ascitic fluid total protein

Portal hypertensionincreased resistance to portal blood flow prehepatic, intrahepatic, and posthepaticIntrahepatic sites of increased resistance presinusoidal, sinusoidal, or postsinusoidalSite Site CausePre-hepatic Extra-hepatic Portal vein thrombosis,↑splenic flowHepatic Sinusoidal Liver cirrhosisPost-hepaticPost-sinusoidalTumorRight heart failure,IVC occlusion

Pathogenesis ( non-Cirrhotic) Heart failure & Nephrotic syndrome MalignancyPeritoneal carcinomatosis( tumor cell production )Occlusion of portal veinsLymph node obstructionRupture of chyle-containing lymphatics

Clinical FeatureMost patients (80%) with ascites Cirrhosis AlcoholChronic hepatitis NASHCauses of AscitesCausative Disorder % of Affected PatientsCirrhosis (with or without infection) 85Miscellaneous portal HTN–related disorder 8Cardiac disease 3Peritoneal carcinomatosis 2Miscellaneous nonportal HTN– related disorders 2Ann Intern Med 117:215, 1992.

Physical examination Ultrasound : >100ml of fluid Shifting dullness : >1500ml of fluid Fluid wave : not useful Puddle sign : not useful( old lecture: can detect acites < 200ml )

DiagnosisAbdominal paracentesis~most efficient way to confirmIndication :Diagnosis Relief of symptomsDetection of infectionComplication :Abdominal wall hematoma 1%Bowel entry / hemoperitoneum < 1/1000No death reported in recent years

Diagnosisrisks and costs of prophylactictransfusions exceed the benefit.

AASLD PRACTICE GUIDELINERecommendations1. Abdominal paracentesis should beperformed and ascitic fluid should beobtained from inpatients and outpatients withclinically apparent new-onset ascites.(Class I, Level C)2. Since bleeding is sufficiently uncommon, theprophylactic use of FFP or platelets beforeparacentesis is not recommended.(Class III, Level C)

Ascitic fluid analysis Gross appearanceTransparent / yellow Neu< 250 /cummCloudy (mayonnaise) Neu>50000/cummPinkRBC>10000/cummRedRBC>20000/cummMilkyTG>200 mg/dlDark brown JaundiceBlackMelanoma

Ascitic fluid analysisAscitis fluid testRoutineOptionalUnusualUnhelpfulCell count /DCAlbuminGlucoseLDHAmylaseGram stainCulture inbloodculturebottlesTB smear &TB cultureCytologyTGBilirubinpHLactateCholesterolFibronectin

Ascitic fluid analysisCell CountWBC elevation Diuresis Inflammatory>> Peritonitis ( PMN >250 /cumm )>> TB or Peritoneal carcinomatosis( lymphocyte predominant )

Ascitic fluid analysisSerum-AscitesAlbuminGradient (SAAG(SAAG)SAAG= Serum albumin – Ascites albuminSAAG > 1.1 gm/dl portal HTN with accuracy of 97 %False low: Serum albumin < 1.1gm/dlFalse high: chylous ascites / hyperlipidemia

Ascitic fluid analysisNormal peritoneumPortal hypertension[SAAG] >1.1 g/dL)Liver diseaseCirrhosisAlcoholic hepatitisFatty liver of pregnancyFulminant hepatic failureMassive hepatic metastasesHepatic congestionCongestive heart failureConstrictive pericarditisTricuspid insufficiencyBudd-Chiari syndrome

Ascitic fluid analysisNormal peritoneumHypoalbuminemia(SAAG

Ascitic fluid analysisDiseased peritoneum (SAAG

Ascitic fluid analysisRare conditionsFamilial Mediterranean feverGranulomatous peritonitisVasculitisEosinophilic peritonitisWhipple's diseaseEndometriosisSarcoidosisPrimary lymphatic hypoplasia

Ascitic fluid analysisCulture PMN count > 250 /cumm (neutrocytic)older culture : 50 % culture rateblood culture : 80 % culture rate

Ascitic fluid analysisExudate/TransudateAscitic total protein> 2.5gm/dl Exudate< 2.5gm/dl TransudateLess used in recent days !!

