Ascites

Specialty: Gastrointestinal.

• Intraperitoneal free fluid accumulation
• abdominal dropsy
• abdominal fluid distension

Why it occurs

• Liver cirrhosis with sinusoidal portal hypertension (most common cause, >80% of cases)
• Severe right congestive heart failure or constrictive pericarditis with passive hepatic congestion
• Peritoneal carcinomatosis secondary to neoplasms of the ovary, colon, stomach or pancreas
• Nephrotic syndrome due to massive proteinuria that decreases plasma oncotic pressure
• Peritoneal tuberculosis with granulomatous inflammation and exudation into the cavity.

Initial workup

Abdominal ultrasound with portal Doppler (to confirm the presence of free fluid, evaluate the spleen and liver, and rule out portal thrombosis) | Diagnostic paracentesis (with cell count, polymorphonuclear [PMN], culture in blood culture bottles, albumin and total protein levels in fluid) | Calculation of serum-ascites albumin gradient (SAG): SABG >= 1.1 g/dL indicates portal hypertension; ABG < 1.1 g/dL suggests non-portal causes such as malignancy or tuberculous infection | General analysis with kidney function, electrolytes in blood and urine.

Standard management

• Spironolactone — aldosterone antagonist, starting dose of 100 mg/day, adjustable up to a maximum of 400 mg/day as a single morning dose, monitoring the appearance of hyperkalemia and gynecomastia
• Furosemide — loop diuretic, initial dose of 40 mg/day combined with spironolactone in a 40:100 ratio to balance potassium levels, maximum dose of 160 mg/day
• 20% human albumin — administered intravenously at a dose of 8 g for each liter of ascitic fluid extracted during evacuating paracentesis >5 liters to prevent postparacentesis circulatory dysfunction
• Norfloxacin (400 mg/day orally as prophylaxis in high-risk patients or with a history of SBP).