Ascites of local cause

By: Assistant lecturer

Waleed Fouad

Definition

Ascites describes the condition of pathologic fluid accumulation within the abdominal cavity.

Healthy men have little or no intraperitoneal fluid, but women may normally have as much as 20 mL depending on the phase of the menstrual cycle.

Etiology

Normal peritoneum

Portal hypertension [SAAG] >1.1 g/dL)

Hepatic congestion

Congestive heart failure

Constrictive pericarditis

Tricuspid insufficiency

Budd-Chiari syndrome

Liver disease

Cirrhosis

Fulminant hepatic failure

Alcoholic hepatitis

Massive hepatic metastases

Etiology cont.

Normal peritoneum

Hypoalbuminemia (SAAG <1.1 g/dL)

Chylous ascites

Pancreatic ascites

Bile ascites

Urine ascites

Nephrotic syndrome

Protein-losing enteropathy

Miscellaneous conditions (SAAG <1.1 g/dL)

Ovarian disease Severe malnutrition with anasarca

Etiology cont.

Diseased peritoneum (SAAG <1.1 g/dL)

Infections

Peritoneal carcinomatosis

Primary mesothelioma

Pseudomyxoma peritonei

Bacterial peritonitis

TB peritonitis

Hepatocellular carcinoma

Fungal peritonitis

Malignant conditions

Chlamydia peritonitis

Alveolar hydatid disease

HIV-associated peritonitis

Strongyloidiasis

CMV

Etiology cont.

Eosinophilic peritonitis

Whipple's disease

Primary lymphatic hypoplasia

Endometriosis

Familial Mediterranean fever

Granulomatous peritonitis

Sarcoidosis

Rare conditions

Vasculitis

Grading of ascites

A grading system for ascites has been proposed by the International Ascites Club:

An older system that grades ascites from 1+ to 4+ is also used.

Grade 1Mild ascites

detectable only by ultrasound

Grade 2 Moderate ascites manifested

by moderate symmetrical distension of the abdomen

Grade 3Large or gross ascites

with marked abdominal distension

1+ is minimal and barely detectable

2+ is moderate3+ is massive but not tense

4+ is massive and tense

Diagnosis

The diagnosis of ascites is established with a combination of a physical examination and an imaging test (usually ultrasonography).

Abdominal paracentesis with appropriate ascetic fluid analysis is the most efficient way to confirm the presence of ascites and diagnose its cause.

Peritoneoscopy with culture and histology of a biopsied nodule is the most rapid route to the diagnosis.

Tests performed on ascitic fluid

Routine tests Optional tests Unusual tests

Cell count anddifferential

Albumin concentration

Total protein concentration

Culture in blood culture bottles

Glucose concentration

LDH concentration

Gram stain

Amylase concentration

Tuberculosis smear and culture

Cytology

Triglyceride Bilirubin

Adenosine deaminase CEA

PH & lactate

Cholesterol

Fibronectin

Tuberculous Peritonitis

Tuberculous peritonitis should be considered in all patients presenting with unexplained lymphocytic ascites with a serum-ascites albumin gradient of <1.1 g/dL.

The gold-standard for diagnosis is culture growth of Mycobacterium on ascetic fluid or a peritoneal biopsy.

Tuberculous Peritonitis cont.

Other Tests

Routine laboratory tests Normocytic normochromic anemia in 50 %

Tuberculin skin testing Positive in 70 % of patients

Chest x-ray Old tuberculosis in 20 to 30 %

US & CT Peritoneal thickening, omental caking and /or ascites with fine mobile septations.

Peritoneal fluid analysis

Ascitic leukocyte count

150 to 4000 mm3

+

Lymphocytic Pleocytosis

> 50%

Albumin content

Useful in differentiating

tuberculous ascites from

carcinomatous ascites

SAAG <1.1

Sensitivity of 0 to 6 %

Direct smear for Ziehl-Neelson

stain

>3.0 g/dL

>1.1

PCR

Underlying cirrhosis

If

ADA

Rapid detection

Multiple miliary nodules

over the peritoneum with an

adhesion band attached

to anterior surface

of liver capsule.

