Ascites – Important viva questions

the 5 Fs (Fat, fluid, faeces, flatus and fetus)

It is the pathological accumulation of fluid in the peritoneal cavity.

· Portal hypertension with cirrhosis.
· Abdominal malignancy.
· Congestive cardiac failure.

Diagnostic paracentesis for proteins and malignant cells, ultrasonography of the abdomen, peritoneal biopsy or laparoscopy if the
cause remains unclear.

An exudate has a protein content of over 25 g/l.

The most important treatments are sodium restriction and diuretics 
· Sodium restriction to 88 mmol per day; only 15% of these patients lose weight or have a reduction in ascitic fluid with this
therapy alone.
· Fluid restriction is usually not necessary unless the serum sodium concentration drops below 120 mmol/1.
· When the patient has tense ascites, 5 litres or more of ascitic fluid should be removed to relieve shortness of breath, to
diminish early satiety and to prevent pressure-related leakage of fluid from the site of a previous paracentesis.
· Diuretic therapy should be initiated immediately, before which the serum sodium concentration of a random urine sample
should be measured. Serial monitoring of urinary sodium concentration helps to determine the optimal dose of diuretic; doses
are increased until a negative sodium balance is achieved. The most effective diuretic regimen is a combination of
spironolactone and furosemide (frusemide). More than 90% of patients respond to this therapy.
· Diuretic-resistant ascites:
-Therapeutic paracentesis with infusion of salt-free albumin (reported to
decrease hospital stay).
-Peritoneovenous shunting, e.g. LeVeen shunt, limited by the high rate of
infection and disseminated intravascular coagulation.
-Transjugular intrahepatic portosystemic stent shunt (TIPS) is a non-surgical side-to-side shunt consisting of a stented channel
between a main branch of the portal vein and the hepatic vein. The stent shunt is associated with an operative mortality rate of
1% compared with 5-39% lor surgical shunts . -Extracorporeal ultrafiltration of ascitic fluid
with reinfusion. – Liver transplantation

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