Ascites zaydooni

AscitesAscitesPresented byPresented byZaYDoon H.AZaYDoon H.A

AscitesAscites

• Derived from the Greek word Derived from the Greek word “askos”, “askos”, meaning bag or sac.meaning bag or sac.

• Defined as the accumulation of fluid in the Defined as the accumulation of fluid in the peritoneal cavity. peritoneal cavity.

• It is a common clinical finding, with many It is a common clinical finding, with many extraperitoneal and peritoneal causes , extraperitoneal and peritoneal causes , but most common from liver cirrhosis .but most common from liver cirrhosis .

Peritoneal cavityPeritoneal cavity• It is a potential space between the It is a potential space between the

parietal peritoneum and visceral parietal peritoneum and visceral peritoneum, the two membranes peritoneum, the two membranes separate the organs in the abdominal separate the organs in the abdominal cavity from the abdominal wall.cavity from the abdominal wall.

• Derived from the coelomic cavity of the Derived from the coelomic cavity of the embryo. embryo.

• Largest serosal sac in the body and Largest serosal sac in the body and secretes approximately 50 ml of fluid per secretes approximately 50 ml of fluid per day.day.

Peritoneal fluidPeritoneal fluid

• It is a normal, lubricating fluid found in the It is a normal, lubricating fluid found in the peritoneal cavity.peritoneal cavity.

• The fluid is mostly water with electrolytes, The fluid is mostly water with electrolytes, antibodies, white blood cells, albumin, antibodies, white blood cells, albumin, glucose and other biochemicals. glucose and other biochemicals.

• Reduce the friction between the Reduce the friction between the abdominal organs as they move around abdominal organs as they move around during digestion.during digestion.

Patient with AscitesPatient with Ascites

Etiology of ascitesEtiology of ascites

Most Common causes(90% of cases):Most Common causes(90% of cases):• Portal HTN secondary to chronic liver Portal HTN secondary to chronic liver

diseases ( cirrhosis) diseases ( cirrhosis) • Intra-abdominal malignancy Intra-abdominal malignancy • Congestive Heart Failure Congestive Heart Failure • Mycobacterium tuberculosis Mycobacterium tuberculosis

portal hypertensionportal hypertension

• It is a high blood pressure in the portal It is a high blood pressure in the portal vein and its tributaries(portal venous vein and its tributaries(portal venous system).system).

• It is defined as a portal pressure gradient It is defined as a portal pressure gradient (the difference in pressure between the (the difference in pressure between the portal vein and the hepatic veins) of 5 mm portal vein and the hepatic veins) of 5 mm Hg or greater.Hg or greater.

Causes of portal hypertensionCauses of portal hypertension

• Intrahepatic causes: Intrahepatic causes: liver cirrhosis and hepatic liver cirrhosis and hepatic fibrosis (e.g. due to Wilson's disease, fibrosis (e.g. due to Wilson's disease, hemochromatosis, or congenital fibrosis).hemochromatosis, or congenital fibrosis).

• Prehepatic causes : Prehepatic causes : portal vein thrombosis or portal vein thrombosis or congenital atresia.congenital atresia.

• Posthepatic obstruction Posthepatic obstruction occur at any level occur at any level between liver and right heart, including hepatic between liver and right heart, including hepatic vein thrombosis, IVC thrombosis, IVC congenital vein thrombosis, IVC thrombosis, IVC congenital malformation, and constrictive pericarditis.malformation, and constrictive pericarditis.

