Curriculum · Gastroenterology
Management of ascites in cirrhosis
What it is
Ascites is one of the complications of cirrhosis, and portal hypertension is responsible for most of these complications. A patient with compensated cirrhosis and no complications may be asymptomatic, or have nonspecific symptoms such as fatigue, poor sleep, or itching. Once ascites appears, along with hepatic encephalopathy, variceal bleeding, spontaneous bacterial peritonitis, hepatorenal syndrome, jaundice, or HCC, the cirrhosis is decompensated. Portal hypertension can be divided into prehepatic, intrahepatic, and posthepatic causes, and the most common cause is cirrhosis, an intrahepatic form. Portal vein thrombosis and Budd-Chiari syndrome are the pre- and posthepatic examples.
How it is diagnosed
Ultrasonography is used to diagnose ascites. Paracentesis is done for newly discovered ascites, with calculation of the serum-ascites albumin gradient to diagnose the cause. In cirrhosis the gradient is above 1.1. Gradient and fluid protein are read together: with a gradient above 1.1, ascitic fluid protein under 2.5 g/dL fits cirrhosis while protein above 2.5 g/dL fits right-sided HF or Budd-Chiari syndrome; with a gradient under 1.1, protein under 2.5 g/dL fits nephrotic syndrome and protein above 2.5 g/dL fits malignancy or TB. The gross appearance is read as well: clear and translucent yellow is usual for cirrhosis, turbid or cloudy means infection, milky chylous ascites means a triglyceride concentration exceeding the serum concentration and greater than 200 mg/dL (2.26 mmol/L), and pink or bloody fluid, usually with a red cell concentration above 10,000 per mm3, means a traumatic tap or malignancy. An ascitic fluid granulocyte count above 250/uL confirms spontaneous bacterial peritonitis.