Ascitic fluid analysisTotal protein Ascites fluid total protein (AFTP):SAAG > 1.1 to distinguishCirrhosis (AFTP< 2.5g/dl) fromCardiac ascites (AFTP>2.5g/dl) Low ascitic protein susceptible to SBP

AASLD PRACTICE GUIDELINERecommendations3. The initial laboratory investigation of ascitic fluidshould include an ascitic fluid cell count anddifferential, ascitic fluid total protein, andSAAG.(Grade II-2)4. If ascitic fluid infection is suspected, ascitic fluidshould be cultured at the bedside in bloodculture bottles.(Grade II-2)

Ascitic fluid analysisSBP Vs. Gut perforationA. Neutrocytic ascitesB. Total protein > 1gm/dlLDH > ULN ( mostly ½ serum level)Glucose < 50mg/dl 2 of three meet critieriapreferred to Gut perforationJ Hepatol 2001;34:215–221.

Ascitic fluid analysisAmylase Normal range : ½ serum level ( 50 U/L) If > 2000 U/L Acute pancreatitis Gut perforation

Ascitic fluid analysisGram stainGram stain(+) 10000 bacteria / mlSBP 1 organismMost helpful in Gut perforation

Ascitic fluid analysisTB culture & Smear TB culture of 1000ml of ascites~ 50 % sensitivity rateTB smear of ascites ~ near 0 % sensitivity rate Laparoscopy with histology/bx culture~ almost 100% sensitivity rate~ most accurate & rapid method DNA probe ~ a new methodHEPATOLOGY 1996;24:1408–1412.

Ascitic fluid analysisCytology examOnly sensitive to peritoneal carcinomatosisSensitivity rate 96.7% if 3 samples are sentSensitivity rate 93.3% if 2 samplesHEPATOLOGY 1988;8:1104–1109.

Ascitic fluid analysis TriglycerideChylous ascites : ascites TG>200mg/dlMeasured as milky ascitesPresence of intestinal or thoracic LNs BilirubinAscites bilirubin : ascites > 6mg/dl or greaterthan serum levelMeasured as dark brown ascites> serum level Upper Gut perforation biliary tract perforation

Treatment of AscitesLow SAAG ascites treat underlying diseaseNon-ovarian peritoneal carcinomatosis : tap.Ovarian peritoneal carcinomatosis: debulky opTB peritonitis : tx TBPancreatic ascites: resolved spontaneousChlamydia peritonitis : TetracyclinLupus serositis : steroid

Treatment of AscitesHigh SAAG ascites related to portal HTN

AASLD PRACTICE GUIDELINERecommendations6. Patients with ascites who are thought to have analcohol component to their liver injury shouldabstain from alcohol consumption.(Grade II-2)7. First-line treatment of patients with cirrhosis andascites consists of sodium restriction (88 mmolper day [2000 mg per day]) and diuretics (oralspironolactone and furosemide).(Grade I)

AASLD PRACTICE GUIDELINERecommendations8. Fluid restriction is not necessary unless serumsodium is less than 120-125 mmol/L.(Grade III)9. An initial therapeutic abdominal paracentesisshould be performed in patients with tenseascites. Sodium restriction and oral diureticsshould then be initiated.(Grade II-3)

AASLD PRACTICE GUIDELINERecommendations10. Diuretic-sensitive patients should preferablybe treated with sodium restriction and oraldiuretics rather than with serial paracenteses.(Grade III)11. Liver transplantation should be considered inpatients with cirrhosis and ascites.(Grade II-3)

AASLD PRACTICE GUIDELINERecommendationsRefractory Ascites12. Serial therapeutic paracenteses may be performedin patients with refractory ascites.(Grade III)13. Post-paracentesis albumin infusion may not benecessary for a single paracentesis of < 4 to 5L.For large-volume paracenteses, an albumin infusionof 8 to 10 g per liter of fluid removed can beconsidered.(Grade II-2)

AASLD PRACTICE GUIDELINERecommendationsRefractory Ascites14. Referral for liver transplantation should be expeditedin patients with refractory ascites.(Grade II-3)15. TIPS should be considered in appropriately selectedpatients who meet criteria similar to those of publishedrandomized trials.(Grade I)16. Peritoneovenous shunt should be considered for patients withrefractory ascites who are not candidates for paracenteses,transplant, or TIPS. (Grade I)

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