ascites,peritoneal cavity,peritoneal fluid,etiology of ascites 腹水，腹膜腔，腹水，腹水的病因

This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only. AscitesAscites Presented byPresented by Maha Al-SulaimaniMaha Al-Sulaimani 425200716425200716 AscitesAscites Derived from the Greek word Derived from the Greek word “ “askosaskos”, ”, meaning bag or sac.meaning bag or sac. Defined as the accumulation of fluid in Defined as the accumulation of fluid in the peritoneal cavity. the peritoneal cavity. It is a common clinical finding, with many It is a common clinical finding, with many extraperitonealextraperitoneal and peritoneal causes , but and peritoneal causes , but most common from liver cirrhosis .most common from liver cirrhosis . Peritoneal cavityPeritoneal cavity It is a potential space between the It is a potential space between the parietal peritoneum and visceral parietal peritoneum and visceral peritoneum, the two membranes peritoneum, the two membranes separate the organs in the abdominal separate the organs in the abdominal cavity from the abdominal wall.cavity from the abdominal wall. Derived from the Derived from the coelomiccoelomic cavity of the cavity of the embryo. embryo. Largest Largest serosalserosal sac in the body and sac in the body and secretes approximately 50 ml of fluid per secretes approximately 50 ml of fluid per day.day. Peritoneal fluidPeritoneal fluid It is a normal, lubricating fluid found in It is a normal, lubricating fluid found in the peritoneal cavity.the peritoneal cavity. The fluid is mostly water with electrolytes, The fluid is mostly water with electrolytes, antibodies, white blood cells, albumin, antibodies, white blood cells, albumin, glucose and other glucose and other biochemicalsbiochemicals. . Reduce the friction between the Reduce the friction between the abdominal organs as they move around abdominal organs as they move around during digestion.during digestion. Patient with Patient with AscitesAscites Etiology of Etiology of ascitesascites Most Common causes(90% of cases):Most Common causes(90% of cases): Portal HTN secondary to chronic liver Portal HTN secondary to chronic liver diseases ( cirrhosis) diseases ( cirrhosis) Intra-abdominal malignancy Intra-abdominal malignancy Congestive Heart Failure Congestive Heart Failure Mycobacterium tuberculosis Mycobacterium tuberculosis portal hypertensionportal hypertension It is a high blood pressure in the portal It is a high blood pressure in the portal vein and its vein and its tributaries(portaltributaries(portal venous venous system).system). It is defined as a portal pressure gradient It is defined as a portal pressure gradient (the difference in pressure between the (the difference in pressure between the portal vein and the hepatic veins) of 5 mm portal vein and the hepatic veins) of 5 mm Hg or greater.Hg or greater. Causes of portal hypertensionCauses of portal hypertension IntrahepaticIntrahepatic causes: causes: liver cirrhosis and hepatic liver cirrhosis and hepatic fibrosis (e.g. due to Wilsons disease, fibrosis (e.g. due to Wilsons disease, hemochromatosishemochromatosis, or congenital fibrosis)., or congenital fibrosis). PrehepaticPrehepatic causes : causes : portal vein thrombosis or portal vein thrombosis or congenital congenital atresiaatresia. . PosthepaticPosthepatic obstruction obstruction occur at any level occur at any level between liver and right heart, including hepatic between liver and right heart, including hepatic vein thrombosis, IVC thrombosis, IVC congenital vein thrombosis, IVC thrombosis, IVC congenital malformation, and constrictive malformation, and constrictive pericarditispericarditis. . CirrhosisCirrhosis most common causes of cirrhosis:most common causes of cirrhosis: Alcoholic liver disease or alcoholic hepatitisAlcoholic liver disease or alcoholic hepatitis viral hepatitis (B or C) viral hepatitis (B or C) fatty liver disease fatty liver disease Other causes of Other causes of ascitesascites HypolalbuminemiaHypolalbuminemia NephroticNephrotic syndrome syndrome Protein-losing Protein-losing enteropathyenteropathy malnutrition malnutrition Other causes of Other causes of ascitesascites Bacterial, fungal or parasitic disease Bacterial, fungal or parasitic disease VasculitisVasculitis Whipples Disease Whipples Disease Familial Mediterranean fever Familial Mediterranean fever EndometriosisEndometriosis Starch peritonitis Starch peritonitis Budd-Budd-ChiariChiari Syndrome Syndrome MyxedemaMyxedema Ovarian disease (e.g. Ovarian disease (e.g. MeigsMeigs Syndrome) Syndrome) Pancreatic disease Pancreatic disease ChylousChylous AscitesAscites PathophysiologyPathophysiology 1-1- Increased hydrostatic pressure Increased hydrostatic pressure Cirrhosis