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Evaluation of Ascites

Evaluation of Ascites. Andrew Maclennan Morning Report July 24, 2009. Pathophysiology of Ascites. From: Robbins Basic Pathology. Causes of Ascites. Source: UpToDate. Rare Causes of Ascites. Imaging. Ultrasound with Dopplers Easily confirms ascites May see nodularity of cirrhosis

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Evaluation of Ascites

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  1. Evaluation of Ascites Andrew Maclennan Morning Report July 24, 2009

  2. Pathophysiology of Ascites From: Robbins Basic Pathology

  3. Causes of Ascites Source: UpToDate

  4. Rare Causes of Ascites

  5. Imaging • Ultrasound with Dopplers • Easily confirms ascites • May see nodularity of cirrhosis • Evaluate patency of vasculature • No radiation, contrast • CT / MRI • Evaluation for malignancy

  6. Tests on Ascitic Fluid

  7. Cell Count, differential and culture • Is ascites infected? • Greater than 250 PMN = SBP • If ascites is bloody ( > 50,000 RBC/mm3), correct by subtracting 1 PMN / 250 RBC • Is ascites bloody? • 5% of pts w/ cirrhosis - spontaneous or s/p traumatic tap. • Non-traumatic  associated with malignancy • 20% of malignant ascites • 10% of peritoneal carcinomatosis

  8. Serum to Ascites Albumin Gradient • Is portal hypertension present? • 97% accurate SAAG > 1.1 g/dL  Portal HTN SAAG < 1.1 g/dL  Other causes The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20.

  9. Serum to Ascites Albumin Gradient

  10. Total Protein • Exudate ( > 2.5 g/dL) or Transudate? • Supplanted by SAAG • Is there gut perforation? (vs SBP) • Total protein >1 g/dL • Glucose <50 mg/dL (2.8 mmol/L) • LDH greater than serum ULN

  11. Glucose and LDH • Consistent with infection or malignancy? • Infection and cancer consume glucoselow • LDH is a larger molecule than glucose, enters ascitic fluid with difficulty. • Ascitis/Serum LDH ratio • ~ 0.4 in cirrhotic ascites • Approaches 1.0 in SBP • >1.0, usually infection or tumor

  12. Other tests • Amylase • Uncomplicated cirrhotic ascites • About 40 IU/L. The AF/S ratio is about 0.4 • Pancreatic ascites • About 2000 IU/L. The AF/S ratio is about 6 • Triglycerides — run on milky fluid. • Chylous ascites - TG > 200 mg/dL, usually 1000 mg/dL • Bilirubin — run on brown ascites. • Biliary perforation – AF Bili > serum Bili

  13. Tests for TB • Smear – extremely insensitive • Culture – 62-83% when large volumes cultured • Cell count – mononuclear cell predominance • Adenosine deaminase – • Enzyme involved in lymphoid maturation • Falsely low in pts with both cirrhosis and TB

  14. Cytology • “almost 100%” with peritoneal carcinomatosis have positive cytology • Malignant ascites from massive hepatic mets, HCC, lymphoma are usually negative • Overall sensitivity for detection of malignancy-related ascites is 58 to 75 %

  15. Not helpful • “Some tests of ascitic fluid appear to be useless. These include pH, lactate, and ‘humoral tests of malignancy’ such as fibronectin, cholesterol, and many others”

  16. Biopsy Cirrhosis Fatty Liver http://library.med.utah.edu/WebPath/LIVEHTML/LIVERIDX.html#2

  17. Causes of Cirrhosis

  18. Malignant Ascites • Definition: abnormal accumulation of fluid in the peritoneal cavity as a consequence of cancer. • Commonly caused by cancers of: • Breast, bronchus, ovary, stomach, pancreas, colon • 20% of cases have tumors of unknown primary • Survival poor – usually less than 3 months Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597

  19. Malignant Ascites: Pathophysiology • Obstruction of lymphatics by tumor • Prevents absorption of fluid and protein • Alteration in vascular permeability • Hormonal mechanisms (VEGF, IL2, TNF alpha) • Decreased circulating blood volume • Activates RAAS leading to Na retention Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597

  20. Pathophysiology of Malignant Ascites http://www.fresenius.de/internet/fag/com/faginpub.nsf/Content/Pressemappe+ASCO+2007

  21. Management of Malignant Ascites • Therapeutic paracentesis • Removing up to 5L appears safe • No good data on role of volume expanders • Diuretics • Equivocal evidence of efficacy • May be helpful for portal HTN • Less/minimally useful when no portal HTN • Drainage Catheters • Peritoneovenous shunts

  22. Peritoneovenous Shunt • Contraindications • Protein > 4.5 g/l (occlusion) • Loculated ascites • Coagulopathy • Advanced renal/cardiac disease • GI malignancy • Complications • Infection • Hematogenous spread of mets • DIC • Pulmonary edema • Pulmonary emboli Denver Shunt (Similar to LaVeen Shunt)

  23. Transjugular intrahepatic portosystemic shunt (TIPS)

  24. References • Up to Date • Ascites and renal dysfunction in liver disease, Second edition. Edited by PereGinès, Vicente Arroyo, Juan Rodés, and Robert W. Schrier. Malden, Mass., Blackwell, 2005. • The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20. • Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597 • Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis, and management. Arch Intern Med. Vol 161. Dec 10/24, 2001.

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