Ascites: Diagnosis and Management

Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, MCV Box 980341, Richmond, VA 23298-0341, USA.
The Medical clinics of North America (Impact Factor: 2.61). 08/2009; 93(4):801-17, vii. DOI: 10.1016/j.mcna.2009.03.007
Source: PubMed


Ascites is the pathologic accumulation of fluid in the peritoneal cavity and is a common manifestation of liver failure, being one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its cause by determining the serum-ascites albumin gradient and the exclusion of complications eg, spontaneous bacterial peritonitis. Although sodium restriction and diuretics remain the cornerstone of ascites management, many patients require additional therapy when they become refractory to such medical treatment. These include repeated large volume paracentesis and transjugular intrahepatic portosystemic shunts. This review article summarizes diagnostic tools and provides an evidence-based approach to the management of ascites.

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    • "However, many patients with cirrhotic ascites fail to respond to the maximum dose of diuretics and are classified as having refractory ascites [3]-[5]. In contrast, failure to optimize the dose of diuretics due to the side effects of the treatment is defined as diuretic intractable ascites [2]-[5]. The management of diuretic refractory and intractable cirrhotic ascites includes frequent therapeutic paracentesis (removing more than five liters of ascetic fluid), which can be continued until liver transplantation or the insertion of a transjugular portosystemic shunt [2]-[5]. "
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    ABSTRACT: Background: Liver cirrhosis is the most common cause of ascites. For cirrhotic ascites that does not respond to diuretics and salt restriction, large-volume paracentesis is an alternative option. Methods: A retrospective cohort study of patients admitted to the Day care unit at King Abdulaziz University Hospital for therapeutic paracentesis of cirrhotic ascites was performed from March 2013-April 2014. The demographic data and results, including the platelet count, hemoglobin level, prothrombin time (PT), international normalized ratio (INR), serum creatinine, serum albumin, and bilirubin levels, were recorded. We recorded all of the bleeding episodes. Results: We recorded 118 admissions for 13 patients. Nine of them were male (69.2%), and the mean age was 58.6 ± 15.8 years. All patients had a Child-Pugh score of C. The platelet count was lower than normal for 78 admissions (66.1%), and the PT was prolonged for 99 admissions (84%). Three episodes of bleeding occurred in our cohort, all of which were mild and controlled by the local application of pressure. One patient required a platelet transfusion for severe thrombocytopenia, low platelets count was associated with elevated creatinine and low albumin levels (P = 0.014 and 0.003, respectively). Similarly, a prolonged PT was associated with low albumin, high bilirubin, low platelet, and high creatinine levels (P = 0.013, < 0.001, = 0.006, and < 0.001, respectively). Conclusions: Large-volume paracentesis is associated with only a small risk of bleeding in patients with cirrhotic ascites, and a transfusion of fresh frozen plasma (FFP) and platelets is not needed for the majority of patients.
    Full-text · Article · Dec 2015 · Open Journal of Blood Diseases
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    • "El uso de albúmina tiene como objetivo evitar la disfunción circulatoria que propicia daño renal y muerte a mediano plazo (18). Si se extraen menos de 5 litros se puede dar algún expansor sintético (6) o nada.13141519)(20,21)Hay factores precipitantes de la ascitis refractaria, como es uso de medicamentos nefrotóxicos ( aminoglucosidos y antinflamatorios no esteroideos), agudización de una hepatopatía crónica ( hepatitis autoinmune, hepatitis viral) y cirugía abdominal reciente. "
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    ABSTRACT: La Asociación Mexicana de Gastroenterología (AMG), para este año 2014, ha diseñado un programa académico que se ha denominado Gastrotrilogía. Este programa consiste en 3 simposios enfocados en los tópicos más sobresalientes de la Gastroenterología de esta década que incluyen: la microbiota intestinal, obesidad y nutrición; la enfermedad por reflujo gastroesofágico y los trastornos funcionales digestivos; las hepatitis virales y la enfermedad inflamatoria intestinal. Es una iniciativa de la mesa directiva de la AMG, la publicación de un libro con el contenido de cada uno de estos simposios. Consideramos que los conocimientos científicos abordados por expertos nacionales e internacionales en estos 3 eventos deben quedar plasmados en una obra escrita, Gastrotrilogía, para que el interesado pueda hacer las consultas necesarias e incrementar su acervo de conocimientos. En este tercer volumen de Gastrotrilogía se abordan los avances más importantes en el diagnóstico y el tratamiento de las hepatitis virales, con especial énfasis en los nuevos antivirales para la hepatitis C con los que se han logrado tasas de respuesta viral sostenida cercanas al 90%. También se discuten las complicaciones de la cirrosis hepática, las hepatitis tóxicas y el hepatocarcinoma. De la misma manera se tratan puntualmente las manifestaciones clínicas, el diagnóstico diferencial, la evaluación de la actividad y las nuevas modalidades de tratamiento de la enfermedad inflamatoria intestinal. Con Gastrotrilogía, los autores pretendemos que el lector aumente significativamente sus conocimientos en los principales temas de la gastroenterología moderna y de esta manera se logre nuestro objetivo primario, una mejor atención de nuestros pacientes.
    Full-text · Chapter · Jun 2014
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    • "Several studies have shown that routine cytopathology using ascitic fluid smears is positive for malignant cells in two out of 10 patients with ascites [12]. This is because, unless the ascitic fluid is cytospun, smears on slides will give false-negative results since the malignant cells are widely dispersed in the vast amounts of ascitic fluid. "
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    ABSTRACT: Adenocarcinoma of the colon is the most common histopathological type of colorectal cancer. In Western Europe and the United States, it is the third most common type and accounts for 98% of cancers of the large intestine. In Uganda, as elsewhere in Africa, the majority of patients are elderly (at least 60 years old). However, more recently, it has been observed that younger patients (less than 40 years of age) are presenting with the disease. There is also an increase in its incidence and most patients present late, possibly because of the lack of a comprehensive national screening and preventive health-care program. We describe the clinicopathological features of colorectal carcinoma in the case of a young man in Kampala, Uganda. A 27-year-old man from Kampala, Uganda, presented with gross abdominal distension, progressive loss of weight, and fever. He was initially screened for tuberculosis, hepatitis, and lymphoma, and human immunodeficiency virus/acquired immunodeficiency syndrome infection. After a battery of tests, a diagnosis of colorectal carcinoma was finally established with hematoxylin and eosin staining of a cell block made from the sediment of a liter of cytospun ascitic fluid, which showed atypical glands floating in abundant extracellular mucin, suggestive of adenocarcinoma. Ancillary tests with alcian blue/periodic acid Schiff and mucicarmine staining revealed that it was a mucinous adenocarcinoma. Immunohistochemistry showed strong positivity with CDX2, confirming that the origin of the tumor was the colon. Colorectal carcinoma has been noted to occur with increasing frequency in young adults in Africa. Most patients have mucinous adenocarcinoma, present late, and have rapid disease progression and poor outcome. Therefore, colorectal malignancy should no longer be excluded from consideration only on the basis of a patient's age. A high index of suspicion is important in the diagnosis of colorectal malignancy in young African patients.
    Full-text · Article · Feb 2012 · Journal of Medical Case Reports
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