Cirrhosis Hepatic vein occlusion (Budd-Hepatic vein occlusion (Budd-ChiariChiari Syndrome) Syndrome) InveriorInverior vena vena cavalcaval obstruction obstruction Constrictive Constrictive PericarditisPericarditis Congestive heart failureCongestive heart failure PathophysiologyPathophysiology 2.2.Decreased colloid osmotic pressureDecreased colloid osmotic pressure End-stage liver disease with poor protein End-stage liver disease with poor protein synthesissynthesis NephroticNephrotic syndrome syndrome MalnutritionMalnutrition Protein-losing Protein-losing enteropathyenteropathy 3.3.Increase permeability of peritoneal Increase permeability of peritoneal capillariescapillaries TuberculousTuberculous peritonitis peritonitis Bacterial peritonitisBacterial peritonitis Malignant disease of the peritoneumMalignant disease of the peritoneum PathophysiologyPathophysiology 4.4.Leakage of fluid into the peritoneal Leakage of fluid into the peritoneal cavitycavity Bile Bile ascitesascites Pancreatic Pancreatic ascitesascites ChylousChylous ascitesascites Urine Urine ascitesascites 5.5.Miscellaneous causesMiscellaneous causes MyxedemaMyxedema Ovarian disease (Ovarian disease (MeigsMeigs syndrome) syndrome) Chronic hemodialysisChronic hemodialysis Morbidity and MortalityMorbidity and Mortality Ambulatory patients with an episode of Ambulatory patients with an episode of cirrhotic cirrhotic ascitesascites have a 3-year mortality have a 3-year mortality rate of 50%. The development of rate of 50%. The development of refractory refractory ascitesascites carries a poor prognosis, carries a poor prognosis, with a 1-year survival rate of less than with a 1-year survival rate of less than 50%.50%. DiagnosisDiagnosis 1-history1-history Pts should be questioned about:Pts should be questioned about: Liver diseases Liver diseases Risk factors for Hepatitis C ( needle Risk factors for Hepatitis C ( needle sharing, tattoos, cocaine, heroin use and sharing, tattoos, cocaine, heroin use and emigration from Egypt or Southeast Asia)emigration from Egypt or Southeast Asia) Risk factors for Hepatitis B (needle Risk factors for Hepatitis B (needle sharing, tattoos, acupuncture, and sharing, tattoos, acupuncture, and emigration from China, Korea, Taiwan, or emigration from China, Korea, Taiwan, or Southeast Asia). Southeast Asia). Pts with obesity, diabetes, Pts with obesity, diabetes, hyperlipidemiahyperlipidemia and Nonalcoholic and Nonalcoholic steatohepatitissteatohepatitis ( NASH ) should be ruled ( NASH ) should be ruled out. out. Pts with Pts with ascitesascites who lack risk factors for who lack risk factors for cirrhosis should be questioned aboutcirrhosis should be questioned about cancer, heart failure, TB, dialysis, and cancer, heart failure, TB, dialysis, and pancreatitispancreatitis. . Operative injury to the Operative injury to the ureterureter or bladder or bladder can lead to leakage of urine into can lead to leakage of urine into peritoneal cavity. peritoneal cavity. HIV pts may have infections lead to HIV pts may have infections lead to ascitesascites. . diagnosisdiagnosis 2-Clinical Features2-Clinical Features A- Asymptomatic (fluid 400ml): B- symptomatic (fluid 400ml): Increased abdominal girth, presence of Increased abdominal girth, presence of abdominal pain or discomfort,abdominal pain or discomfort, early satiety, pedal edema, weight gain early satiety, pedal edema, weight gain and respiratory distress depending on the and respiratory distress depending on the amount of fluid accumulated in the amount of fluid accumulated in the abdomen.abdomen. Physical examination findings:Physical examination findings: Umbilicus Umbilicus EversionEversion (often with umbilical (often with umbilical herniationherniation) ) TympanyTympany at the top of the abdomen at the top of the abdomen Fluid waveFluid wave Peripheral edemaPeripheral edema Shifting dullness ( 500ml fluid)Shifting dullness ( 500ml fluid) Bulging flanks (500ml fluid) Bulging flanks (500ml fluid) Shifting DullnessShifting Dullness Bulging Flanks and Umbilical HerniaBulging Flanks and Umbilical Hernia DiagnosisDiagnosis 3-paracentesis3-paracentesis It is a diagnostic procedure to establish It is a diagnostic procedure to establish the etiology of new-onset the etiology of new-onset ascitesascites or to rule or to rule out spontaneous bacterial peritonitis in out spontaneous bacterial peritonitis in patients with preexisting patients with preexisting ascitesascites. Large . Large volume volume paracentesisparacentesis is performed in is performed in hemodynamicallyhemodynamically stable patients with stable patients with tense or refractory tense or refractory ascitesascites to alleviate to alleviate discomfort or