CURRENT Essentials of Critical Care.pdf

Chapter 11 Gastrointestinal Disease 163■■■AscitesEssentials of Diagnosis• Increasing abdominal girth and pressure, anorexia, early satiety,nausea, dyspnea• Shifting dullness, fluid wave, bulging flanks• If due to liver disease: jaundice, spider angiomas, caput medusa,palmar erythema, testicular atrophy, gynecomastia• Ascitic fluid assessment: cell count and differential, albumin,protein, Gram stain plus culture; amylase, cytology, glucose,LDH, triglycerides• Calculate serum-ascites albumin gradient (SAAG): portal hypertension(1.1 g/dL) or nonportal hypertensive causes (1.1g/dL)• Spontaneous bacterial peritonitis (SBP) frequent complication;ascitic fluid with 250 neutrophils/L diagnostic• Ultrasound and CT scan: useful in localizing small volume ascites,identifying vascular thrombosis, determining etiology• Grossly bloody ascites: repeat paracentesis in another location;if hemoperitoneum confirmed, emergent CT scan and surgicalconsultDifferential Diagnosis• Portal Hypertension (High SAAG): cirrhosis, cardiac failure,portal or hepatic venoocclusive disease, fatty liver of pregnancy• Nonportal Hypertensive Ascites (Low SAAG): malignancy, intraperitonealinfection, nephrotic syndrome, pancreatitisTreatment• Sodium and fluid restriction for mild ascites• Spironolactone and loop diuretics for moderate ascites• Monitor weight, electrolytes, creatinine during diuresis• Paracentesis for tense refractory ascites; consider salt-poor albumininfusions during large volume paracentesis• Transjugular intrahepatic portosystemic shunt (TIPS) for intractableascites; other options include surgical peritoneovenousshunting, liver transplantation• Treat SBP with antibiotics, albumin infusion; consider prophylacticantibiotics for prior SBP, upper GI hemorrhage, low proteinascites■ PearlOver 50% of patients with cirrhosis will develop ascites. Once ascitesdevelops, the median survival is only 1 year.ReferenceMoore KP et al: The management of ascites in cirrhosis. Hepatology2003;38:258. [PMID: 12830009]