Ascites

Ascites and Hepatic Hydrothorax – Lauren Evers Carlini, Thomas Strobel

Ascites

Background

  • US ~80% due to cirrhosis and associated portal hypertension
  • Less common causes: peritoneal or metastatic cancer, heart failure, tuberculosis, nephrotic syndrome, Budd-Chiari, sinusoidal obstructive syndrome (S.O.S), or complications from procedures and pancreatitis

 

Grade

Definition

Treatment

Grade 1 Ascites

Only seen on imaging

2g Na restriction

Grade 2 Ascites

Moderate, symmetric abdominal distension

2g Na restriction, diuretics

Grade 3 Ascites

Marked, tense abdominal distension

LVP + Na restriction, diuretics (unless refractory)

 

Evaluation

  • Bedside ultrasound on admission to confirm presence of ascites
  • Diagnostic paracentesis in all pts with ascites on admission mainly to rule out occult SBP
    • Initial paracentesis or when cause of ascites is uncertain: Total Protein, serum and BF Albumin, cell count w/diff, culture
    • Subsequent/Serial paracenteses: cell count w/diff, culture, protein
    • Always inoculate culture bottles at bedside (aerobic, then anaerobic)! Use luer-lock syringe and vacutainer, then hand deliver samples to 4th floor lab to ensure proper/timely delivery
  • There is no guideline for INR cutoff for paracentesis, although our procedure team often looks for INR < 3.5 (IR usually doesn’t care about INR)
  • Serum-ascites albumin gradient (SAAG) = serum albumin - ascites albumin. SAAG ≥ 1.1 accurately predicts portal hypertension, but this may be due to either cardiac or hepatic causes which can be further evaluated with total protein in the ascites:

 

 Total Protein Ascites

(not serum)

SAAG > 1.1 g/dL

(Portal HTN )

SAAG < 1.1 g/dL

(Non-portal HTN )

< 2.5 g/dL

Cirrhosis

Nephrotic Syndrome

Myxedema

> 2.5 g/dL

Post-hepatic portal HTN:

Cardiac Ascites

Budd-Chiari  

Malignant Ascites

Pancreatic Ascites

TB

 

  • Calculate PMNs from fluid: Total nucleated cells x percent neutrophils
    • If ≥> 250, diagnostic of SBP in cirrhosis
  • Correction for RBCs: For every 250 RBCs in fluid, subtract 1 PMN
  • Other tests:
      • Triglycerides: if fluid is milky
      • Cytology: if very concerned for peritoneal carcinomatosis. May need up to 3 separate samples (50ml or more) to be able to detect malignant cells
      • ADA: if concern for peritoneal TB
      • Hematocrit: For bloody appearing fluid (not just serosanguinous) to rule out hemoperitoneum. There needs to be a recent serum HCT for comparison.
      • Amylase: If concerned for pancreatic ascites
      • Glucose, LDH if concern about secondary peritonitis (see below)

Management

  • Cessation of alcohol, if applicable
  • 2000mg sodium restriction per day for all ascites (Grade 1-3)
  • Diuretics (spironolactone and typically oral furosemide)
    • Start at 100mg of spironolactone with up titration to 400mg
    • Furosemide is added if insufficient diuresis or if limited by hyperkalemia
    • Can then to a max of 400:160
    • If poor response can change to torsemide 10 and 40 mg max for cirrhotics
    • Fluid restriction usually not necessary unless serum sodium <130 mmol/L
  • Large volume paracentesis should be performed for tense ascites or refractory ascites (grade 3), regardless of serum Cr. PTs should be tapped dry with each paracentesis
  • 6-8g of albumin per liter of ascites removed , even if < 5L
      • So, if 7L removed, you would give 42-56g of albumin
  • Target weight loss of 0.5kg/day when diuresing to avoid renal injury
     

Refractory Ascites:

  • Two distinctions:
    • Diuretic-resistant: lack of response to diuretics (max spironolactone 400mg/lasix160mg), Na restriction and rapid recurrence following paracentesis
    • Diuretic-intractable: unable to tolerate diuretic therapy 2/2 adverse drug effects (unexplained HE, AKI, K abnormalities, hypoNa, intractable muscle cramps)
  • Management aside from liver transplant:
    • Discontinue of diuretics once refractory ascites has been established
    • Consider oral midodrine; can be especially helpful if pt is also hypotensive
    • Serial paracenteses, generally arranged OP with IR
    • Consider TIPS (trans jugular intrahepatic portosystemic shunt; has survival benefit)
    • Following TIPS, cessation or decrease in ascites should occur in 4-6 weeks
      •  If pt with TIPS presents to hospital with accumulation of ascites, can signal that shunt is no longer patent. Obtain RUQ w/doppler or CTA abdomen/pelvis to look for patency. May require IR study if high enough concern
  • Medications to avoid or discontinue with refractory ascites:
    • ACE/ARB, NSAIDS, β Blockers (if Na <130, systolic <100, MAP <65 or AKI)

 

 

 

Hepatic Hydrothorax

Background

  • transudative effusion, typically unilateral (right sided); reflects ascitic fluid that passes through a small defect in the diaphragm
  • present in 5% of cirrhosis with ascites and portends a poor prognosis

 

Evaluation

  • Often suspected clinically, though must exclude pleural/cardiopulmonary process
  • Thoracentesis will demonstrate a transudative effusion and should be evaluated with standard pleural fluid lab tests:
    • Cell count w/ diff
    • Culture (inoculated at the bedside!)
    • Protein, albumin, LDH, bilirubin
    • Other considerations: triglycerides, amylase, cytology
  • Rule out SBE:
    • Diagnosed by the following criteria:
      • Positive pleural fluid culture, PMN>250
      • Negative pleural fluid culture with PMN >500
      • No evidence of pneumonia on imaging (to r/o parapneumonic effusion)
    • ½ of cases will present with concomitant SBP

 

Management

  • Similar management of ascites as noted above
  • AVOID chest-tube placement. Associated with increased morbidity and mortality due to extensive loss of fluid, electrolytes and protein as well as increased infection risk
    • Once placed, may be impossible to remove due to constant reaccumulation of fluid
    • PleurX catheters can be considered for palliation (e.g., hospice patients)
  • Tension hydrothorax with pronounced dyspnea and hemodynamic instability require immediate decompression with thoracentesis
  • Refractory Hydrothorax is defined similarly and managed similarly with serial thoracentesis or TIPS. For those who are not candidates, consider:
    • Chemical pleurodesis (fraught w/ complications, not commonly performed at VUMC)
    • Thoracoscopic mesh repair in patients with clear diaphragmatic deficits, but again, this is not common practice at VUMC 
  • Management of spontaneous bacterial empyema is the same as in SBP, as noted below