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Ascites

Medicine > Gastrointestinal

Differential Diagnosis Schema 🧠

Liver-related Causes

  • Cirrhosis: Commonest cause of ascites; look for stigmata of chronic liver disease.
  • Acute liver failure: Rapid onset; often associated with jaundice and coagulopathy.
  • Hepatic vein obstruction (Budd-Chiari syndrome): Presents with abdominal pain, hepatomegaly, and ascites.
  • Portal vein thrombosis: May present with ascites without cirrhosis.

Malignancy-related Causes

  • Peritoneal carcinomatosis: Often secondary to GI or ovarian cancer; presents with weight loss and early satiety.
  • Hepatocellular carcinoma: May develop on the background of cirrhosis.
  • Pancreatic cancer: May cause ascites by direct invasion or secondary to portal hypertension.

Cardiac Causes

  • Right heart failure: Ascites in the context of peripheral oedema and elevated JVP.
  • Constrictive pericarditis: Presents with ascites, hepatomegaly, and elevated JVP.
  • Tricuspid regurgitation: Can cause ascites due to chronic venous congestion.

Renal Causes

  • Nephrotic syndrome: Massive proteinuria leading to hypoalbuminemia and ascites.
  • Chronic kidney disease: Ascites may occur in advanced stages.

Infective Causes

  • Tuberculous peritonitis: Ascites with a high lymphocyte count; associated with fever and weight loss.
  • Spontaneous bacterial peritonitis: Occurs in patients with cirrhotic ascites; presents with fever and abdominal pain.

Key Points in History 🥼

Presenting Symptoms

  • Abdominal distension: Gradual onset suggests chronic conditions like cirrhosis, while rapid onset may indicate acute causes such as Budd-Chiari syndrome.
  • Abdominal pain: Consider peritonitis, Budd-Chiari syndrome, or malignancy.
  • Weight gain: Suggests fluid retention; common in cirrhosis and nephrotic syndrome.
  • Breathlessness: May indicate large ascites or concurrent pleural effusion.

Background

  • Past medical history: Ask about liver disease, heart failure, renal disease, malignancy, and infections.
  • Drug history: Check for use of NSAIDs, ACE inhibitors, or alcohol, which may exacerbate or contribute to ascites.
  • Family history: Consider hereditary causes like haemochromatosis or alpha-1 antitrypsin deficiency.
  • Social history: Assess alcohol intake, IV drug use, and occupational exposure to hepatotoxins.

Possible Investigations 🌡️

Initial Investigations

  • Full blood count: To assess for infection, anaemia, or thrombocytopenia.
  • Urea and electrolytes: To evaluate renal function and electrolyte imbalances.
  • Liver function tests: Key in diagnosing liver-related causes of ascites.
  • Clotting screen: Essential in assessing liver synthetic function.

Imaging

  • Ultrasound abdomen: First-line imaging to confirm ascites, assess liver architecture, and identify any masses.
  • CT abdomen: Useful for detailed assessment if malignancy or pancreatic disease is suspected.
  • Echocardiography: To evaluate for cardiac causes such as right heart failure or pericardial disease.

Special Tests

  • Diagnostic paracentesis: Analysis of ascitic fluid (including cell count, culture, albumin, and cytology) to identify the underlying cause.
  • Serum-ascites albumin gradient (SAAG): Differentiates between portal hypertension-related ascites (high SAAG) and non-portal hypertension causes (low SAAG).
  • Ascitic fluid cytology: Especially important if malignancy is suspected.

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Gastrointestinal