CirrhosisCirrhosis

most common causes of cirrhosis:most common causes of cirrhosis:• Alcoholic liver disease or alcoholic Alcoholic liver disease or alcoholic

hepatitishepatitis• viral hepatitis (B or C)viral hepatitis (B or C)• fatty liver disease fatty liver disease

Other causes of ascitesOther causes of ascites

HypolalbuminemiaHypolalbuminemia • Nephrotic syndromeNephrotic syndrome• Protein-losing enteropathyProtein-losing enteropathy• malnutrition malnutrition

Other causes of ascitesOther causes of ascites• Bacterial, fungal or parasitic disease Bacterial, fungal or parasitic disease • Vasculitis Vasculitis • Whipple's Disease Whipple's Disease • Familial Mediterranean fever Familial Mediterranean fever • EndometriosisEndometriosis• Starch peritonitis Starch peritonitis • Budd-Chiari Syndrome Budd-Chiari Syndrome • MyxedemaMyxedema• Ovarian disease (e.g. Meigs' Syndrome) Ovarian disease (e.g. Meigs' Syndrome) • Pancreatic disease Pancreatic disease • Chylous AscitesChylous Ascites

PathophysiologyPathophysiology

1-1- Increased hydrostatic pressure Increased hydrostatic pressure• CirrhosisCirrhosis• Hepatic vein occlusion (Budd-ChiariHepatic vein occlusion (Budd-Chiari Syndrome)Syndrome)• Inferior vena caval obstructionInferior vena caval obstruction• Constrictive PericarditisConstrictive Pericarditis• Congestive heart failureCongestive heart failure

PathophysiologyPathophysiology2.2. Decreased colloid osmotic Decreased colloid osmotic

pressurepressure• End-stage liver disease with poor protein End-stage liver disease with poor protein

synthesissynthesis• Nephrotic syndrome Nephrotic syndrome • MalnutritionMalnutrition• Protein-losing enteropathyProtein-losing enteropathy3.3. Increase permeabil ity of peritoneal Increase permeabil ity of peritoneal

capil lariescapil laries• Tuberculous peritonitisTuberculous peritonitis• Bacterial peritonitisBacterial peritonitis• Malignant disease of the peritoneumMalignant disease of the peritoneum

PathophysiologyPathophysiology4.4. Leakage of f luid into the Leakage of f luid into the

peritoneal cavityperitoneal cavity• Bile ascitesBile ascites• Pancreatic ascitesPancreatic ascites• Chylous ascitesChylous ascites• Urine ascitesUrine ascites5.5. Miscellaneous causesMiscellaneous causes• MyxedemaMyxedema• Ovarian disease (Meig’s syndrome)Ovarian disease (Meig’s syndrome)• Chronic hemodialysisChronic hemodialysis

Morbidity and MortalityMorbidity and Mortality

• Ambulatory patients with an episode of Ambulatory patients with an episode of cirrhotic ascites have a 3-year mortality cirrhotic ascites have a 3-year mortality rate of 50%. The development of rate of 50%. The development of refractory ascites carries a poor refractory ascites carries a poor prognosis, with a 1-year survival rate of prognosis, with a 1-year survival rate of less than 50%.less than 50%.

DiagnosisDiagnosis1-history1-history

Pts should be questioned about:Pts should be questioned about:• Liver diseases Liver diseases • Risk factors for Hepatitis C ( needle Risk factors for Hepatitis C ( needle

sharing, tattoos, cocaine, heroin use and sharing, tattoos, cocaine, heroin use and emigration from Egypt or Southeast emigration from Egypt or Southeast Asia)Asia)

• Risk factors for Hepatitis B (needle Risk factors for Hepatitis B (needle sharing, tattoos, acupuncture, and sharing, tattoos, acupuncture, and emigration from China, Korea, Taiwan, emigration from China, Korea, Taiwan, or Southeast Asia). or Southeast Asia).

• Pts with obesity, diabetes, Pts with obesity, diabetes, hyperlipidemia and Nonalcoholic hyperlipidemia and Nonalcoholic steatohepatitis ( NASH ) should be ruled steatohepatitis ( NASH ) should be ruled out. out.

• Pts with ascites who lack risk factors for Pts with ascites who lack risk factors for cirrhosis should be questioned aboutcirrhosis should be questioned about

cancer, heart failure, TB, dialysis, and cancer, heart failure, TB, dialysis, and pancreatitis.pancreatitis.

