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  • • Pathologic accumulation of free fluid within the abdominal cavity

    • Ascites develops from

    • -Decreased plasma oncotic pressure (liver disease, malnutrition)

      -Increased lymph/peritoneal fluid production (liver disease, malignant ascites)

      -Blockage or disruption of abdominal lymphatic drainage (chylous ascites, congenital)

    • Patients typically complain of abdominal distention or vague constitutional symptoms

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Epidemiology

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  • • Over 80% of patients with ascites have portal hypertension secondary to chronic liver diseases

    • Less common causes are chylous, malignant, or pancreatic ascites

    • Chylous ascites is most commonly due to occult tumor obstructing the lymphatic ducts (lymphoma or adenocarcinoma), external trauma, operative disruption, or congenital anomalies

    • Malignant ascites occurs secondary to peritoneal implants stimulating ascitic fluid production or if there is advanced venous or lymphatic obstruction

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Symptoms and Signs

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  • • Vague, diffuse, constant abdominal discomfort associated with distention

    • Ascites from cirrhosis associated with systemic signs of liver disease including palmar erythema, spider angiomas, gynecomastia, evidence of portosystemic shunting, and encephalopathy

    • Malignant ascites associated with weight loss, a history of cancer, or symptoms related to the neoplasm (eg, fever, night sweats, and weight loss in cases of lymphoma)

    • Chylous ascites often relatively asymptomatic with vague abdominal discomfort and mild abdominal distention

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Laboratory Findings

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Liver Failure

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  • • Systemic

    • -Hypoalbuminemia

      -Increased bilirubin

      -Increased prothrombin time/international normalized ratio (PT/INR)

    • Paracentesis

    • -Serum-ascites albumin

      -Gradient > 1.1

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Chylous Ascites

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  • • Systemic

    • -Hypoalbuminemia

      -Lymphocytopenia

      -Anemia

    • Paracentesis

    • -Grossly milky appearance

      -Serum-ascites albumin gradient (SAAG) < 1.1

      -Triglyceride level > 200 mg/dL

      -Leukocyte count > 1000/µL

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Malignant Ascites

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  • • Systemic

    • -Positive tumor markers

      -Evidence of malnutrition

    • Paracentesis

    • -Positive cytologic diagnosis

      -Aneuploidy (flow cytometry)

      -High lactic dehydrogenase (LDH) (> 500 IU/L)

      -High carcinoembryonic antigen (CEA)

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Imaging Findings

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  • • Abdominal US verifies the presence of ascites, suggests the presence of liver disease, and guides diagnostic/therapeutic paracentesis

    • Abdominal/pelvic CT scans are useful in documenting ascites; suggesting liver disease; detecting lymphadenopathy and masses of the mesentery as well as of solid organs, such as the liver, ovaries, and pancreas

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  • • Portal hypertension

    • Chylous ascites

    • Malignant ascites

    • Normal postoperative intra-abdominal fluid

    • Sterile fluid collection

    • Intra-abdominal abscess

    • Hematoma

    • Biloma

    • Urinoma

    • Soft-tissue neoplasm

    • Chronic inflammatory peritonitis

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Rule Out

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  • • Spontaneous bacterial peritonitis (SBP)

    • Underlying malignancy

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  • Diagnostic paracentesis: LDH level, albumin, amylase, triglyceride level, WBC count, cytologic studies, Gram stain, and culture

    Abdominal/pelvic CT scan:

    • -Plus a full colonoscopy to search for primary neoplasm in malignant ascites

      -Used to search for underlying neoplasm in cases of chylous ascites occurring in adults with constitutional symptoms

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When to Admit

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  • • Cirrhotic patients with an exacerbation of ascites should be admitted to rule out SBP, and initiate or adjust medical management

    • Most ...

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