic protein >1gm/dl against SBP.10-30% are ascitic fluid culture negative.3% have secondary Bacterial Peritonitis.Ascitic fluid Glucose, LDH and total proteins may be helpful in DDx.Erect Abd X-ray in suspicious cases.NEJM 350:Hepatology 2003; 38:
58 SBP: Treatment and Prophylaxis Treat with 3rd generation Cephalosporins.Repeat PMN count after 48 hrs.40% develop HRS during the course of illness.Human Albumin 1.5gm/Kg o day one and 1 gm/Kg on day three has shown improvement in both morbidity and mortality.Prophylaxis:70% recur within one year.Norfloxacin 400mg qdCiprofloxacin 750mg q weekTri-Sulpha: Has never been tested in a trial with mortality.Ultimate treatment:Liver transplant.
59 ReferencesMoore K, Wong F, Gines P, Bernardi M et al. The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club. Hepatology 2003;38:Gines P, Cardenas A, Arroyo V, Rodes J. Management of Cirrhosis and Asictes. NEJM. 2004;350:Haskal Z. Improved Patency of TIPS in Humans: Creation and Revision with PTFE Stent-Grafts. Radiology. 1999; 213:Cardenas A, Arroyo V. Refractory Ascites. Dig Dis. 2005; 23:30-38Russo M, Sood A, Jacobson I, Brown R. TIPS for Refractory Ascites: An Analysis of the Literature on Efficacy, Morbidity and Mortality. Am J Gastroenterol. 2003; 98:Heuman D, Abou-assi S, Habib A et al. Persistent Ascites and Low Serum Sodium Identify Patients with Cirrhosis and Low MELD Scores who are at High Risk for Early Death. Hepatology. 2004; 40:Salerno F, Merli M, Riggio O, Cazzangia M, et al. Randomized Controlled Study of TIPS v. Paracentesis Plus Albumin in Cirrhosis with Severe Ascites. Hepatology 2004;40:Ring-Larsen H, Henriksen J, Wilken C, Clausen J, et al. Diuretic treatment in decompensated cirrhosis and congestive heart failure: effect of posture. Br Med J 1986; 292:Lebrec D, Giuily N, Hadengue A, Vilgrain V, et al. TIPS: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. French Group of Clinicians and a Group of Biologists.Saabs, Nieto JM, Ly D, Runyon BA. TIPS versus paracentesis for cirrhotic patients with refractory ascites. The Cochrane database of Systematic Reviews 2004, Issue 3 Art. No.: CD004889Cattau EL, Stanley BB, Knuff TE, et al. The Accuracy of the Physical Examination in the Diagnosis of Suspected Ascites. JAMA. 1982; 247:Williams JW, Simel DL. Does This Patient Have Ascites?. JAMA. 1992; 267:Mallory A, Schaefer JW. Complications of Diagnositc Paracentesis in Patients with Liver Disease. JAMA. 1978; 239:Runyon BA. Paracentesis of Ascitic Fluid a Safe Procedure. Arch Intern Med. 1986; 146:Simel DL, Halvorsen RA, Feussner JR. Quantitating bedside diagnosis: clinical evaluation of ascites. J Gen Intern Med. 1988; 3:Images:
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