• Operative injury to the ureter or bladder Operative injury to the ureter or bladder can lead to leakage of urine into can lead to leakage of urine into peritoneal cavity. peritoneal cavity.

• HIV pts may have infections lead to HIV pts may have infections lead to ascites.ascites.

diagnosisdiagnosis2-Clinical Features2-Clinical Features

• A- Asymptomatic (fluid <100 - 400ml):A- Asymptomatic (fluid <100 - 400ml): Mild ascites Mild ascites

• B- symptomatic (fluid >400ml): B- symptomatic (fluid >400ml): Increased abdominal girth, presence of Increased abdominal girth, presence of

abdominal pain or discomfort,abdominal pain or discomfort, early satiety, pedal edema, weight gainearly satiety, pedal edema, weight gain and respiratory distress depending on the and respiratory distress depending on the

amount of fluid accumulated in the amount of fluid accumulated in the abdomen.abdomen.

Physical examination findings:Physical examination findings:• Umbilicus Eversion (often with umbilical Umbilicus Eversion (often with umbilical

herniation)herniation)• Tympany at the top of the abdomenTympany at the top of the abdomen• Fluid waveFluid wave• Peripheral edemaPeripheral edema• Shifting dullness (> 500ml fluid)Shifting dullness (> 500ml fluid)• Bulging flanks (>500ml fluid) Bulging flanks (>500ml fluid)

Shifting DullnessShifting Dullness

Bulging Flanks and Umbilical Bulging Flanks and Umbilical HerniaHernia

DiagnosisDiagnosis3-paracentesis3-paracentesis

• It is a diagnostic procedure to establish It is a diagnostic procedure to establish the etiology of new-onset ascites or to rule the etiology of new-onset ascites or to rule out spontaneous bacterial peritonitis in out spontaneous bacterial peritonitis in patients with preexisting ascites. Large patients with preexisting ascites. Large volume paracentesis is performed in volume paracentesis is performed in hemodynamically stable patients with hemodynamically stable patients with tense or refractory ascites to alleviate tense or refractory ascites to alleviate discomfort or respiratory compromise.discomfort or respiratory compromise.

• For diagnostic purposes, a small amount For diagnostic purposes, a small amount (20cc) may be enough for adequate (20cc) may be enough for adequate testing.testing.

Ascitic fluid analysisAscitic fluid analysisCell count: Cell count: • A white blood cell count is the most A white blood cell count is the most

important.important.• A neutrophil > 250 cells/mm3 A neutrophil > 250 cells/mm3

spontaneous bacterial peritonitisspontaneous bacterial peritonitis• An elevated lymphocyte An elevated lymphocyte tuberculosis tuberculosis

or peritoneal carcinomatosisor peritoneal carcinomatosis• Gram stain and culture:Gram stain and culture:for bacteria and acid fast bacillifor bacteria and acid fast bacilli

• Red cell countRed cell count > 50.000/microliter > 50.000/microliter hemorrhagic ascites, hemorrhagic ascites,

which usually is due to malignancy, which usually is due to malignancy, tuberculosis or trauma.tuberculosis or trauma.

Serum-Ascites Albumin GradientSerum-Ascites Albumin Gradient• Best single test for classifying ascites into Best single test for classifying ascites into

portal hypertensive and non-portal portal hypertensive and non-portal hypertensive causes.hypertensive causes.

