Management of Ascites

Rowen K. Zetterman, MD


April 05, 2011

In This Article

Evaluation of the Patient With Ascites

In addition to a careful history and physical examination,[4] an ultrasound of the abdomen and paracentesis should be considered[5] to establish a likely etiology for ascites. In patients with suspected upper gastrointestinal malignancy, endoscopic ultrasound may allow identification and aspiration of ascites too minimal to be seen with CT or ultrasound.[6] Diagnostic laparoscopy can be helpful in tuberculous peritonitis and peritoneal malignancy.[7] Paracentesis is generally safe, even in patients with coagulopathy.[8] Ascitic fluid tests should include white blood cell and red blood cell counts, total protein, albumin, amylase, cytology, and bacterial culture. Lactate levels are also recommended because lactate can be increased in spontaneous bacterial peritonitis.[9]The author still inoculates a blood culture bottle with ascites fluid at the bedside and draws a peripheral blood culture when SBP is likely. Red blood cells can indicate a traumatic tap during needle insertion, hepatocellular carcinoma, or tuberculous peritonitis. The serum-ascites albumin gradient is determined by subtracting the ascites albumin level from the serum albumin level. A gradient > 1.1 gm/dL suggests portal hypertension as the cause of ascites.[10]

Differential Diagnosis of Ascites

Causes of ascites include cirrhosis of the liver, malignancy, infections, and congestive heart failure (Table).[1] Hydrothorax can also develop with transfer of ascites from the positive pressure of the abdomen to the negative pressure of the thorax through transdiaphragmatic channels.[11] In some patients, the right pleural space can fill with fluid without development of abdominal ascites.

Table. Causes of Ascites

Massive liver necrosis
Peritoneal carcinomatosis
Primary and secondary malignancies of the liver
Right heart failure
Constrictive pericarditis
Hepatic vein thrombosis (Budd-Chiari) and veno-occlusive disease
Portal vein thrombosis (especially if the serum albumin is reduced)
Peritonitis (eg, tuberculous or fungal peritonitis)
Chylous ascites from trauma, surgery, or lymphatic obstruction
Pancreatitis, acute and chronic
Meigs syndrome
Biliary ascites
Systemic diseases such as vasculitis and systemic lupus erythematosus
Eosinophilic gastroenteritis and Whipple disease


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