Anurag Goel ST5, Gastroenterology.

Transcription

1 Anurag Goel ST5, Gastroenterology.

2 Definition: presence of free fluid in the peritoneal cavity

3 Causes of Ascites Cause Frequency Cirrhosis 81% Cancer 10% Heart Failure 3% Tuberculosis 2% Dialysis 1% Pancreatic Disease 1% Other 2%

4 Non-peritoneal causes Intrahepatic portal hypertension Extrahepatic portal hypertension Hypoalbuminemia Miscellaneous disorders Chylous Examples Cirrhosis Fulminant hepatic failure Veno-occlusive disease Hepatic vein obstruction (ie, Budd-Chiari syndrome) Congestive heart failure Nephrotic syndrome Protein-losing enteropathy Malnutrition Myxedema Ovarian tumors Pancreatic & Biliary ascites Secondary to malignancy, trauma

5 Peritoneal Causes Malignant ascites Granulomatous peritonitis Vasculitis Miscellaneous disorders Examples Primary peritoneal mesothelioma Secondary peritoneal carcinomatosis Tuberculous peritonitis Fungal and parasitic infections Sarcoidosis Foreign bodies (cotton,starch, barium) Systemic lupus erythematosus Henoch-Schönlein purpura Eosinophilic gastroenteritis Whipple disease Endometriosis

6 Category Infectious diseases Amebiasis, Ascariasis, Brucellosis, Chlamydia peritonitis, Complications related to HIV infection, Pelvic inflammatory disease, Pseudomembranous colitis, Salmonellosis, Whipple's disease Hematologic Amyloidosis, Castleman's syndrome, Extramedullary hematopoiesis, Hemophagocytic syndrome, Histiocytosis X, Leukemia, Lymphoma, Mastocytosis, Multiple myeloma Miscellaneous Abdominal pregnancy, Crohn's disease, Endometriosis, Gaucher's disease, Lymphangioleiomyomatosis, Myxedema, Nephrotic syndrome, lymphatic tear or ureteral injury. Ovarian hyperstimulation

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8 Ultrasound with Dopplers Easily confirms ascites May see nodularity of cirrhosis Evaluate patency of vasculature No radiation, contrast CT / MRI Evaluation for malignancy

9 Grade 1 Mild, only detectable by U/S Grade 2 Moderate, symmetrical distension Grade 3 Gross or large with marked distension Large typically means painful/uncomfortable Refractory Ascites (5-10%) Can not be mobilized or early recurrence refractory to medical management NEJM 350: Hepatology 2003; 38:

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11 15cm lateral and 2 cms below umbilicus Avoid enlarged spleen and liver Avoid sp and inf epigastric arteries No data to support use of FFP Most clinicians would give pooled platelets if <40 Complication: Haematoma<1% Bowel perforation/haemoperitoneum <0.1% 10-20ml of fluid in a syringe with blue/green needle

12 Go 2cm below the umbilicus in the midline or 3 cm superior and medial to the anterior superior iliac spine

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15 Routine Optional Unusual Cell count and differential Glucose concentration Albumin concentration LDH concentration Total protein concentration Culture in blood culture bottles Gram stain Tuberculosis smear and culture, adenosine deaminase Cytology Triglyceride concentration Amylase concentration Bilirubin concentration

16 Is portal hypertension present? 97% accurate SAAG > 11 g/l Portal HTN SAAG < 11 g/l Other causes SAAG = (albumin concentration of serum) - (albumin concentration of ascitic fluid) The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):

17 SAAG > 11 g/l (PORTAL HT) Cirrhosis Alcoholic hepatitis CHF Massive hepatic metastases Budd Chiari Syndrome Congestive heart failure/constrictive pericarditis SAAG < 11 g/l Peritoneal carcinomatosis Peritoneal tuberculosis Pancreatitis Serositis Nephrotic syndrome

