Ascites and Hepatic Hydrothorax

Thomas Strobel

Ascites

Background

  • Associated with a reduction in 5-year survival from 80% to 30%.
  • Most often due to portal HTN. Less common causes include peritoneal or metastatic cancer, CHF, TB, nephrotic syndrome, Budd-Chiari, sinusoidal obstructive syndrome (S.O.S), or complications from procedures and pancreatitis

Grade

Definition

Treatment
Grade 1 Ascites Only seen on imaging 2g Na restriction
Grade 2 Ascites Moderate, symmetric abdominal distension 2g Na restriction, diuretics
Grade 3 Ascites Marked, tense abdominal distension LVP + Na restriction, diuretics (unless refractory)

Evaluation

  • Bedside ultrasound on admission to confirm presence of ascites
  • Diagnostic paracentesis in all pts with ascites on admission mainly to rule out occult SBP
    • Initial paracentesis or when cause of ascites is uncertain: ascitic fluid total protein, serum and BF Albumin, cell count w/diff, culture
    • Subsequent/Serial paracenteses: cell count w/diff, culture, protein
    • Always inoculate culture bottles at bedside
  • Per AASLD guidelines elevated INR and thrombocytopenia (<50K) are not contraindications for paracentesis. Additionally, administration of clotting factors or platelets is not recommended. However, practically our procedure team often looks for INR < 3.5 (IR usually does not care about INR)
  • Serum-ascites albumin gradient (SAAG) = serum albumin - ascites albumin.

Total Protein Ascites (not serum)

SAAG ≥1.1 g/dL (Portal HTN)

SAAG < 1.1 g/dL (Non-portal HTN)
< 2.5 g/dL Cirrhosis

Nephrotic Syndrome

Myxedema
≥2.5 g/dL

Post-hepatic portal HTN:

Cardiac Ascites

Budd-Chiari

Malignant Ascites

Pancreatic Ascites

TB
  • Other tests:
    • Triglycerides: if fluid is milky
    • Cytology: if very concerned for peritoneal carcinomatosis. May need up to 3 separate samples (50ml or more) to be able to detect malignant cells
    • ADA: if concern for peritoneal TB
    • Hematocrit: For bloody appearing fluid (not just serosanguinous) to rule out hemoperitoneum. There needs to be a recent serum HCT for comparison.
    • Amylase: If concerned for pancreatic ascites
    • Glucose, LDH if concern about secondary peritonitis (see below)

Refractory Ascites

Two distinctions

  • Diuretic-resistant: lack of response to diuretics (max spironolactone 400mg/Lasix 160mg), Na restriction and rapid recurrence following paracentesis
  • Diuretic-intractable: unable to tolerate diuretic therapy due to adverse drug effects (unexplained HE, AKI, K abnormalities, hypoNa, intractable muscle cramps)

Management aside from liver transplant

  • Discontinue diuretics once refractory ascites has been established, but continue Na dietary restriction
  • Consider oral midodrine; can be especially helpful if pt is also hypotensive
  • Serial paracenteses, generally arranged OP with IR
  • Consider TIPS (trans jugular intrahepatic portosystemic shunt; has survival benefit) for refractory ascites or recurrent ascites (>3 LVPs in one year despite compliance with diet and diuretics). Following TIPS, cessation or decrease in ascites should occur in ~6 weeks
  • Consider discontinuing beta blockers in patients with refractory ascites if sBP <90, SCr >1.5, or Na <130
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