• Calculated by: Calculated by: Serum albumin – Ascites albumin= SAAGSerum albumin – Ascites albumin= SAAGSAAG >1.1 g/dL= Portal HTNSAAG >1.1 g/dL= Portal HTNSAAG < 1.1 g/dL= Non-Portal hypertensive SAAG < 1.1 g/dL= Non-Portal hypertensive

cause cause

SAAGSAAGSAAG >1.1SAAG >1.11.1. Liver DiseaseLiver Disease2.2. Hepatic Hepatic

CongestionCongestion3.3. CHFCHF4.4. Tricuspid Tricuspid

InsufficiencyInsufficiency5.5. Massive Hepatic Massive Hepatic

MetastasisMetastasis

SAAG <1.1SAAG <1.11.1. Peritoneal Peritoneal

carcinomatosiscarcinomatosis2.2. Peritoneal Peritoneal

InfectionInfection(TB, Fungal, (TB, Fungal, CMV)CMV)

3.3. Nephrotic Nephrotic syndromesyndrome

4.4. Pancreatic ascitesPancreatic ascites

• Total protein:Total protein:Helpful in diagnosing spontaneous bacterial Helpful in diagnosing spontaneous bacterial

peritonitisperitonitisPts with a value<1 g/dl protein and glucose Pts with a value<1 g/dl protein and glucose

of <50mg/dlof <50mg/dlhave high risk of SBPhave high risk of SBP• Cytology:Cytology:for malignant cellsfor malignant cells• Amylase:Amylase: to exclude pancreatic ascitesto exclude pancreatic ascites

ascitic fluidascitic fluidAppearance:Appearance: The gross appearance of the ascitic fluid The gross appearance of the ascitic fluid

can be helpful in the differential diagnosis.can be helpful in the differential diagnosis.Turbid or cloudyTurbid or cloudy: : infected fluid.infected fluid.MilkyMilky:: Triglyceride concentration of greater than 200mg/dl Triglyceride concentration of greater than 200mg/dl

(often greater than 1000mg/dl), malignancy is usually (often greater than 1000mg/dl), malignancy is usually MC cause, but cirrhosis may present with chylous fluid.MC cause, but cirrhosis may present with chylous fluid.

Pink or BloodyPink or Bloody: : Pink fluid usually traumatic tap. Frankly Pink fluid usually traumatic tap. Frankly bloody may occur in hepatocellular carcinoma, or other bloody may occur in hepatocellular carcinoma, or other malignancy related ascites.malignancy related ascites.

BrownBrown:: Deeply jaundiced pts may present with brown Deeply jaundiced pts may present with brown ascitic fluid, which may represent gallbladder rupture or ascitic fluid, which may represent gallbladder rupture or perforated duodenal ulcer. perforated duodenal ulcer.

diagnosisdiagnosis4-Imaging Studies4-Imaging Studies

A-A- Chest and Plain Abdominal Films Chest and Plain Abdominal Films• Elevation of the diaphram (usually with Elevation of the diaphram (usually with

>500 ml of fluid)>500 ml of fluid)• Abdominal hazinessAbdominal haziness• Bulging FlanksBulging Flanks• Poor definition of intra abdominal organsPoor definition of intra abdominal organs

--

• Medial displacement of the cecum and Medial displacement of the cecum and ascending colon.ascending colon.

• Hellmer's sign: the lateral liver angle is Hellmer's sign: the lateral liver angle is displaced medially from the displaced medially from the thoracoabdominal wall in a patient with a thoracoabdominal wall in a patient with a large extraperitoneal fluid collection large extraperitoneal fluid collection extending into the flank (Pathologic extending into the flank (Pathologic processes in both the intra- and processes in both the intra- and extraperitoneal spaces). extraperitoneal spaces).

bilateral pleural effusions in a bilateral pleural effusions in a patient with ascitespatient with ascites

loss of any loss of any definition of definition of the edge of the the edge of the spleen or liver spleen or liver and and displacement displacement of the bowel of the bowel loops out of loops out of the pelvis and the pelvis and bulging flanksbulging flanks

Pelvic AscitesPelvic Ascites

Imaging StudiesImaging Studies

B-B- CT scanCT scan• Well visualized Well visualized • Fluid may be visualized in the:Fluid may be visualized in the:• Right perihepatic spaceRight perihepatic space• Posterior subhepatic space (Morison Posterior subhepatic space (Morison

pouch)pouch)• Pouch of DouglasPouch of Douglas

Large ascitesLarge ascitesdisplacing bowel posteriorlydisplacing bowel posteriorly

Perihepatic ascitesPerihepatic ascites

[CT] Small amount of ascitic fluid in the pouch of Douglas and surrounding the adjacent

small bowel loops

Abdominal CT, showing Morison's Abdominal CT, showing Morison's pouch as the dark margin surrounding pouch as the dark margin surrounding the right kidney (at lower left corner of the right kidney (at lower left corner of image).image).

