Ascites

By

R.Gnanaraj

Definition
From greek derivation askhos which
refers to a bag or sack.
Pathologic fluid accumulation in the
peritoneal cavity.

Causes of ascites

Hepatic
Renal
Cardiac
Infectious
GI
Neoplasm
Gynecological
Pancreatic
miscellaneous

Causes of ascites
Ascites in newborn is classified as
1.associated with hydrops
2.isolated ascites
3.ascites due to peritonitis

Associated with hydrops

1.CVS(20%)- heart block
auricular tachycardia
hypoplastic left heart
ebstein disease
2.Hematological (10%)-isoimmune hemolytic disease
homozygous alpha thalassemia
3.Chromosomal(10%)-turner syndrome
trisomy 13,18,21
4.Infection(10%)-TORCH group
syphilis
5.Pulmonary(5%)-diaphramatic hernia

Contd
6.Gastrointestinal(5%)-atresia
7.Renal(5%)-nephrosis
8.Maternal conditions(5%)-Toxemia,
Diabetes
9.Miscellaneous(5%)- Wilms tumors
Neuroblastoma
10.Liver-Cirrhosis
Alpha-1 antitrypsin deficency
Neonatal hemochromatosis
11.Placenta or cord-Cord compression
Chorangioma
12.Unknown(20%)

 Isolated ascites-Chylous ascites

Obstructive uropathy
Biliary ascites
Ascites due to peritonitis
Bacterial
Chemical

Causes of ascites in children

Extrahepatic-Venous obstruction
CHF
AV fistula
Intrahepatic-Biliary tract disease
Hepatocellular disease
Toxins
Schistosomiasis
Other causes-TB
Nephrotic syndrome
Pancreatitis
Chlamydial infection
Rheumatoid arthritis

Causes of acute ascites

Venous obstruction
Peritonitis
Fulminant hepatic failure

Pathophysiology
Underfill theory
Overflow theory
Peripheral vasodilation
theory

Clinical features
Distension of abdomen
Abdominal pain
Respiratory distress

Signs of ascites
5 classic physical signs
Bulging flanks
Flank dullness
Shifting dullness
Fluid wave
Puddle sign

Look for
Triad of PHT
Umbilical herniation
Pedal edema & anasarca
Hepatojugular reflux & dilated veins
with flow upwards
Fever & abdominal pain with
guarding & rigidity
Evidence of malignancy

Investigations
Blood cell counts,viral markers
Urine analysis
LFT
Mantoux test
Renal & cardiac evaluation
Ascitic fluid analysis
USG, CT scan , MRI

Grading of ascites
Mild - only seen in USG or puddle
sign
Moderate shifting dullness present
Severe fluid thrill present

Abdominal paracentesis
Position
Site
Technique Z tract

Ascitic fluid analysis

Colour
Cell count
Protein
Culture
SAAG
LDH
Amylase
TG, bilirubin

Serum ascites albumin

gradient(SAAG)
Ratio >1.1 portal hypertension
Ratio <1.1 peritoneal pathology
-TB
-SBP
-Malignancy

Exudative & transudative

causes
Exudative(<1.1)
1.Peritonitis
2.IVC
obstruction
3.Malignancy
4.Pancreatitis
5. Chylous
ascites
6.Hemorrhagic

Transudative(>1.1)
1.Nephritic
syndrome
2.Hypoproteinemia
3.CCF
4.End stage liver
cell failure
5.Protein losing
enteropathy

Complications
Spontaneous bacterial peritonitis
Hernias
Respiratory distress

Management
Depends on the SAAG
Low albumin gradient ascites
High albumin gradient ascites

Low albumin gradient

ascites
Does not respond to salt restriction & diuretics
Treatment depends on the cause
TB peritonitis- ATT
Pancreatic ascites- endoscopic stenting
somatostatin therapy
surgery
Chlamydial-tetracycline
Nephrotic & lupus ascites-steroids
Malignancy-chemotherapy
surgery

High albumin gradient

ascites
Bed rest
Diet restriction
Diuretics
Beta blockers

Diet restriction
Sodium restriction
upto 5 mEq/day (1-4 yrs)
upto 20mEq/day (4-11 yrs)
upto 30mEq/day (>12 yrs)
No fluid restriction

Diuretics
Potassium sparing diuretics
Loop diuretics
Thiazides

Spironolactone
Starting Dose - 1-2mg/kg/day
Gradually increased upto
6mg/kg/day
Onset 2-4days
Side effects hyperkalemia
metabolic acidosis
gynecomastia
Others triamterene,amiloride

Loop diuretics

Furosemide,bumetanide,ethacrynic acid
Starting Dose - 1-2mg/kg/day
Gradually increased upto 6mg/kg/day
Onset 2-4days
Side effects hypokalemia
hyperchloremic acidosis
ototoxicity

Thiazide diuretics
Hydrochlorthiazide indicated when
diuresis on high doses are
inadequate.
Dose 2-3mg/kg/day
Side effects-hypokalemia
hyperglycemia
hyperuricemia

Duration of diuretics
Treatment till ascites is cured
Maintenance in case of cirrhosis for
months to years.

Beta blockers
Causes increased natriuresis by
1.lowering of portal pressure
2.inhibition of renin secretion

Refractory ascites
Fluid overload unresponsiveness to
salt restriction & high dose diuretic
Causes-infection
malignancy
TB
liver cell failure
renal causes

Treatment for refractory

ascites
Paracentesis
LeVcen shunt (peritoneal venous
shunt)
Orthotropic liver transplantation

Paracentesis
LVP - 200-400ml/kg/day slowly over
4-6hrs
Simultaneous infusion of 6g of 20%
albumin for every liter of fluid
removed.
Mechanism-paracentesis decreases
systemic venous congestion,
increases GFR & renal plasma flow

Chylous ascites
Causes
Anomaly of lymphatics
cirrhosis
trauma
Tumor
Rheumatoid arthritis
Infections

Clinical features
Abdominal distension
Poor weight gain
Loose stools
Anasarca

Management
Fluid analysis-white in colour
Increased protein
Increased TG
Decreased gamma globulin
Lymphocytosis
Treatment
1.diet- low fat diet with MC TG
High protein diet
2.paracentesis
3.surgery

Reference
OP Ghai
Nelson
IAP
Pediatricks

Thank you