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Ascites

Aug 25, 2021

Ascites is accumulation of protein-containing (ascitic) fluid within the abdomen.

Medications:

  • For cirrhotic ascites – tab. Aldactone (Spironolactone 25 mg) 1 tablet once a day. Gradually increase till maximum dose of 100 mg/day. Note this may take 48 hours to work.
  • If tab. Aldactone fails to resolve ascites, add tab. Lasix 40 (Furosemide 40 mg) 1 tablet in the morning. Gradually increase till maximum dose of 160 mg per day.
  • For bacterial peritonitis – tab. Oflox 400 (Ofloxacin 400 mg) 1 tablet twice a day for 7 – 10 days.
  • For severe bacterial peritonitis – inj. Taxim 1gm (Cefotaxime 1 gm) – Give 2 gm i.v. 8 hourly for 7 days.
  • In extreme cases – consider ascitic tap or paracentesis.

Aim to lose body weight by not more than 0.5 kg/day.

Various conditions causing ascites

  • Cirrhosis – Serum to Ascites Albumin Gradient (SAAG) more than 1.1 g/dl, and ascitic fluid total proteins less than 2.5 g/dl
  • Cardiac ascites – SAAG more than 1.1 g/dl and fluid total protein is more than 2.5 g/dl
  • Nephrotic ascites – SAAG more than 1.1 g/dl and ascitic fluid total protein is less than 2.5 g/dl
  • Pancreatitis – SAAG is usually less than 1.1 g/dl, ascitic fluid amylase increased up to 5 times the serum level or fluid amylase > 100 U/L.
  • Neoplasm – Elevated RBC in ascitic fluid; SAAG is usually less than 1.1 g/dl, ascitic fluid total proteins more than 2 g/dl, elevated WBCs (neutrophils less than 50%, lymphocytes more than 50%).
  • Tuberculosis – Elevated RBCs (more than 100/mcl), raised WBCs (more than 70% lymphocytes), raised triglycerides in ascitic fluid, ascitic fluid total proteins more than 2 g/dl, sugars less than serum and positive tuberculosis culture.
  • Spontaneous bacterial peritonitis (SBP) – Ascitic WBC count more than 500 cells/mm3, proteins more than 2 g/dl, sugars less than serum
  • Small bowel perforation and strangulation – SAAG less than 1.1 mg/dl, raised alkaline phosphatase (ALP)
  • Budd-Chiari syndrome, myxedema – SAAG is usually more than 1.1 g/dl.
  • Peritonitis, vasculitis, nephrotic syndrome, biliary or chylous ascites – SAAG is usually less than 1.1 g/dl.

General advice:

  • Monitor daily weight
  • Maintain strict intake and output chart
  • Restrict salt intake to less than 2 grams per day
  • Stop alcohol intake and smoking
  • Avoid hepatotoxic drugs such as paracetamol
  • Ensure regular follow up to assess effectiveness of treatments

Investigations:

  • Ascitic diagnostic tap – for biochemistry analysis and microscopy.
  • Ascites and serum albumin levels (SAAG) – to confirm differential diagnosis.
  • Ascitic fluid cell count with differential count – to confirm differential diagnosis as above.
  • Culture of ascitic fluid – to rule out tuberculosis and other infective pathologies.
  • Ascitic fluid amylase, triglycerides – to rule out pancreatitis.
  • Abdominal CT scan – to look for splenomegaly, evidence of malignancy.

Referral:

Consider referral to hepatologist or gastroenterologist if patient fails to respond to treatment or presents with additional complications.