2. Definition
-Ascites is of greek derivation(askos)
which refers to bag or sack
-The word describes pathological fluid
accumulation in peritoneal cavity
5. Pathophysiology
• Under filling theory
primarily there is inappropriate
sequestration of fluid within the splanchnic
vascular bed as a consequence of portal
hypertension (PHT) that produces
decrease in effective circulating blood
volume. This activates the plasma rennin,
aldosterone, and sympathetic nervous
system, resulting in renal sodium and
water retention
6. Overflow theory
primary abnormality is
inappropriate
renal retention of sodium and water in the
absence of volume depletion. Basis of this
theory is that patients with cirrhosis have
intravascular hypervolemia rather than
hypovolemia
7. Peripheral arterial vasodilatation
• The major factor of ascites formation
is splanchnic vasodilation.
• Cirrhosis causes increased hepatic
resistance to portal flow that results in
PHT and shunting of blood to the syst
emiccirculation.
• Local production of vasodilators, mainly
nitric oxide due to PHT results in
splnchnic and peripheral arterial
vasodilatation. This leads to decrease in
effective arterial blood volume (EABV)
8. Pathogenic mechanism
• Increased hydrostatic pressure
• Decreased colloid osmotic pressure
• Increased permeability of peritoneal
capillaries
• Leakage of fluid into peritoneal cavity
• Misc.
20. Risk factors
•
•
•
•
•
•
Chronic viral hepatitis
Intravenous drug use
Sexual promiscuity
Transfusions
Tattos
Habitation or origination from endemic
hepatitis
25. Imaging studies
• Chest and abdominal films
-elevation of diaphragm
-nonspecific signs
-hellmer sign
-obliteration of hepatic angle
-dogs ear/mickey mouse sign
-med displacement of cecum &
ascending colon & lat displacement of
properitoneal line
26. • USG
-site for paracentesis
-100ml fluid
-uncomplicated ascites
homogenous ,freely mobile, anechioc
collection in peritoneal cavity,deep
acoustic enhancement
-massive ascites
small bowel loops-polycyclic,lollypop
like arcuate app.
27. -coarse internal echoes(blood)
-fine internal echoes(chyle)
-multiple septa(TB,pseudomyxoma
peritonei)
-loculated /atypical fluid distribution
-matting or clumping bowel loops
-thickening of interface betn fluid & adjacent
structure
28.
29. • Upper GI endoscopy
-oesophageal/fundal varices
CT/MRI
-rt perihepatic space,morrisons
pouch,douglas pouch
-malignant ascites
prop fluid in lesser & greater sac
-benign ascites
fluid in greater sac
41. Peritoneovenous shunt
• A peritoneovenous
shunt (also
called Denver shunt)
is a shunt which
drains peritoneal fluid
from the peritoneum
into veins, usually
the
internal jugular vein or
the
superior vena cava
42. Portocaval shunt
• A portacaval
shunt (or portal caval
shunt) is a treatment for
high blood pressure in the
liver. A connection is
made between the
portal vein, which
supplies 75% of the liver's
blood, and the
inferior vena cava, the
vein that drains blood
from the lower two-thirds
of the body.
44. Refractory ascitis
• Fluid load that is non responsive to
restriction of dietary sodium to
88mmol/day and maximal dose diuretic
therapy in absence of ingestion of
prostaglandin inhibitors(NSAID)
• Management
serial large volume paracentesis
100ml/kg at a time
iv albumin 6-8g/lit