respiratory compromise.discomfort or respiratory compromise. For diagnostic purposes, a small amount For diagnostic purposes, a small amount (20cc) may be enough for adequate (20cc) may be enough for adequate testing.testing. AsciticAscitic fluid analysis fluid analysis Cell count: Cell count: A white blood cell count is the most A white blood cell count is the most important.important. A A neutrophilneutrophil 250 cells/mm3 250 cells/mm3 spontaneous bacterial peritonitisspontaneous bacterial peritonitis An elevated lymphocyte An elevated lymphocyte tuberculosis or tuberculosis or peritoneal peritoneal carcinomatosiscarcinomatosis Gram stain and culture:Gram stain and culture: for bacteria and acid fast bacillifor bacteria and acid fast bacilli Red cell countRed cell count 50.000/microliter 50.000/microliter hemorrhagic hemorrhagic ascitesascites, , which usually is due to malignancy, which usually is due to malignancy, tuberculosis or trauma.tuberculosis or trauma. Serum-Serum-AscitesAscites Albumin Gradient Albumin Gradient Best single test for classifying Best single test for classifying ascitesascites into into portal hypertensive and non-portal portal hypertensive and non-portal hypertensive causes.hypertensive causes. Calculated by: Calculated by: Serum albumin Serum albumin AscitesAscites albumin= SAAG albumin= SAAG SAAG 1.1 SAAG 1.1 g/dLg/dL= Portal HTN= Portal HTN SAAG 1.1SAAG 1.1 1.1.Liver DiseaseLiver Disease 2.2.Hepatic Hepatic CongestionCongestion 3.3.CHFCHF 4.4.Tricuspid Tricuspid InsufficiencyInsufficiency 5.5.Massive Hepatic Massive Hepatic MetastasisMetastasis SAAG 500 ml of fluid)500 ml of fluid) Abdominal hazinessAbdominal haziness Bulging FlanksBulging Flanks Poor definition of intra abdominal organsPoor definition of intra abdominal organs - - Medial displacement of the cecum and Medial displacement of the cecum and ascending colon.ascending colon. Hellmers sign: the lateral liver angle is Hellmers sign: the lateral liver angle is displaced medially from the displaced medially from the thoracoabdominal wall in a patient with a thoracoabdominal wall in a patient with a large extraperitoneal fluid collection large extraperitoneal fluid collection extending into the flank (Pathologic extending into the flank (Pathologic processes in both the intra- and processes in both the intra- and extraperitoneal spaces). extraperitoneal spaces). bilateral pleural effusions bilateral pleural effusions in a patient with ascitesin a patient with ascites loss of any loss of any definition of definition of the edge of the edge of the spleen or the spleen or liver and liver and displacement displacement of the bowel of the bowel loops out of loops out of the pelvis and the pelvis and bulging flanksbulging flanks Pelvic AscitesPelvic Ascites Imaging StudiesImaging Studies B-B- CT scanCT scan Well visualized Well visualized Fluid may be visualized in the:Fluid may be visualized in the: Right perihepatic spaceRight perihepatic space Posterior subhepatic space (Morison Posterior subhepatic space (Morison pouch)pouch) Pouch of DouglasPouch of Douglas Large ascitesLarge ascites displacing bowel displacing bowel posteriorlyposteriorly Perihepatic ascitesPerihepatic ascites CT Small amount of ascitic fluid in the pouch of Douglas and surrounding the adjacent small bowel loops Abdominal CT, showing Morisons Abdominal CT, showing Morisons pouch as the dark margin surrounding pouch as the dark margin surrounding the right kidney (at lower left corner of the right kidney (at lower left corner of image).image). Imaging StudiesImaging Studies C-C- UltrasoundUltrasound Easiest and most sensitive technique for Easiest and most sensitive technique for detection of ascitic fluid.detection of ascitic fluid. Volume as small as 5-10ml can be seen.Volume as small as 5-10ml can be seen. . . Morisons Morisons pouchpouch with with abnormal fluid abnormal fluid collection (red collection (red arrows) arrows) between the between the liver and right liver and right kidneykidney Management of AscitesManagement of Ascites The goal is to prevent Na loading and increase The goal is to prevent Na loading and increase renal excretion of Na and H2O and produce a renal excretion of Na and H2O and produce a net re-absorption of fluid from the ascites back net re-absorption of fluid from the ascites back into the circulating o the circulating volume. Dietary Na restrictionDietary Na restriction Diet of 2g sodium per day Diet of 2g sodium per day Fluid Restriction:Fluid Restriction: Only done when serum Na is 205mg/dl or a 50% cause to 205mg/dl or a 50% cause decreasing in 24-hour creatinine decreasing in 24-hour creatinine clearance to 90% without liver Mortality is 90% without liver transplantati