18 1. Check serum and fluid albumin SAAG > 11 SAAG < 11 Hepatic Sinusoid source Peritoneum source 2. Check Ascites Protein Ascites Protein <25 Ascites Protein >25 Capillarized sinusoid Peritoneal lymph Ascites Protein >25 Normal sinusoid 3. Differential Diagnosis Cirrhosis Late Budd-Chiari Cardiac ascites Early Budd-Chiari Veno-occlusive disease Malignancy Tuberculosis The SAAG does not need to be repeated after the initial measurement. Note: Exceptions exist: may have mixed features Adapted from

19 Is ascites infected? Greater than 250 PMN = SBP If ascites is bloody ( > 50,000 RBC/mm3), correct by subtracting 1 PMN / 250 RBC Is ascites bloody? 5% of pts w/ cirrhosis - spontaneous or s/p traumatic tap. Non-traumatic associated with malignancy 20% of malignant ascites 10% of peritoneal carcinomatosis

20 Total protein >10 g/l Glucose <2.8 mmol/l LDH greater than serum ULN Low sensitivity + specificity however.

21 Consistent with infection or malignancy? Infection and cancer consume glucose low LDH is a larger molecule than glucose, enters ascitic fluid with difficulty. Ascitis/Serum LDH ratio ~ 0.4 in cirrhotic ascites Approaches 1.0 in SBP >1.0, usually infection or tumor

22 Amylase Uncomplicated cirrhotic ascites About 40 IU/L. The AF/S ratio is about 0.4 Pancreatic ascites About 2000 IU/L. The AF/S ratio is about 6 Triglycerides milky fluid. Chylous ascites - TG > 200 mg/dl, usually 1000 mg/dl Bilirubin brown ascites. Biliary perforation AF Bili > serum Bili

23 Smear extremely insensitive Culture 62-83% when large volumes cultured Cell count mononuclear cell predominance Adenosine deaminase Enzyme involved in lymphoid maturation Falsely low in pts with both cirrhosis and TB

24 almost 100% with peritoneal carcinomatosis have positive cytology Malignant ascites from massive hepatic mets, HCC, lymphoma are usually negative Overall sensitivity for detection of malignancy-related ascites is 58 to 75 %

25 ph, lactate, humoral tests of malignancy such as fibronectin, cholesterol.

26 No clinical data to back up the finding that upright position is asscociated with reduced GFR and reduced Na excretion and reduced diuretic efficacy Bed rest promote muscle atrophy and other complications and extends hospital stay So bed rest not recommended

27 Typical UK diet has 150mmol/day- 15% added salt and 70% is manufactured salt Suggestion is no added salt diet and avoidance of prepared food So that patient gets 90mmol/day ( 5.2gm) Lowers diuretic requirement, faster resolution of ascites and shorter hospital stay Avoid high salt content of fluid and medicine except in HRS

28 No role in uncomplicated ascites Most hepatologists restrict fluid in ascites associated with hyponatraemia- but is illogical The downside is water restriction causes increase in the central effective hypovolaemia- more ADH- more water retension and further dilutional hyponatraemia So hepatologist including the authors of the BSG guidelines suggest further plasma expansion to inhibit ADH secretion Data emerging supporting use of specific vasopressin 2 receptor antagonists To be effective the intake should be less than urine output rather than arbitrary 1.5L/day If the serum sodium concentration does not increase within the first 24 to 48 hours, the degree of fluid restriction has been insufficient.

