Tuesday, December 15, 2009

December 15th - LBJ - Ascites

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)

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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