Our Second Case at LBJ Today was a patient with 3-4 weeks of abdominal distention (in this case, ascites). The diagnosis ending up being Alcoholic Hepatitis/Cirrhosis.
Just as a review, an Approach to a patient with ascites includes a differentiation based on the serum Albumin-Ascitic Gradient. This has a published accuracy of >97%!
If >1.1 - Consider Liver Disease/Portal Hypertension.
This can be broken into causes based on location:
Pre-Hepatic Causes
Portal Vein Thrombosis
Schistosomiasis (in Egypt!)
Intrahepatic Causes (i.e "Cirrhosis)
Alcohol Abuse
Viral Hepatitis
NASH/NAFLD (i.e. obesity, dyslipidemia, insulin resistance)
Post-Hepatic Causes (i.e. "Congestion")
Constrictive Pericarditis
Budd-Chiari Syndrome
Tricupsid Regurgitation
Right-Sided CHF
If <1.1: Think Low-Albumin States and non-portal hypertensive causes:
Nephrotic Syndrome
Malabsorption/Protein-Losing Enteropathy
Infectious Peritonitis (TB and some fungal diseases)
Malignancy (Peritoneal Carcinomatosis, Ovarian Cancer, HCC, Psedomyxoma peritonii)
Hypothyroidism
All you'll ever need to know about Ascites actually comes from the AASLD - it includes where to do your paracentesis, how to analyze fluid (including SBP and variants) and treatment:
AASLD Practice Guidelines for Cirrhosis and Ascites
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