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(Ascites) . ..

(ascites) II. (ascites) III. (ascites) non-portal hypertension portal hypertension IV. V. (ascites) medical, surgical radiological intervention VI. I. I.

(ascites) (ascites) 1. (fat) 2. (gas) (tympanic) 3. (tumor) ovarian tumor shifting dullness 2 (asymmetrical) 4. (pregnancy) xiphisternum pubic symphysis 2 (symmetrical) fetal heart sound 5. ascites () pubic symphysis xiphisternum umbilical herniaAscites ... (05/2546)

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(ascites) ascites 2 1. Fluid thrill ulnar surface (midline) (fluid thrill) 2. Shifting dullness () 1.5 shifting dullness ascites fluid thrill ascites 80% ascites (ascites) hepatitis B virus hepatitis C virus (decompsensated cirrhosis) Ascites transient portal hypertension alcohol ascites (peritonitis) (hepatocellular carcinoma) ascites tuberculosis, pancreatitis, carcinomatosis peritonii, connective tissue diseases, cardiac causes, etc. ascites stigmata of chronic liver diseases palmar erythrema, spider nevi, parotid gland enlargement, gynecomastia cirrhosis ascites left supraclavicular lymphadenopathy carcinomatosis peritonii malignancy gastrointestinal tract Ascites cardiac causes signs right side heart failure jugular venous distention pulsatile liver Ascites ... (05/2546)

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ascites abdominal ultrasonography ascites 100 ml abdominal ultrasonography cardiac causes tuberculosis (ascites) (ascites) (ascites fluid tapping) ascites .. ascites 10-27% ascites spontaneous bacterial peritonitis 22 1.5 1.5 anterior superior iliac spine inferior hypogastric vessels (Zfashion) omentum synringe 90 synringe 25-30 ml coagulopathy fresh frozen plasma hyperfibrinolysisII.

(ascites) ascites straw color Ascites triglyceride 20% ascites triglyceride 200 400 mg/dl ascites Milk-like chylous ascites triglyceride 1,000 mg/dl Pseudochylous ascites 20,000 cells/mm3 Ascites 10,000 cells/mm3 traumatic bloody ascites non-traumatic bloody ascites traumatic tapping Ascites ... (05/2546)

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traumatic tapping ascites non-traumatic fluid (clot) ascites Table 1 Table 1 Laboratory tests in evaluating patients with ascites Necessary Optional LDH Glucose Amylase Grams stain LDH Glucose Amylase

Rarely Used TB culture and smear Triglyceride Cytology Bilirubin Bilirubin

Ascites Cell count Albumin Total protein Culture Serum Albumin

Cell count and differentiation ascites 500 cells/mm3 280 cells/mm3 PMNs count 27-30% PMNs count 250 cells/mm3 bacterial peritonitis inflammatory peritonitis traumatic tapping PMNs PMN 1 PMN 250 red cells lymphocyte 1 lymphocyte red cells 750 red cells Albumin and Serum-ascites albumin gradient (SAAG) ascites albumin albumin ( 1-2 ) albumin SAAG ascites protein ascites ascites exudate transudate SAAG SAAG portal pressure (r=0.73) SAAG 1.1 g/dl portal hypertension Ascites ... (05/2546)

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accuracy 97% SAAG < 1.1 g/dl ascites portal hypertension ascites Table 2. Total protein ascites SAAG ascites protein ascites SAAG lab ascites (80-85%) SAAG 1.1 g/dl sinusoidal portal hypertension ascites protein 2.5 g/dl 1 g/dl ascites Table 2. Classification of ascites by serum-ascites albumin gradient (SAAG) Low SAAG (< 1.1 g/dl) High SAAG ( 1.1 g/dl) Cirrhosis Tuberculosis peritonitis Fulminant hepatic failure Carcinomatosis peritonii Alcoholic hepatitis Nephrotic syndrome Liver metastasis (masses compress portal vein) Pancreatitis Budd-Chiari syndrome Biliary causes Veno-occlusive disease Connective tissue diseases Myxedema Chlamydia /gonococcal Cardiac ascites ascites protein 2.5 g/dl mixed causes peritoneal diseases tuberculous peritonitis carcinomatosis peritonii presinusoidal portal hypertension ( portal vein thrombosis) ascites transient postsinusoidal portal hypertension ascites high SAAG total protein 2.5 g/dl Ascites protein non-portal hypertension caused 2.5 g/dl nephrotic syndrome Culture of ascites fluid 10-27% ascites .. spontaneous bacterial peritonitis (SBP) 2 3 ascites fluid 10-20 ml blood culture

Ascites ... (05/2546)

