Ascites

Perform diagnostic paracentesis for all new-onset ascites. Obtain abdominal ultrasound before the procedure for fluid confirmation and site selection. In cirrhosis, perform the tap without delay at hospital admission and repeat diagnostic evaluation when ascites worsens or when gastrointestinal bleeding, shock, fever, systemic inflammation, gastrointestinal symptoms, worsening kidney or liver function, or hepatic encephalopathy occurs. Wiley+1WileyUnexplained ascites - Hernaez - 2016 - Clinical Liver Disease - Wiley Online Libraryeasl eu[PDF] EASL Clinical Practice Guidelines for the management of patients ...

Send ascitic fluid for cell count with differential, albumin, and total protein; obtain serum albumin on the same day for SAAG calculation. Send culture when infection is suspected, ideally by bedside inoculation into aerobic and anaerobic blood-culture bottles before antimicrobials. Cytology requires a larger sample than the approximately 50 mL generally sufficient for routine diagnostic studies. ScienceDirect+2ScienceDirectSerum-Ascites Albumin Gradient - an overviewScienceDirectPerforming Abdominal Paracentesis - ScienceDirectPubMedEvidence-based clinical practice guidelines for Liver Cirrhosis 2020

Ascites in cirrhosis is a decompensating event rather than an isolated symptom: five-year survival declines from approximately 80% in compensated cirrhosis to approximately 30% after ascites develops. Clinically significant ascites and associated complications should prompt consideration of liver-transplant evaluation. easl eu+1easl eu[PDF] EASL Clinical Practice Guidelines for the management of patients ...aasldDiagnosis, Evaluation and Management of Ascites, Spontaneous ...

Calculate SAAG as serum albumin minus ascitic albumin. A SAAG ≥1.1 g/dL indicates portal hypertension and correlates with a hepatic vein–portal vein pressure gradient greater than 11 mm Hg; a SAAG <1.1 g/dL redirects the evaluation toward nonportal mechanisms. Although SAAG is highly useful, interpret it with the total clinical picture because exceptions occur. Wiley+1WileyUnexplained ascites - Hernaez - 2016 - Clinical Liver Disease - Wiley Online LibraryPubMedEvidence-based clinical practice guidelines for Liver Cirrhosis 2020

For high-SAAG ascites, ascitic total protein is the key discriminator. A protein concentration <2.5 g/dL supports cirrhosis and portal hypertension, whereas protein ≥2.5 g/dL usually indicates right-heart failure. A high-SAAG result therefore should not automatically be labeled cirrhotic ascites when cardiac congestion is plausible. WileyWileyUnexplained ascites - Hernaez - 2016 - Clinical Liver Disease - Wiley Online Library

For low-SAAG ascites, prioritize peritoneal malignancy, chronic peritoneal infection including tuberculosis, and nephrotic syndrome. Evaluate for nephrotic syndrome or protein-losing enteropathy when the clinical setting supports either diagnosis. Pancreatic ascites may produce an elevated PMN count but generally remains low-SAAG, so neutrophilia alone does not establish SBP in a nonportal fluid pattern. WileyWileyUnexplained ascites - Hernaez - 2016 - Clinical Liver Disease - Wiley Online Library

Diagnose SBP when ascitic fluid neutrophils exceed 250/mm3. This threshold applies whether neutrophils are measured microscopically or by flow cytometry-based automated counting; reagent strips do not have clear evidence for routine diagnosis. In a traumatic paracentesis with ascitic red cells >10,000/mm3, correct the PMN count by subtracting 1 PMN for every 250 red cells/mm3. ScienceDirect+1ScienceDirectSerum-Ascites Albumin Gradient - an overvieweasl eu[PDF] EASL Clinical Practice Guidelines for the management of patients ...

Culture-negative neutrocytic ascites has PMN ≥250/mm3 with a negative culture and remains an infected-ascites phenotype requiring treatment. In contrast, monomicrobial nonneutrocytic bacterascites has a positive culture with PMN <250/mm3: treat symptomatic patients, but in asymptomatic patients repeat paracentesis and start antibiotics if the repeat PMN count reaches ≥250/mm3. ScienceDirectScienceDirectAscites - an overview | ScienceDirect Topics

In SBP with increased or rising serum creatinine, administer albumin 1.5 g/kg within 6 hours of diagnosis followed by 1 g/kg on day 3. This regimen targets the high-risk renal phenotype rather than routine albumin use for every infected ascites presentation. BMJ+2BMJGuidelines on the management of ascites in cirrhosis - GutBMJGuidelines on the management of ascites in cirrhosis - Gut - The BMJPubMedOptimal Management of Cirrhotic Ascites: A Review for Internal Medicine Physicians - PMC

Large-volume paracentesis is standard care for large-volume ascites and is used with diuretic therapy when applicable. In diuretic-refractory ascites, remove as much fluid as feasible for symptom control. Bedside paracentesis is generally safe, and repeated therapeutic paracentesis is commonly used when fluid is refractory to fluid restriction and diuretics. BMJ+2BMJGuidelines on the management of ascites in cirrhosis - GutNEJMTreatment of Patients with CirrhosisScienceDirectPerforming Abdominal Paracentesis - ScienceDirect

After paracentesis removing >5 L, infuse 20% or 25% albumin at 8 g per liter of ascites removed. For removal of <5 L, consider the same 8 g/L replacement in acute-on-chronic liver failure or when post-paracentesis acute kidney injury risk is high. Albumin remains the preferred plasma expander in this setting. BMJ+1BMJGuidelines on the management of ascites in cirrhosis - GutBMJGuidelines on the management of ascites in cirrhosis - Gut - The BMJ

Consider TIPS in selected patients with refractory or recurrent ascites, and assess transplant candidacy at the same decision point. TIPS may improve ascites control and, in more recent randomized studies using contemporary selection and stent approaches, improved survival compared with large-volume paracentesis; selection is crucial because the earlier trials commonly excluded more severe liver disease. BMJ+2BMJGuidelines on the management of ascites in cirrhosis - Gut - The BMJBMJTransjugular intrahepatic portosystemic stent-shunt in the ... - GutNatureLiver diseases: epidemiology, causes, trends and predictions - Nature

A low-SAAG profile should prevent reflex escalation of portal-hypertension therapy. Peritoneal malignancy, chronic peritoneal infection, nephrotic syndrome, and pancreatic ascites each require a cause-specific diagnostic pathway; obtain cytology when malignancy is suspected, evaluate protein-loss disorders when indicated, and interpret pancreatic inflammation or leak in the setting of low-SAAG fluid. WileyWileyUnexplained ascites - Hernaez - 2016 - Clinical Liver Disease - Wiley Online Library

Malignant ascites is associated with advanced cancer and significant morbidity. Use paracentesis for symptom relief and coordinate disease-directed oncologic assessment rather than treating the fluid pattern as cirrhotic ascites. Diuretics are described as a treatment mainstay, but the expected response depends on the underlying physiology and should not delay diagnostic clarification. JAMA+1JAMAMalignant Ascites: New Concepts in Pathophysiology, Diagnosis ...ScienceDirectPerforming Abdominal Paracentesis - ScienceDirect

For chylous ascites, distinguish lymphatic obstruction or leak from portal-hypertensive lymphatic overload. In adults in Western settings, tumors, cirrhosis, and postoperative leakage are common causes; lymphangiography may be a therapeutic option for refractory lymphatic leakage in selected cases. ScienceDirect+1ScienceDirectIntranodal lymphangiography in the treatment of chylous ascites - ScienceDirectWolters KluwerChylous Ascites From Cirrhosis-Related Portal... : ACG Case Reports Journal