29 Spironolactone is drug of choice Aldosterone antagonist acting in distal tubule to increase natriuresis and conserve potassium Initial dose 100mg and increasing up to 400mg Lag of 3-5days Better natriuresis and diuresis than a loop diuretic Antiandrogenic effect- gynaecomaziatamoxifen 20mg bd Hyperkalaemia frequently limits the use

30 Frusemide has low efficacy in cirrhosis Use only if 400mg of spironolactone fails to achieve weight loss Start at 40mg a day and increasing by 40mg every 3 rd day to max of 160mg Watch out for metabolic alkalosis and electrolyte disturbance

31 Weight loss Loose 0.5kg a day when no edema Loose 1kg a day when edema is present Avoid renal failure Response rate in up to 90% patients who do NOT have renal dysfunction Dig Dis 2005; 23:30-38 Hepatology 2003; 38:

32 Over diuresis is associated with intravascular volume depletion, leading to renal impairment, hepatic encephalopathy and hyponatraemia 10% will have refractory ascites Dietary history to exclude salt ingestion- 24hr urinary Na excretion should be less than recommended intake Drug history - NSAID

33 Na and normal creatinine Continue diuretic Do not water restrict Na and normal creatinine Continue/? discontinue Na and high Creatinine Na <120 Stop diuretic and give volume expansion Stop diuretic

34 Give only if renal function is worsening creatinine >150 or 120 and rising Gelofusion/Haemaccel/ 4.5% albumin all have 153mmol of Na per L This will worsen salt retention but better to have ascites than to develop HRS

35 Refractory ascites- cannot be mobilised or early recurrence of which ( that is after therapeutic paracentesis) cannot be prevented by medical treatment Diuretic resistant ascites- refractory to dietary salt restriction and intensive diuretic treatment ( spironolactone 400mg and frusemide 160mg per day and salt restricted diet of less than 90mmol/day ( 5.2g/day) Diuretic intolerant ascites- refractory to therapy due to the development of diuretic induced complications

36 Total paracentesis is associated with significant haemodynamic changes Large volume paracentesis causes marked reduction of IAP and IVC pressure- decrease in right heart pressure and This changes are maximal at 3hrs

37 International ascites club recommend if <5L is removed synthetic plasma expander can be used and as good as albumin ( some hepatologist suggests no albumin/plasma expander if <5L) Compared to albumin, artificial plasma expander cause more activation of Rennin Angiotensin System, causes more hyponatraemia and results in longer hospital stay 20% albumin should be infused after paracentesis of >5L at dose of 8g/L of ascites drained ( 100ml of 20% albumin= 20gm, so 3L of ascites fluid removal needs 3x8=24 gm of albumin replacement = 125ml but we tend to round it to 100ml) 5 percent albumin can be given if dehydration is suspected.

38 Use Z technique- puncture site on the skin does not overlie the puncture site on peritoneum Left flank is preferrable to right flank After drain is out patient lie on opposite site Colostomy bag if continuous leakage ( some use purse string suture) As rapidly as possible- should not be left overnight No upper limit of 8 litres or maximum time of 6 hours has been mentioned in the guidelines

39 Transjugular Intrahepatic Portosystemic Shunt Creates a conduit from the high pressure portal system to the lower pressure systemic circulation

40 Highly effective treatment Complete resolution in 75% of cases No effect on survival in one study and reduced on others- compared with therapeutic paracentesis HE occurs in 25% of patients, more if >60yrs May precipitate heart failure as increase cardiac preload TIPSS should be considered for patients who require frequent paracentesis ( >3 a month) It also shown to resolve hepatic hydrothorax in 60-70% MELD was originally developed to predict survival after TIPSS insertion

41 Mortality of 50% within 2yr of diagnosis Once refractory to medical therapy 50% die within 6 months Time for referral to transplant centre as paracentesis and TIPSS does not improve long term survival except improving quality of life

42 Spontaneous Bacterial Peritonitis

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47 Initiate for PMN 250/mm 3 Antibiotic follow trust guidelines Duration of therapy unclear 2 weeks suggested if Blood cultures(+) If repeat paracentesis at 48 hours shows PMN 250/mm 3, then 5-7 days of treatment may be adequate

48 40% develop HRS during the course of illness. Human Albumin 1.5gm/Kg o day one and 1 gm/kg on day three has shown improvement in both morbidity and mortality. Ultimate treatment: Liver transplant.