Imaging StudiesImaging Studies

C-C- UltrasoundUltrasound• Easiest and most sensitive technique for Easiest and most sensitive technique for

detection of ascitic fluid.detection of ascitic fluid.• Volume as small as 5-10ml can be seen.Volume as small as 5-10ml can be seen.

..

Morison's pouchMorison's pouch with abnormal with abnormal fluid collection fluid collection (red arrows) (red arrows) between the between the liver and right liver and right kidneykidney

Management of AscitesManagement of AscitesThe goal is to prevent Na loading and increase The goal is to prevent Na loading and increase renal excretion of Na and H2O and produce a renal excretion of Na and H2O and produce a net re-absorption of fluid from the ascites back net re-absorption of fluid from the ascites back into the circulating volume.into the circulating volume.

• Dietary Na restrictionDietary Na restriction Diet of 2g sodium per dayDiet of 2g sodium per day

• Fluid Restriction:Fluid Restriction: Only done when serum Na is <128mmol/LOnly done when serum Na is <128mmol/L

• Check LabsCheck Labs Ck serum electrolytes and creatinine every Ck serum electrolytes and creatinine every other day.other day. Weigh the patient and measure urinary Weigh the patient and measure urinary output daily.output daily.

Management of AscitesManagement of AscitesDiuretic therapy:Diuretic therapy:• Spironolactone: diuretic of choiceSpironolactone: diuretic of choice

(25-200mg PO daily or bid)(25-200mg PO daily or bid)• Lasix: (20-80 mg/d PO/IV/IM)Lasix: (20-80 mg/d PO/IV/IM)• Zaroxolyn: (works on Edema of CHF)Zaroxolyn: (works on Edema of CHF)

(5-20 mg/dose PO q24hr)(5-20 mg/dose PO q24hr)• Mannitol: (0.5-2 g/kg IV over 30-60 min, Mannitol: (0.5-2 g/kg IV over 30-60 min,

repeat q6-8hrs)repeat q6-8hrs)• Amilioride: 5-20 mg/d PO Amilioride: 5-20 mg/d PO

Management of AscitesManagement of AscitesLarge Volume ParacentesisLarge Volume Paracentesis• To relieve symptomatic tense ascites and To relieve symptomatic tense ascites and

peripheral edema.peripheral edema.• Up to 20L can be removed over 4-6hr.Up to 20L can be removed over 4-6hr.• Removal of 5L or more of ascitic fluid Removal of 5L or more of ascitic fluid

during a single session. during a single session.

Paracentesis Contraindications:Paracentesis Contraindications:

• Acute abdomen (absolute)Acute abdomen (absolute)• Severe bowel distentionSevere bowel distention• Previous abdominal surgery (if necessary perform Previous abdominal surgery (if necessary perform

open procedure)open procedure)• Pregnancy (if necessary perform after first trimester Pregnancy (if necessary perform after first trimester

using an open technique above the umbilicus)using an open technique above the umbilicus)• Distended bladder that cannot be relieved by foley Distended bladder that cannot be relieved by foley

cathedercatheder• Infection at site of insertion (cellulitis or abscess)Infection at site of insertion (cellulitis or abscess)• Thrombocytopenia (relative)Thrombocytopenia (relative)• Coagulopathy (relative)Coagulopathy (relative)

Paracentesis Complications:Paracentesis Complications:

