Ascites



Ascites


Evelyn K. Hsu



INTRODUCTION

Ascites is the pathologic accumulation of fluid in the peritoneal cavity. It can be caused by decreased plasma oncotic pressure, obstructed lymphatic or venous drainage, or irritation of the peritoneum (e.g., as a result of infection, trauma, or neoplasia).


DIFFERENTIAL DIAGNOSIS LIST


Gastrointestinal/Hepatic Causes



  • Chronic liver failure/cirrhosis


  • Protein-losing enteropathy (PLE) (see Table 16-1 for differential diagnosis)


  • Pancreatitis


Infectious Causes



  • Bacterial peritonitis


  • Chronic tuberculous peritonitis


  • Congenital TORCH infection: toxoplasmosis, other, rubella, cytomegalovirus, and herpes simplex virus


Neoplastic Causes



  • Hodgkin disease


  • Intraperitoneal tumor


Congenital or Vascular Causes



  • Hepatic vein occlusion (Budd-Chiari syndrome, veno-occlusive disease)


  • Portal vein obstruction/portal hypertension


  • Renal vein thrombosis


  • Congestive heart failure


  • Thoracic duct obstruction (chylous ascites)


Metabolic or Congenital Causes



  • Lysosomal storage disease


Inflammatory Causes



  • Chronic adhesive pericarditis


  • Peritonitis—rheumatic, meconium, bile


Renal Causes



  • Nephrotic syndrome


  • Perforation of the urinary tract


  • Obstructive uropathy


  • Acute glomerulonephritis


  • Chronic renal failure


Miscellaneous Causes



  • Systemic lupus erythematosus


  • Familial Mediterranean fever


  • Maternal diabetes


  • Enlarged lymph node


  • Pulmonary lymphangiectasia


  • Malnutrition


EVALUATION OF A PATIENT WITH ASCITES

Paracentesis is an essential tool for determining the cause of new-onset ascites, and is also recommended to detect bacterial peritonitis in the setting of abdominal pain
or fever. Fluid should be obtained for cell count and differential, gram stain and culture, and albumin concentration. Serum-ascites albumin gradient (SAAG), the difference in albumin concentration between serum and ascitic fluid, is a useful measurement that dividing ascites into two categories—high gradient (>1.1 g/dL) and low gradient (<1.1 g/dL). High gradient SAAG is suggestive of portal hypertension, most suggestive of cirrhosis, heart failure, fulminant hepatic failure, and hepatic venous outflow obstruction (Budd-Chiari or veno-occlusive disease). Low-gradient ascites suggests conditions without portal hypertension, such as pancreatic ascites, tuberculous ascites, peritoneal carcinomatosis, and nephrotic syndrome. The SAAG is a superior measure compared to total protein of the fluid in differentiating cases of portal hypertension.








TABLE 16-1 Diseases Associated with Enteric Protein Loss





















































Loss from Intestinal Lymphatics


Intestinal lymphangiectasia


Primary


Secondary (i.e., resulting from cardiac disease)




  • Constrictive pericarditis



  • Congestive heart failure



  • Cardiomyopathy



  • Fontan physiology


Obstructive lymphatic disorders




  • Malrotation



  • Lymphoma



  • Tuberculosis



  • Sarcoidosis



  • Radiation therapy and chemotherapy



  • Retroperitoneal fibrosis or tumor



  • Arsenic poisoning


Loss from an Abnormal or Inflamed Mucosal Surface


Ménétrier disease


Eosinophilic gastroenteritis


Milk- and soy-induced enterocolitis


Celiac disease


Tropical sprue


Ulcerative jejunitis or colitis


Radiation enteritis


Graft-versus-host disease


Necrotizing enterocolitis


Crohn disease


Hirschsprung disease


Systemic lupus erythematosus


Bacterial overgrowth


Giardiasis


Bacterial and parasitic infections


Common variable immunodeficiency


Modified from Proujansky R. Protein-losing enteropathy. In: Walker WA, Durie PR, Hamilton JR, et al., eds. Pediatric Gastrointestinal Disease, 2nd ed. Philadelphia, PA: BC Decker; 1996.

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Sep 14, 2016 | Posted by in PEDIATRICS | Comments Off on Ascites

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