Transcript Ascites
Evaluation of Ascites Andrew Maclennan Morning Report July 24, 2009 Pathophysiology of Ascites From: Robbins Basic Pathology Causes of Ascites Cause Frequency Cirrhosis 81% Cancer 10% Heart Failure 3% Tuberculosis 2% Dialysis 1% Pancreatic Disease 1% Other 2% Source: UpToDate Rare Causes of Ascites Category Infectious diseases Amebiasis, Ascariasis, Brucellosis, Chlamydia peritonitis, Complications related to HIV infection, Pelvic inflammatory disease, Pseudomembranous colitis, Salmonellosis, Whipple's disease Hematologic Amyloidosis, Castleman's syndrome, Extramedullary hematopoiesis, Hemophagocytic syndrome, Histiocytosis X, Leukemia, Lymphoma, Mastocytosis, Multiple myeloma Miscellaneous Abdominal pregnancy, Crohn's disease, Endometriosis, Gaucher's disease, Lymphangioleiomyomatosis, Myxedema, Nephrotic syndrome, lymphatic tear or ureteral injury. Ovarian hyperstimulation Imaging • Ultrasound with Dopplers – Easily confirms ascites – May see nodularity of cirrhosis – Evaluate patency of vasculature – No radiation, contrast • CT / MRI – Evaluation for malignancy Tests on Ascitic Fluid Routine Optional Unusual Cell count and differential Glucose concentration Tuberculosis smear and culture, adenosine deaminase Albumin concentration LDH concentration Cytology Total protein concentration Gram stain Triglyceride concentration Culture in blood culture bottles Bilirubin concentration Amylase concentration Cell Count, differential and culture • Is ascites infected? – Greater than 250 PMN = SBP • If ascites is bloody ( > 50,000 RBC/mm3), correct by subtracting 1 PMN / 250 RBC • Is ascites bloody? – 5% of pts w/ cirrhosis - spontaneous or s/p traumatic tap. • Non-traumatic associated with malignancy – 20% of malignant ascites – 10% of peritoneal carcinomatosis Serum to Ascites Albumin Gradient • Is portal hypertension present? • 97% accurate SAAG > 1.1 g/dL Portal HTN SAAG < 1.1 g/dL Other causes The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20. Serum to Ascites Albumin Gradient SAAG > 1.1 g/dL SAAG < 1.1 g/dL Cirrhosis Peritoneal carcinomatosis Alcoholic hepatitis Peritoneal tuberculosis CHF Pancreatitis Massive hepatic metastases Serositis Budd Chiari Syndrome Nephrotic syndrome Congestive heart failure/constrictive pericarditis Total Protein • Exudate ( > 2.5 g/dL) or Transudate? – Supplanted by SAAG • Is there gut perforation? (vs SBP) – Total protein >1 g/dL – Glucose <50 mg/dL (2.8 mmol/L) – LDH greater than serum ULN Glucose and LDH • Consistent with infection or malignancy? – Infection and cancer consume glucoselow • LDH is a larger molecule than glucose, enters ascitic fluid with difficulty. – Ascitis/Serum LDH ratio • ~ 0.4 in cirrhotic ascites • Approaches 1.0 in SBP • >1.0, usually infection or tumor Other tests • Amylase – Uncomplicated cirrhotic ascites • About 40 IU/L. The AF/S ratio is about 0.4 – Pancreatic ascites • About 2000 IU/L. The AF/S ratio is about 6 • Triglycerides — run on milky fluid. – Chylous ascites - TG > 200 mg/dL, usually 1000 mg/dL • Bilirubin — run on brown ascites. – Biliary perforation – AF Bili > serum Bili Tests for TB • Smear – extremely insensitive • Culture – 62-83% when large volumes cultured • Cell count – mononuclear cell predominance • Adenosine deaminase – – Enzyme involved in lymphoid maturation – Falsely low in pts with both cirrhosis and TB Cytology • “almost 100%” with peritoneal carcinomatosis have positive cytology • Malignant ascites from massive hepatic mets, HCC, lymphoma are usually negative • Overall sensitivity for detection of malignancyrelated ascites is 58 to 75 % Not helpful • “Some tests of ascitic fluid appear to be useless. These include pH, lactate, and ‘humoral tests of malignancy’ such as fibronectin, cholesterol, and many others” Biopsy Cirrhosis Fatty Liver http://library.med.utah.edu/WebPath/LIVEHTML/LIVERIDX.html#2 Causes of Cirrhosis Cause Testing Alcoholic liver disease History, AST / ALT > 2 Chronic hepatitis C Hep C Ab, Viral load Primary biliary cirrhosis Antimitochondrial antibodies Primary sclerosing cholangitis Contrast cholangiography , ANA, Anti smooth muscle Ab, ANCA Autoimmune hepatitis Type 1: ANA, ANCA antismooth muscle Ab Type 2: anti-LKM-1 Chronic hepatitis B Hepatitis B serologies Hemochromatosis Ferritin, genetic testing Wilson’s disease Ceruloplasmin Alpha-1-antitrypsin deficiency Serum AAT Nonalcoholic fatty liver disease Hx of DM or metabolic syndrome Malignant Ascites • Definition: abnormal accumulation of fluid in the peritoneal cavity as a consequence of cancer. • Commonly caused by cancers of: – Breast, bronchus, ovary, stomach, pancreas, colon • 20% of cases have tumors of unknown primary • Survival poor – usually less than 3 months Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597 Malignant Ascites: Pathophysiology • Obstruction of lymphatics by tumor – Prevents absorption of fluid and protein • Alteration in vascular permeability – Hormonal mechanisms (VEGF, IL2, TNF alpha) • Decreased circulating blood volume – Activates RAAS leading to Na retention Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597 Pathophysiology of Malignant Ascites http://www.fresenius.de/internet/fag/com/faginpub.nsf/Content/Pressemappe+ASCO+2007 Management of Malignant Ascites • Therapeutic paracentesis – Removing up to 5L appears safe – No good data on role of volume expanders • Diuretics – Equivocal evidence of efficacy – May be helpful for portal HTN – Less/minimally useful when no portal HTN • Drainage Catheters • Peritoneovenous shunts Peritoneovenous Shunt Contraindications •Protein > 4.5 g/l (occlusion) •Loculated ascites •Coagulopathy •Advanced renal/cardiac disease •GI malignancy Complications Denver Shunt (Similar to LaVeen Shunt) •Infection •Hematogenous spread of mets •DIC •Pulmonary edema •Pulmonary emboli Transjugular intrahepatic portosystemic shunt (TIPS) References 1. 2. 3. 4. 5. • Up to Date Ascites and renal dysfunction in liver disease, Second edition. Edited by Pere Ginès, Vicente Arroyo, Juan Rodés, and Robert W. Schrier. Malden, Mass., Blackwell, 2005. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20. Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597 Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis, and management. Arch Intern Med. Vol 161. Dec 10/24, 2001.