Abdominal Ascites

Pt with h/o liver cirrhosis, right HF, Budd-Chiari syndrome, portal vein thrombosis presents with abdominal fullness. Reports weight gain, shortness of breath, early satiety. Weight increased from baseline, decreased breath sounds, flank dullness, abdominal fullness, shifting abdominal dullness/fluid wave on exam.

  • Obtain CBC, CMP, GGT, PT, PTT, INR

  • Abdominal U/S shows large-volume ascites

  • Obtain Doppler U/S of hepatic/portal veins

  • Paracentesis

    • Perform diagnostic/therapeutic paracentesis

    • Send ascitic fluid for differential leukocyte count, total protein level, a serum-ascites albumin gradient, fluid cultures

    • SAAG >1.1/dL indicating high likelihood of portal hypertension

    • Paracentesis >5L; consider albumin 10g/L albumin infusion

  • Treatment

    • Start oral spironolactone 100mg qd and titrate to 400mg/day

    • Consider adding furosemide 40mg/day and titrating to 160mg/day for refractory ascites

    • Serum sodium <125 mEq/L; fluid restrict to 1.5L/day

    • Refractory ascites and

      • May require transplant: Consider TIPS procedure

      • Not a candidate for paracentesis, TIPS, transplant: Consider peritoneovenous shunt

    • Pt advised to abstain from alcohol, restrict sodium to 2g/day

Notes

  • 85% of abdominal ascites is due to portal hypertension

  • SAAG = serum-ascites albumin gradient = serum albumin - ascitic fluid albumin

  • For SAAG <1.1/dL; evaluate for peritoneal carcinomatosis vs. pancreatic ascites