Malignant ascites

• It occurs most often with ovarian cancer in about one-third of women at the time of diagnosis.

• It is also associated with a variety of other primary cancer sites: Stomach, Liver, Uterus, Testis, Breast, Pancreas, Colon, Lymphoma, Mesothelium, Lung, Unknown primary site.

In the presence of malignant cytologic findings without a primary tumor diagnosis, further investigations of male patients may not lead to improved survival, since all primary tumour groups are associated with a uniformly poor prognosis.

Female patients may benefit from further investigations, possibly including lapa roscopy or even laparotomy, since ovarian cancer is treatable.

Serum tumour markers

Peritoneal nodules, omental caking and 1ry tumour site.

US & CT

CEA - CA125 – α feto protein

Peritoneal fluid analysis

Albumin content

>3.0 g/dL

Ascetic WBCs

Lymphocytic Pleocytosis

> 50%

Other tests

α1-antitrypsin Cyclic AMP

Cholesterol Fibronectin

GlycosaminoglycansSAAG <1.1

Cytology

Gold standardMalignancies can produce ascites

without shedding many neoplastic cells

Diagnostic sensitivity of only 40% to 60%.

Immunohistochemical staining can increase the diagnostic sensitivity

Laparoscopy

Used with caution in patients with malignant ascites

High risk for trocar implantation metastasis

Positron Emission Tomography- CT scan shows peritoneal nodule characterized by abnormally high radiotracer uptake.

Positron emission tomography (PET) is a nuclear medicine medical imaging technique which produces a three-dimensional image or map of functional processes in the body.

• Axial intravenous contrast-enhanced abdominal CT scan shows tiny nodules in the gastrohepatic ligament (short arrows) and in the inferior portion of the falciform ligament (long arrow).

• Axial intravenous contrast-enhanced abdominal CT scan shows nodules in the lesser sac (arrows).

• Close-up view showing peritoneal implants, as well as abnormal feeding blood vessels.

• Laparoscopy demonstrated obvious diffuse carcinomatosis, with implants on all peritoneal surfaces.

Chylous ascites

Chylous ascites is a milky-appearing peritoneal fluid

Abdominal malignancy and cirrhosis

Two-thirds of all cases

Other etiologies

Infections

Primary lymphatic Hypo or hyperplasia

Filariasis

TB

Congenital Inflammatory Post-operative

yellow-nail syndrome Radiation therapy

Sarcoidosis Lymphatic injury or

compression

Malignancy particularly Lymphoma is a common cause.

CT

Can identify pathologic intra abdominal lymph nodes and masses

Lymphangiography & lymphoscintigraphy

Abnormal retroperitoneal nodes, leakage from dilated lymphatics, fistulization, and patency of the thoracic duct

Triglyceride values are typically above 200 mg/dL

PANCREATIC ASCITES Massive accumulation of pancreatic

fluid in the peritoneal cavity

The most common underlying cause is chronic pancreatitis secondary to alcohol abuse.

Following an episode of acute pancreatitis or a traumatic injury to the pancreas.

Also has been described with pancreatic pseudocysts.

US & CT Can detect the presence of a pseudocyst

Accurately demonstrate the normal pancreatic duct and detect any abnormalities arising from itMRCP

ERCP Localize the site of leakage and endoscopic therapy if possible

Peritoneal fluid analysis

SAAG <1.1

Albumin content

>3.0 g/dL

Ascitic amylase

> 1,000 IU/L

Elevated Ascitic WBCs

Ascitic/serum amylase

ratio is 6.0

Ascites due to more than 1 cause

Approximately 5 percent of patients with ascites have more than one cause, such as cirrhosis plus Tuberculous peritonitis, peritoneal carcinomatosis or heart failure.

Patients with more than one cause for ascites formation tend to be the most confusing to diagnose because each partial cause may not be severe enough to lead to fluid retention by itself.

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