What is the definition of ascites?
Pathologic accumulation of fluid in the peritoneal cavity (>25 mL)
Most commonly caused by portal hypertension from cirrhosis (85%), but also occurs in heart failure, malignancy, tuberculosis, and nephrotic syndrome.
What are the primary symptoms of ascites?
- Progressive abdominal distension
- Weight gain (>1kg/day in decompensated cirrhosis)
- Early satiety, nausea
- Dyspnea
These symptoms can develop over weeks to months.
What are the red flag symptoms of ascites that require urgent intervention?
- Fever >38°C or abdominal pain
- Hypotension/syncope
- Altered mental status
- Acute urinary retention
These symptoms may indicate serious complications such as spontaneous bacterial peritonitis.
What are some chronic complications of ascites?
- Umbilical/inguinal hernias
- Pleural effusions
- Spontaneous fungal peritonitis
These complications can arise from the underlying condition of ascites.
What are the essential tests in a diagnostic paracentesis for new ascites?
- Cell count with differential
- Albumin
- Total protein
- Culture
These tests help determine the cause and characteristics of the ascitic fluid.
What does a SAAG ≥1.1 g/dL indicate?
Portal hypertension present
Common causes include cirrhosis, heart failure, and Budd-Chiari syndrome.
What does a SAAG <1.1 g/dL indicate?
Non-portal hypertension causes
Examples include peritoneal carcinomatosis, tuberculous peritonitis, and pancreatic ascites.
What is the first-line treatment for cirrhotic ascites?
- Sodium restriction (<2 g/day)
- Spironolactone
- Add furosemide if inadequate response
Sodium restriction is more effective than diuretics alone.
What is the goal of weight loss during diuretic therapy for ascites?
≤0.5 kg/day (≤1 kg/day if no edema)
This helps manage fluid retention effectively.
What are the indications for SBP prophylaxis?
- Ascitic protein <1.5 g/dL
- Prior SBP episode
Prophylaxis is critical to prevent spontaneous bacterial peritonitis.
What is the management for tense ascites causing respiratory distress?
- Therapeutic paracentesis
- Albumin replacement
Removing fluid can alleviate pressure and improve breathing.
What should be monitored during diuretic initiation for ascites?
- Daily weights
- Serum Na⁺, K⁺, Cr
- Assess for HE/encephalopathy
Monitoring is crucial to avoid complications.
What dietary advice should be given to patients with ascites?
- No added salt
- Use lemon juice/vinegar for flavor
Hidden salt can be found in many processed foods.
What are the warning signs that require an ER visit for ascites patients?
- Fever >38°C or abdominal pain
- Dark, tarry stools
- Confusion or drowsiness
These signs may indicate serious complications.
What is the disposition for a patient with SBP and septic shock?
ICU admission
This is necessary for close monitoring and intensive treatment.
What are the contraindications to paracentesis?
- INR >2.5
- Platelets <20,000/mm³
- Abdominal wall cellulitis at puncture site
These conditions increase the risk of complications during the procedure.
