A 64-year-old obese man presents for evaluation of the development of ascites and
peripheral edema. He is a heavy smoker and has no history of liver disease. Physical
examination reveals congested neck veins, decreased breath sounds, moderate ascites, and
peripheral edema, but no other abnormalities. Laboratory tests reveal a total bilirubin of
1.2 mg/dL, AST of 37 IU/mL, ALT of 35 IU/mL, albumin of 3.7 g/dL, and an INR of 1.4.
Paracentesis discloses clear yellow fluid with a total protein of 3.5 g/dL, albumin of
1.7 g/dL, and white blood cell count of 640/mm3
(12% neutrophils).
A-What is your provisional diagnosis and how to confirm?
*Cardiac asites
Confirmed by:
ECHO
ECG
Chest x ray
Active Natruretic peptide
B-What is your differential diagnosis with prioritization?
1-cardiac ascites(the most accurate diagnosis) due to:
*Signs of right-sided heart failure:
Congested neck veins
Peripheral edema
Decreased breath sounds (possible pleural effusion)
Moderate ascites
*Normal liver enzymes and bilirubin: No intrinsic hepatic injury
*Paracentesis findings:
Serum-ascites albumin gradient (SAAG) = 3.7 - 1.7 = 2.0 g/dL → high SAAG (>1.1), suggests portal hypertension
Ascitic fluid total protein = 3.5 g/dL → high protein (>2.5 g/dL), which is more typical of cardiac ascites
Moderate WBC with low neutrophils (no spontaneous bacterial peritonitis)
2-Budd chiari syndrome
Less expected
3-constrictive pericarditis
Refractory Ascites
Definition
Ascites that cannot be mobilized or reaccumulates rapidly despite maximum tolerated doses of diuretics (spironolactone 400 mg/day and furosemide 160 mg/day) and salt restriction.
Types of Refractory Ascites
- Diuretic-resistant ascites:
No response despite maximal diuretics and dietary sodium restriction.
- Diuretic-intractable ascites:
Cannot be treated with diuretics due to complications (e.g., renal failure, electrolyte imbalance).
Diagnosis of refractory Ascites
Based on clinical failure to control ascites + low urinary sodium (<78 mmol/day) despite treatment
Treatment of refractory Ascites
1-LVP+ albumin infusion (8 gm for every 1 litre above 5)
2-TIPS
3-Lee ven shunt
4-Liver transplantation
Contraindications of LVP
*SBP
*Sepsis
*Azotemia
*Hypotension
*Recent GIT bleeding
