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AscitesAka: Abdominal Dropsy

Definition
1. Accumulation of peritoneal fluid
Symptoms
1. Small amount of ascites
  1. Asymptomatic
2. Large amount of ascites
  1. Abdominal distention and discomfort
  2. Anorexia
  3. Nausea
  4. Early satiety
  5. Heartburn (Gastroesophageal Reflux)
  6. Flank pain
  7. Respiratory distress
Signs
1. Umbilicus may evert
2. Bulging flanks with patient lying supine
  1. Weight of ascitic fluid pushes against side walls
3. Tympany at the top of the abdominal curve
  1. Patient lies supine
  2. Gas filled bowel floats upward over ascites
4. Fluid Wave Test
5. Shifting Dullness Test
6. Puddle Sign
Causes
1. See Ascites Causes
2. Most common etiologies
  1. Cirrhosis (Cirrhotic Ascites): 85% of cases
  2. Cancer (Malignant ascites)
  3. Congestive Heart Failure
  4. Tuberculosis
Labs
1. Diagnostic abdominal Paracentesis in all cases
2. Ascites Fluid: Serum ascites albumin gradient (SAAG)
  1. Gradient is the difference between Serum Albumin and ascites albumin
    1. Greater difference (SAAG>1.1 g/dl) implies Portal Hypertension
  2. Exudate or Low Gradient Ascites (Serum to ascites albumin gradient <1.1 g/dl)
    1. Peritonitis
    2. Neoplasm (Malignant Ascites, peritoneal carcinomatosis)
    3. Pancreatitis
    4. Vasculitis
    5. Nephrotic Syndrome
    6. Biliary or chylous ascites
  3. Transudate (Serum to ascites albumin gradient >1.1 g/dl)
    1. Low ascitic fluid total protein (<1 g/dl)
      1. Cirrhosis (Cirrhotic Ascites)
      2. Alcoholic Hepatitis
    2. High ascitic fluid total protein (>2 g/dl)
      1. Congestive Heart Failure
      2. Budd-Chiari Syndrome
      3. Myxedema
      4. Constrictive Pericarditis
3. Ascites Fluid: Cell Count with Differential
  1. Ascites Red Blood Cells (RBC) elevated
    1. Neoplasm (Malignant ascites)
    2. Tuberculous Peritonitis (variably elevated)
    3. Pancreatitis (variably elevated)
  2. Ascites White Blood Cells <250 cells/mm3
    1. Serum to Ascites Albumin Gradient (SAAG) < 1.1 g/dl
      1. Fluid total protein >2.5: Cardiac ascites
      2. Fluid total protein <2.5: Cirrhotic Ascites
    2. Serum to Ascites Albumin Gradient (SAAG) > 1.1 g/dl
      1. Fluid total protein <2.5: Nephrotic ascites
  3. Ascites White Blood Cells >500 (or PMNs >250)
    1. WBC Differential <50% Neutrophils (PMNs)
      1. Peritoneal carcinomatosis (>50% Lymphocytes)
        
        Search for primary tumor
      2. Tuberculous Peritonitis (>70% Lymphocytes)
        
        Culture fluid for Tuberculosis
    2. WBC Differential >50% Neutrophils (PMNs)
      1. Pancreatic Ascites (Fluid amylase >100 U/L)
        
        Evaluate with abdominal CT
      2. Spontaneous Bacterial Peritonitis (single colony)
        
        Fluid total protein <1 g/dl
        
        Fluid glucose >50 mg/dl
        
        Fluid LDH <225 U/L
      3. Bacterial peritonitis (polymicrobial)
        
        White Blood Cell count often > 10,000
        
        Fluid total protein >1 g/dl
        
        Fluid glucose <50 mg/dl
        
        Fluid LDH >225 U/L
4. Ascites fluid color
  1. Transparent to cloudy yellow or clear (typical)
  2. Dark brown: Obtain quantitative fluid Bilirubin
  3. Milky: Obtain Triglyceride concentration
  4. Bloody: Adjust Leukocyte count
    1. Subtract 1 White Blood Cell per 750 Red Blood Cells
    2. Subtract 1 Neutrophil (PMN) per 250 Red Blood Cells
5. Ascites fluid assorted labs
  1. Lactate Dehydrogenase
  2. Amylase
  3. pH
  4. Lipids
  5. Culture and cytology
Diagnostics: Diagnostic Paracentesis
1. Identify site at linea alba, 2 cm below Umbilicus
2. Use 22 gauge needle with catheter
Imaging
1. Ultrasound abdomen or CT Abdomen
  1. Very sensitive for ascitic fluid
Management
1. Cirrhosis
  1. See Cirrhotic Ascites
2. Malignant ascites
  1. Paracentesis offers symptomatic relief as needed
  2. Medication Management
    1. Spironolactone and
    2. Thiazide or Loop Diuretic

Ascites (C0003962)
Definition (MSH)	Accumulation or retention of free fluid within the peritoneal cavity.
Definition (CSP)	effusion and accumulation of serous fluid in the abdominal cavity.
Definition (NCI)	(ah-SYE-teez) Abnormal buildup of fluid in the abdomen.
Definition (NCI)	Accumulation of fluid in the peritoneal cavity. The fluid may be serous, hemorrhagic, or the result of tumor metastasis to the peritoneum. -- 2004
Concepts	Finding (T033)
ICD9	789.5, 789.5
MSH	D001201
English	abdominal dropsy, Ascites, Fluid in peritoneal cavity, Hydroperitoneum, Hydroperitonia, Hydrops abdominis, Peritoneal dropsy, peritoneal exudate
Spanish	ascitis, hidroperitoneo, liquido ascitico, liquido en cavidad peritoneal
Parent Concepts	Peritoneal Diseases (C0031142), Other liver disorders (C0156194), Signs and Symptoms (C0037088), Abdomen (C0000726), Chronic liver disease NOS (C0341439), Disorder of abdomen (C1290864), Body part (C0229962), Other symptoms involving abdomen and pelvis (C0159065), Pathologic Processes (C0030660), Ascites (C0003962), Fluid thrill in abdomen (C0426682), [D]Other abdominal or pelvic symptom (C0476316), Ambiguous concept (C1274012), Duplicate concept (C1274013)
Sources	AOD, CCS, COSTAR, CSP, CST, DXP, HL7V2.5, ICD9CM, LCH, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT Derived from the NIH UMLS (Unified Medical Language System)

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AscitesAka: Abdominal Dropsy

Ascites (C0003962)

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