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Causes of ascites

  • Cirrhosis (75%)
  • Malignancy (10%)
  • Heart failure (3%)
  • TB (1%)


Investigations in ascites

  • Blood
    • FBC (anaemia and platelets), U&E, LFT, clotting, gas for pH
  • Imaging
    • Abdominal USS
      • Liver mets, hepatic vein and artery Doppler, splenomegaly (portal HTN)
    • Chest x-ray may show pleural effusion or HF
  • Ascitic Tap (click here for details on how to perform and interpret an ascitic tap)
    • A diagnostic paracentesis, when only about 20 ml is required, is standard in the investigation of ascites
    • Ascitic fluid should be sent for measurement of:
        • Albumin or protein
        • Neutrophil count
        • Amylase (>2000 is pancreatitis)
        • Culture and sensitivity
        • Cytology where malignancy is suspected
      • Transudate vs exudate
        • Use serum-ascites albumin gradient (SA-AG)
        • If low (<11g/l [or 1.1g/dl]) = non-portal hypertensive (sort of =) exudate
        • High = portal hypertensive = fluid leaking into peritoneum


Video on ascites management


Management of ascites

  • Non-drug
    • Avoid alcohol (no matter what the cause of ascites)
    • Salt restrict (<90 mmol =  5.2g)
  • Drugs
    • Diuretics
      • Spironolactone at higher doses than for heart failure
        • Start at 50-100mg and can go up to 400mg daily
      • Aim for weight loss of 1kg/day initially
      • Loop diuretics may be used as an adjunct to spironolactone
  • Therapeutic paracentesis (click here for the procedures page)
    • Patients with diuretic-refractory ascites or who are intolerant to diuretics should undergo regular large-volume paracentesis
    • This can be done in a day-case setting
    • Human albumin solution (20%) should be given alongside all large-volume paracentesis where more than 5L is removed (AASLD guidelines 2012)
    • Caution if patient is encephlopathic. Ensure platelets >50
  • Transjugular intrahepatic portosystemic shunt (TIPSS)
    • Can be used in patients with refractory ascites needing frequent paracentesis (>3/month).


Prognosis in ascites

  • 50% mortality over two years, and signifies the need to consider liver transplantation.
  • Refractory ascites carries an even poorer prognosis, 50% patients dying within six months.
    • Therapeutic paracentesis and TIPSS do not improve long term survival


Click here to download free teaching notes on ascites and other consequnces of decompensated chronic liver disease

Perfect revision for medical students, finals, OSCEs and MRCP PACES