Ascites resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Steven Bellm, M.D. [2]

Ascites resident survival guide Microchapters
[[Ascites resident survival guide#Abdominal paracentesis|Abdominal paracentesis]]


Accumulation of fluid within the peritoneal cavity results in ascites. Most important for a successful treatment of ascites is an accurate diagnosis of its cause. Most common causes are portal hypertension, malignancy and heart failure. The diagnosis is made with a combination of physical examination and abdominal imaging. The next step is typically a paracentesis to evaluate the ascitic fluid for causes.[1]


Ascites can be classified based on the underlying causes. Common causes are:[1]

Portal hypertension:

❑  Cirrhosis
❑  Alcoholic hepatitis
❑  Acute liver failure
❑  Hepatic veno-occlusive disease (eg, Budd-Chiari syndrome)
❑  Heart failure
❑  Constrictive pericarditis

❑  Hemodialysis-associated ascites (nephrogenic ascites)

❑  Nephrotic syndrome
❑  Protein-losing enteropathy

❑  Severe malnutrition
Peritoneal disease:

❑  Malignant ascites
❑  Infectious peritonitis/ Spontaneous bacterial peritonitis
❑  Eosinophilic gastroenteritis
❑  Starch granulomatous peritonitis

❑  Peritoneal dialysis
Other etiologies:

❑  Chylous ascites
❑  Pancreatic ascites (eg, from a disrupted pancreatic duct)
❑  Myxedema

❑  Hemoperitoneum

A grading system for ascites has been proposed by the International Ascites Club:[2]
❑  Grade 1:Mild ascites detectable only by ultrasound examination
❑  Grade 2:Moderate ascites manifested by moderate symmetrical distension of the abdomen
❑  Grade 3:Large or gross ascites with marked abdominal distension

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

History and symptoms:

❑  Hints for etiology (i.e. signs and symptoms for cirrhosis, malignancy)?
❑  Abdominal distension/abdominal discomfort?
❑  Duration and onset of illness/ symptoms?
❑  Severity and triggers?
❑  Weight loss/weight gain/early satiety?
❑  Presence of peripheral edema, anasarca?
❑  Problems with breathing at night/ sleep?
❑  Fever, abdominal tenderness, and altered mental status?
❑  Diarrhea and steatorrhea, malnutrition, nausea, enlarged lymph nodes, hemoptysis?
❑  Medical history

❑  Prior hospitalizations?
❑  Medication?
Physical examination:

❑  Vital signs:

❑  Pulse (strength and regularity)
❑  Blood pressure
❑  Respiratory rate

❑  General appearance:

❑  BMI(weight loss/weight gain)
❑  Jaundice, muscle wasting, gynecomastia, and leukonychia, lymphadenopathy
❑  Peripheral edema
❑  JVD

❑  Heart:

❑  Murmur
❑  Carotid and peripheral pulses

❑  Lungs:

❑  Rales?
❑  Pleural effusion?

❑  Abdomen:

❑  Hepatomegaly
❑  Pulsatile liver and/or ascites (volume overload)
❑  Flank dullness, shifting dullness, a fluid wave, evidence of pleural effusions
❑  Stigmata of cirrhosis (spider angioma, palmar erythema, and abdominal wall collaterals)
❑  Umbilical nodule that is not bowel or omentum
Laboratory findings:

❑  Complete blood count
❑  Chemistry:

❑  Consider Troponin, BNP or NT-proBNP
❑  Serum electrolytes (including calcium and magnesium)
❑  Kidney function tests: Blood urea nitrogen, serum creatinine, GFR
❑  Liver function tests (including ammonia blood test)
❑  Glucose
❑  Fasting lipid profile, albumin, total protein, decreased gamma globulin levels?
❑  Coagulation testing (i.e. INR)
❑  Infection markers
Imaging and additional tests:

❑  Ultrasound with Doppler:

❑  Dilation of the portal vein to ≥13 mm
❑  Dilation of the splenic and superior mesenteric veins to ≥11 mm
❑  Reduction in portal venous blood flow velocity
❑  Splenomegaly (diameter >12 cm), and recanalization of the umbilical vein
❑  Nodular liver, hepatocellular carcinoma?

❑  Consider computed tomographic (CT)
❑  Consider magnetic resonance imaging (MRI)
❑  Consider check for esophageal varices/ hypertensive gastropathy (esophagogastroscopy)
❑  Paracentesis: (details)

❑  Determining cause and confirming spontaneous bacterial peritonitis




Abdominal paracentesis

It is a bedside or clinic procedure in which a needle is inserted into the peritoneal cavity and ascitic fluid is removed. It can be used therapeutic or diagnostic.[3]





  1. 1.0 1.1 1.2 Runyon BA, AASLD (2013). "Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012". Hepatology. 57 (4): 1651–3. doi:10.1002/hep.26359. PMID 23463403.
  2. Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F; et al. (2003). "The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club". Hepatology. 38 (1): 258–66. doi:10.1053/jhep.2003.50315. PMID 12830009.
  3. Runyon BA, AASLD Practice Guidelines Committee (2009). "Management of adult patients with ascites due to cirrhosis: an update". Hepatology. 49 (6): 2087–107. doi:10.1002/hep.22853. PMID 19475696.

CME Category::Cardiology