• Bladder perforationBladder perforation• Small or large bowel perforationSmall or large bowel perforation• Stomach perforationStomach perforation• Laceration of major vessels ( mesenteric, iliac, Laceration of major vessels ( mesenteric, iliac,

aorta)aorta)• Laceration of catheter or guide wire and loss in Laceration of catheter or guide wire and loss in

peritoneal cavity (requires laparotomy)peritoneal cavity (requires laparotomy)• Abdominal wall hematomaAbdominal wall hematoma• Incisional herniaIncisional hernia• Wound infection Wound infection • Wound dehiscence Wound dehiscence

Management of AscitesManagement of Ascites

Transjugular Intrahepatic Transjugular Intrahepatic Portasystemic Shunt:Portasystemic Shunt:The TIPS procedure is an interventional The TIPS procedure is an interventional radiologic technique that reduces portal radiologic technique that reduces portal pressure and may be the most effective pressure and may be the most effective treatment for treatment for diuretic resistant diuretic resistant ascites.ascites.

Risks:• Hepatic Encephalopathy (30% of pts)• Thrombosis and shunt stenosis.

TIPS ProcedureTIPS Procedure

• side to side portacaval shunt, usually placed through side to side portacaval shunt, usually placed through the right internal jugular vein. A needle is placed the right internal jugular vein. A needle is placed through the IJV into the hepatic vein.through the IJV into the hepatic vein.

Peritoneovenous shunt:Peritoneovenous shunt: • Developed to return Developed to return ascitic fluid from the ascitic fluid from the peritoneal cavity directly peritoneal cavity directly to the systemic to the systemic circulation.circulation.

• Consists of an intra-Consists of an intra-abdominal tube abdominal tube connected through a connected through a valve to silicone tube that valve to silicone tube that transverses the transverses the subcutaneous tissue up subcutaneous tissue up to the neck and enters to the neck and enters one of the jugular veins.one of the jugular veins.

• This leads to diuresis This leads to diuresis and mobilization of and mobilization of ascites.ascites.

::

Risks of Risks of Peritoneovenous shunt:Peritoneovenous shunt:• DICDIC• InfectionInfection• Variceal bleedingVariceal bleeding• Small bowel obstructionSmall bowel obstruction• Shunt occlusion Shunt occlusion • DeathDeathDue to these risk this procedure is rarely Due to these risk this procedure is rarely

used.used.Peritoneovenous shunts are therapeutic but Peritoneovenous shunts are therapeutic but

do not improve survival rates in patients do not improve survival rates in patients with cirrhosis and ascites.with cirrhosis and ascites.

Management of AscitesManagement of Ascites l iver transplantation:l iver transplantation:• Tx of choiceTx of choice• Corrects portal hypertensionCorrects portal hypertension• Changes the natural course of progressive Changes the natural course of progressive

liver failure due to cirrhosisliver failure due to cirrhosis• Not all pts are candidates for transplant, Not all pts are candidates for transplant,

and those who are may wait for years for a and those who are may wait for years for a donordonor

• Many die from complications of ascites Many die from complications of ascites while waiting for transplant donorwhile waiting for transplant donor

Complications from AscitesComplications from Ascites

1.1. Refractory Ascites:Refractory Ascites:• Fluid overload that is unresponsive to Fluid overload that is unresponsive to

Na-restricted diet and high dose anti-Na-restricted diet and high dose anti-diuretic treatment.diuretic treatment.

• Usually in the setting of chronic or acute Usually in the setting of chronic or acute liver diseases with associated portal liver diseases with associated portal hypertension.hypertension.