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Gram stain spontaneous bacterial peritonitis ascites fluid 50 ml sensitivity 10% Gram stain secondary bacterial peritonitis bowel perforation mixed fungal infections Glucose ascites fluid glucose secondary bacterial peritonitis glucose ascites peritoneal surface glucose spontaneous bacterial peritonitis Cytology cytology ascites SAAG < 1.1 g/dl protein 2.5 g/dl cell mononuclear cells carcinomatosis peritonii tuberculosis peritonitis Lactate dehydrogenase (LDH) LDH enzyme ascites uncomplicated cirrhosis LDH ascites 0.40.5 ascites nonportal hypertension caused 1.0 Amylase ascites amylase pancreatitis bowel perforation ascites amylase uncomplicated cirrhosis 42-50 IU/L ascites amylase 2,000 IU/L pancreatitis Bilirubin rupture biliary tract bowel perforation ascites fluid bilirubin bilirubin ascites 6 mg/dl bilirubin ascites 1.0 Acid-fast (AFB) stained for tuberculosis Ascites fluid stained for AFB tuberculosis peritonitis sensitivity 0-2% ascites fluid adenosine deaminase (ADA) specificity 90%

Ascites ... (05/2546)

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(ascites) portal hypertension non-portal hypertension (ascites) non-portal hypertension ascites non-portal hypertension peritoneal diseases peritoneum ( tuberculous peritonitis), inflammatory process involve peritoneum ( serositis systemic lupus erythrematosus) metastasis peritoneum carcinomatosis peritonii peritoneal inflammation exudation malignancy-related ascites ascites tumor lymphatic drainage system tumor cytokines permeability endothelial cells peritoneal surface leakage rupture ductal structure irritate peritoneal surface content leak ascites pancreatic ascitis biliary ascites Chylous ascites leakage rupture lymphatic vessels ascites nephrotic syndrome hypoalbuminemia decreased intravascular oncotic pressure (ascites) portal hypertension ascites (cirrhosis) portal hypertension 1. Local factors Intra-hepatic portal hypertension Lymphatic formation splanchnic vascular system 2. Functional renal abnormalities Sodium retention hormones rennin-angiotensin aldosterone system (RAAS) sympathetic nervous system (SNS) Water retention impaired free water clearance arginine vasopressin ascending limb of the Henle loop Renal vasoconstriction vasoconstrictors extreme underfilling arterial circulation 3. Systemic and renal hemodynamic abnormalities Intense systemic and splanchnic arterial vasodilatation nitric oxide Neurohormonal activation RAAS, SNS, endothelin Renal activation ascites (cirrhosis) severe sinusoidal portal hyertension splanchnic arterial vasodilatation forward increase III. Ascites ... (05/2546)

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splanchnic lymph splanchnic lymph flow splanchnic vascular system arterial vascular underfilling RAAS, SNS AVP sodium water retention ascites hypoalbuminemia decreased intravascular oncotic pressure IV. cell count, SAAG ascites protein peritoneal diseases ascites cytology rule out malignancy ascited fluid adenosine deaminase Computerized Axial Tomography malignancy peritoneoscopy tissue biopsy peritoneal diseases tuberculous peritonitis Portal hypertension ascites SAAG 1.1 g/dl ascites protein < 2.5 g/dl immunology viral markers abdominal ultrasonography hepatocellular carcinoma alpha-fetoprotein ascites protein > 2.5 mg/dl Chest x-ray rule out tuberculosis cardiac ascites thyroid function test hypothyroid ascites SAAG high protein content (ascites) medical, surgical radiological intervention (ascites) ascites peritoneal diseases tuberculosis peritonii ascites carcinomatosis peritonii V.

(ascites) Portal hypertension ascites (cirrhosis) Ascites ... (05/2546)

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1. 2. 2 3. serum sodium < 120 mmol/L 4. spironolactone 100 mg ascites furosemide spironolactone 100 mg: furosemide 40 mg 0.5 kg hepatic encephalopathy, serum sodium < 120 mmol/L serum creatinine > 2.0 mg/dl 5. ascites fluid ascited fluid 20-25% human albumin 50 ml i.v. ascites 5-6 refractory ascites ( ascites sodium high dose diuretics = 400 mg of spironolactone plus 160 mg of furosemide) 1. Large volume paracentesis human albumin i.v. 2. Peritoneovenous shunts LeVeen Denver shunts 3. Transjugular Intrahepatic Portosystemic shunt (TIPS) side-to-side non-surgical shunt portal hypertension 4. Liver transplantation References 1. Caldwell SH, Battle EH. Ascites and spontaneous bascterial peritonitis. In: Schiff ER, Sorrell MF, Maddrey WC, editors. Schiffs Diseases of the liver. 8th ed. Philadelphia: Lippincott-Raven; 1999. p. 503-44. 2. Sherlock S, Dooley J. Ascites. In: Sherlock S, Dooley J, editors. Disease of the liver and biliary system. 10th ed. Oxford: Blackwell Science; 1997. p. 119-34. 3. McHutchison JG. Differential diagnosis of ascites. Semin Liver Dis 1997;17:191-202. 4. Runyon BA. Care of patients with ascites. N Eng J Med 1994;330:337-42. 5. Runyon BA. Management of adult patients with ascites caused by cirrhosis. Hepatology 1998;27:26472) 6. Arroyo V, Colmenero J. Ascites and hepatorenal syndrome in cirrhosis: pathophysiological basis of therapy and current management. J Hepatol 2003;38:S69-S89. 7. Bhuva M, Ganger D, Jensen D. Spontaneous bascterial peritonitis: An update on evaluation, management, and prevention. Am J Med 1994;97:169-75.Ascites ... (05/2546)