49 70 % recurrence in 1 yr

50 Prophylactic antibiotics should also be prescribed indefinitely until ascites has eliminated Options include: -Bactrim DS 1 tab po 5 days/week -Cipro 750mg po q week

51 1. Up to Date 2. Ascites and renal dysfunction in liver disease, Second edition. Edited by Pere Ginès, Vicente Arroyo, Juan Rodés, and Robert W. Schrier. Malden, Mass., Blackwell, The serum-ascites albumin gradient is superior to the exudatetransudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3): Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis, and management. Arch Intern Med. Vol 161. Dec 10/24, 2001.

52 Cause Testing Alcoholic liver disease History, AST / ALT > 2 Chronic hepatitis C Primary biliary cirrhosis Primary sclerosing cholangitis Autoimmune hepatitis Chronic hepatitis B Hemochromatosis Wilson s disease Alpha-1-antitrypsin deficiency Nonalcoholic fatty liver disease Hep C Ab, Viral load Antimitochondrial antibodies Contrast cholangiography, ANA, Anti smooth muscle Ab, ANCA Type 1: ANA, ANCA antismooth muscle Ab Type 2: anti-lkm-1 Hepatitis B serologies Ferritin, genetic testing Ceruloplasmin Serum AAT Hx of DM or metabolic syndrome

53 Occur when weight of ascites is sufficient to push the flanks outwards Difficult to distinguish from obesity Sensitivity-72-93% Pooled data 81% Specificity-44-70% Pooled data 59% JAMA 1992; 267:

54 Similar to bulging flanks, although uses percussion Typically bowel will float to the top and ascitic fluid sinks to the bottom Sensitivity-80-94% Most sensitive test Pooled data 84% Specificity-29-69% 69% outlying value Pooled data 59% JAMA 1992; 267:

55 Find the point where flank dullness occurs Mark it Roll the patient away from the examiner Repeat percussion and ensure that the point moves to the dependent side Sensitivity-60-83% Pooled data 77% Specificity-56-90% Pooled data 72% JAMA 1992; 267:

56 Medial edges of both hands down midline Tap flank firmly and feel for an impulse on the other side Sensitivity-50-80% Pooled data 62% Specificity-82-92% Most specific test Pooled data 90% JAMA 1992; 267:

57 Have patient prone 3-5 minutes then rise to crawling Place the diaphragm of the stethoscope over the most dependent area of the abdomen Flick a finger until sound detected No longer recommended Formerly used for high sensitivity Sensitivity-43-55% Pooled data 45% Specificity-51-83% Pooled data 73% JAMA 1992; 267:

58 Ultrasound is the most sensitive test for ascites (100mL detection) Have to use caution as small or even moderate ascites may be difficult to tap (even when marked) Ensure mark is appropriate Go with patient to U/S (ideal) If not possible, in order specify location where you want to place your needle Image from

59 Definition: abnormal accumulation of fluid in the peritoneal cavity as a consequence of cancer. Commonly caused by cancers of: Breast, bronchus, ovary, stomach, pancreas, colon 20% of cases have tumors of unknown primary Survival poor usually less than 3 months Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006)

60 Obstruction of lymphatics by tumor Prevents absorption of fluid and protein Alteration in vascular permeability Hormonal mechanisms (VEGF, IL2, TNF alpha) Decreased circulating blood volume Activates RAAS leading to Na retention Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006)

61 Contraindications Protein > 4.5 g/l (occlusion) Loculated ascites Coagulopathy Advanced renal/cardiac disease GI malignancy Denver Shunt (Similar to LaVeen Shunt) Complications Infection Hematogenous spread of mets DIC Pulmonary edema Pulmonary emboli

62 Therapeutic paracentesis Removing up to 5L appears safe No good data on role of volume expanders Diuretics Equivocal evidence of efficacy May be helpful for portal HTN Less/minimally useful when no portal HTN Drainage Catheters Peritoneovenous shunts