ASCITES

Causes: lymphatic blockage, hypoproteinemia, hyperaldosteronemia

Evaluation-

• Serum-ascites albumin gradient ("SAAG"; absolute difference between albumin concentrations in ascitic fluid and serum albumin) can help distinguish portal hypertension from other causes of scites.
• SAAG < 1.1 g/dL traditionally felt to be suggestive of a cause for ascites other than portal hypertensions 
• However, in one retrospective study of 92 pts with cirrhosis undergoing paracentesis with a with SAAG < 1.1 g/dL, undergiong extensive evaluation, only 38% had a cause of ascites other than portal hypertension identified (Am. J. Gastroent. 104:1401, 2009-JW)

Treatment:

• Diuretics--If not responsive, can tx with either of the below:
• Repeated large-volume paracentesis (LVP)
• Transjugular intrahepatic portosystemic shunting ("TIPS")
  • Ass'd with longer survival c/w repeated large-volume paracentesis in a controlled study of 60 pts with refractory ascites (NEJM 342:1701, 2000--JW)
  • 109 pts with cirrhosis and refractory ascites randomized to TIPS vs. repeated paracenteses.  No diff. in medial survival or quality-of-life scores.  TIPS pts had nonsig. higher incidence of mod-to-severe encephalopathy (38% vs. 21%)
• In a meta-analysis of 4 randomized studies comparing TIPS vs. LVP, TIPS had sig. lower ascites recurrence rate (RR 0.14) but no sig. diff. in mortality, and sig. higher incidence of encephalopathy (RR 2.26) (Gastroent. 129:1282, 2005--JW)

See also "Spontaneous Bacterial Peritonitis"