Rosen & Barkin's 5-Minute Emergency Medicine Consult (79 page)

• 1 of the 5 “F” causes of abdominal swelling:
  
  • Fluid (including cysts)
    
  • Fat
    
  • Flatus
    
  • Fetus
    
  • Feces
    
  • Other: Organomegaly
    
• Serum-ascites albumin gradient (SAAG) = serum albumin – ascitic albumin:
  
  • Replaced ascitic fluid total protein in the differential diagnosis of ascites
    
  • SAAG ≥1.1 g/dL:
    
    • 97% accurate in predicting portal hypertension
      
    • Cirrhosis
      
    • Alcoholic hepatitis
      
    • Cardiac
      
    • Liver metastases
      
    • Fulminant hepatic failure
      
    • Portal vein thrombosis
      
    • Veno-occlusive disease
      
    • Myxedema
      
    • Budd—Chiari
      
    • Fatty liver of pregnancy
      
    • SBP
      
  • SAAG <1.1 g/dL:
    
    • Peritoneal carcinomatosis
      
    • TB
      
    • Pancreatic ascites
      
    • Nephrotic syndrome
      
    • Bowel obstruction or infarction
      
    • Vasculitis
      
    • Postoperative lymphatic leak
      

TREATMENT

Symptomatic hypotension:

• Airway, breathing, circulation (ABCs), IV 0.9 NS
  

Sudden increase in abdominal girth, pain, or fever requires urgent evaluation for possible complicating factor such as:

• Infection
  
• Hepatoma
  
• Obstruction of hepatic outflow
  
• Decompensated liver function
  

• Successful treatment depends on accurate diagnosis of underlying cause.
  
• Treat underlying cause.
  
• Minimize ascitic fluid and peripheral edema without causing intravascular volume depletion.
  
• Early detection of complications is necessary:
  
  • SBP:
    
    • High degree of suspicion
      
    • Low threshold for paracentesis
      
    • Prompt therapy
      
  • Tense ascites and hydrothorax:
    
    • Supplemental oxygen
      
    • Therapeutic paracentesis or thoracentesis for respiratory distress
      
  • Abdominal hernias:
    
    • Watch for incarceration, ulceration, or rupture.
      
    • Therapeutic paracentesis
      
    • Surgical consultation
      
  • Persistent leak at paracentesis site:
    
    • Remove more fluid.
      
    • Stomal barrier device
      
  • Meralgia paresthetica:
    
    • Owing to pressure on the lateral femoral cutaneous nerve
      
    • Relieve the pressure by paracentesis or diuresis.
      
• Large-volume paracentesis:
  
  • 5–10 L (100 mL/kg)
    
  • Performed safely in the ED with stable hemodynamics
    
  • Consider replacement with IV albumin (5–10 g/L fluid removed) if >5 L removed.
    
  • Monitor the patient for 8 hr prior to discharge.
    
• Nonparacentesis reduction of ascites:
  
  • Strict sodium restriction:
    
    • <2 g/day
      
    • Restrict water if serum sodium <120–125 mEq/L
      
  • Spironolactone:
    
    • Works best for cirrhotic ascites
      
    • Alternatives: Amiloride or triamterene
      
  • Furosemide:
    
    • Works best for other causes of ascites
      
    • Add to spironolactone in cirrhotics at spironolactone/furosemide ratio of 100 mg/40 mg.
      
    • Add metolazone for less responsive cases.
      
  • Diuretic principles:
    
    • Administer diuretics as single morning dose.
      
    • Obtain spot-urine sodium to evaluate response.
      
    • Patients with urinary Na >10 mEq/L are more responsive to diuretics.
      
    • Diuretic-induced weight loss should not exceed 2 lb/day in patients without edema and 5 lb/day in patients with edema.
      
    • Monitor electrolytes and renal function.
      
    • Avoid hypokalemia since hypokalemia enhances renal ammonia production, precipitating hepatic encephalopathy.
      
  • Refractory ascites:
    
    • Accounts for 10% of patients
      
    • Ensure compliance with diet and medications.
      
    • Treated with peritoneovenous shunt—transjugular intrahepatic portosystemic shunt
      
    • Liver transplantation
      
  • Avoid NSAIDs:
    
    • Diminish response to diuretics
      
    • Decrease renal plasma flow and GFR.
      
    • Cause sodium retention/reduces urinary Na excretion
      
  • Treat underlying cause of ascites owing to conditions other than cirrhosis:
    
    • TB, CHF
      

• Albumin: 5–10 g/L of fluid removed if >5 L removed
  
• Cefotaxime: 2 g IV q8h
  
• Spironolactone: 100–400 mg/d (peds: 1–6 mg/kg) PO in 2 divided doses per day
  
• Furosemide: 40–160 mg/d (peds: 1–3 mg/kg) PO
  

• Amiloride: 5–20 mg/d PO
  
• Metolazone: 5 mg/d
  
• Triamterene: 100–300 mg/d PO in 2 divided doses per day
  

FOLLOW-UP

• Fulminant liver failure
  
• Hepatic encephalopathy
  
• SBP
  
• Hepatorenal syndrome
  
• GI bleeding
  
• Tense ascites not responding to ED treatment
  

Patients responding to ED management

• GI for all new cases
  
• Primary doctor or GI for previously established cases
  

• New cases need full workup and GI consultation for management.
  
• SBP symptoms are frequently vague.
  
• Must have a high suspicion and low threshold for paracentesis when considering SBP
  
• Benefits of confirming SBP outweigh risks of bleeding in a coagulopathic patient undergoing paracentesis.
  
• US guidance is helpful when performing paracentesis in lower-volume ascites.
  

• Feldman M.
  Sleisenger and Fordtran’s Gastrointestinal and Liver Disease
  . 9th ed. Philadelphia, PA: WB Saunders; 2010.
  
• Runyon BA; AASLD Practice Guidelines Committee. Management of Adult Patients with Ascites Due to Cirrhosis: An update.
  Hepatology
  . 2009; 49:2087–2107.
  
• Runyon B, Such J.
  Initial Therapy of Ascites in Patients with Cirrhosis
  .
  UpToDate
  , 2012.
  
• Corey K, Friedman L.
  Harrison’s Principles of Internal Medicine.
  18th ed. New York, NY: McGraw-Hill; 2012.
  

See Also (Topic, Algorithm, Electronic Media Element)

Cirrhosis

CODES

• 789.5 Ascites
  
• 789.51 Malignant ascites
  
• 789.59 Other ascites
  

BASICS

• Increased expiratory resistance:
  
  • Airway inflammation
    
  • Bronchospasm
    
  • Mucosal edema
    
  • Mucous plugging
    
  • Smooth muscle hypertrophy
    
• Consequences:
  
  • Air trapping
    
  • Airway remodeling
    
  • Increased dead space
    
  • Hyperinflation
    
• Status asthmaticus refers to disease that does not respond to therapy within 30–60 min
  
• Risk factors for life-threatening disease:
  
  • Prior intubations
    
  • Intensive care unit admissions
    
  • Chronic steroid use
    
  • Hospital admission for asthma during the past year
    
  • Inadequate medical management
    
  • Increasing age
    
  • Ethnicity (African Americans)
    
  • Lack of access to medical care
    
  • Multiple comorbidities