Treatment of Refractory Ascites:Treatment of Refractory Ascites:Liver transplantation is treatment of choice.Liver transplantation is treatment of choice.If unsuitable, treatment with:If unsuitable, treatment with:• Serial paracentesisSerial paracentesis• TIPS TIPS • Peritoneovenous shuntPeritoneovenous shunt

Complications of AscitesComplications of Ascites2.2. Hepatorenal syndrome:Hepatorenal syndrome: Life-threatening medical condition that consists ofLife-threatening medical condition that consists ofrapid deterioration in kidney function in individualsrapid deterioration in kidney function in individualswith cirrhosis or fulminant liver failure. HRS iswith cirrhosis or fulminant liver failure. HRS isusually fatal unless a liver transplant is performed,usually fatal unless a liver transplant is performed,although various treatments, such as dialysis, canalthough various treatments, such as dialysis, canprevent advancement of the condition. It is aprevent advancement of the condition. It is acommon complication of cirrhosis, occurring incommon complication of cirrhosis, occurring in18% of cirrhotics within one year of their18% of cirrhotics within one year of theirdiagnosis, and in 39% of cirrhotics within fivediagnosis, and in 39% of cirrhotics within fiveyears of their diagnosis.years of their diagnosis.

Type 1 HRS:Type 1 HRS:• Doubling of initial serum creatinine level Doubling of initial serum creatinine level

to >205mg/dl or a 50% cause decreasing to >205mg/dl or a 50% cause decreasing in 24-hour creatinine clearance to in 24-hour creatinine clearance to <20ml/min in < 2 weeks.<20ml/min in < 2 weeks.

• Mortality is >90% without liver Mortality is >90% without liver transplantation.transplantation.

Type 2 HRS:Type 2 HRS:• RF has a slower progressive course.RF has a slower progressive course.• Occur in the setting of chronic or acute liver Occur in the setting of chronic or acute liver

disease with portal hypertension.disease with portal hypertension.• Low GFR (with creatinine >1.5mg/dl)Low GFR (with creatinine >1.5mg/dl)• No evidence of shock, bacterial infection, or No evidence of shock, bacterial infection, or

treatment with nephrotoxic agents + absence of treatment with nephrotoxic agents + absence of GI fluid losses or renal fluid losses.GI fluid losses or renal fluid losses.

• No improvement in renal function following No improvement in renal function following diuretic withdrawal.diuretic withdrawal.

• Proteinuria <500mg/dl and no US evidence of Proteinuria <500mg/dl and no US evidence of renal disease or obstructive uropathy.renal disease or obstructive uropathy.

Treatment of hepatorenal syndrome:Treatment of hepatorenal syndrome:• SupportiveSupportive• Liver transplantation: Tx of Choice.Liver transplantation: Tx of Choice.• It corrects both liver and kidney disease.It corrects both liver and kidney disease.• Is associated with up to 60% survival rate Is associated with up to 60% survival rate

in 3 years.in 3 years.• Shortage of donor organs leads to a high Shortage of donor organs leads to a high

rate of death in these patients.rate of death in these patients.

Complications of AscitesComplications of Ascites

3-3- Spontaneous Bacterial Peritonits Spontaneous Bacterial Peritonits• 20% of patients with cirrhotic ascites20% of patients with cirrhotic ascites• Diagnosed with neutrophil count ofDiagnosed with neutrophil count of>250/mm3>250/mm3• Gram – neg organisms in 60% of casesGram – neg organisms in 60% of cases(E.coli and Klebsiella pneumoniae )(E.coli and Klebsiella pneumoniae )• Gram + organisms 25% of casesGram + organisms 25% of cases(Strep species )(Strep species )

• Symptoms: Symptoms: Abdominal pain, fever, Abdominal pain, fever, development of hepatic encephalopathy, development of hepatic encephalopathy, diarrhea, hypothermia and shock.diarrhea, hypothermia and shock.

• Ascitic Protein level<1 g/dl Ascitic Protein level<1 g/dl is a risk for is a risk for Spontaneous Bacterial Peritonits.Spontaneous Bacterial Peritonits.

• Treatment:Treatment: Cefotaxime sodium Cefotaxime sodium

ReferencesReferences

• ScincedirectScincedirect• UptodateUptodate• eMedicine HealtheMedicine Health• MedicineNet.comMedicineNet.com• Family Practice Notebook.comFamily Practice Notebook.com

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