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Ascites

Definition
  • Accumulation of free fluid within the peritoneal cavity.
Causes
  • Liver disease: Most commonly due to cirrhosis.
  • Heart failure: Right-sided or biventricular heart failure.
  • Malignancy: Peritoneal carcinomatosis, lymphomas.
  • Nephrotic syndrome: Due to significant proteinuria.
  • Tuberculosis: Peritoneal TB.
  • Other causes: Pancreatitis, hypothyroidism, ovarian disease (e.g., Meigs’ syndrome).
Clinical Features
  • Abdominal distension.
  • Flank dullness: On percussion.
  • Shifting dullness: Demonstrates the free fluid nature of ascites.
  • Fluid thrill: If large amounts of fluid are present.
  • Associated symptoms: Shortness of breath, ankle oedema, fatigue.
Investigations
  • Abdominal ultrasound: Confirms fluid and assesses volume.
  • Diagnostic paracentesis: To analyse ascitic fluid for:
    • Protein.
    • White cell count (WCC).
    • Saag (serum-ascites albumin gradient).
  • Liver function tests (LFTs): To evaluate liver status.
  • ECG and echocardiogram: If heart failure is suspected.
  • CT or MRI: If malignancy is suspected.
Management
  • Diuretics: Spironolactone with or without furosemide.
  • Sodium restriction: < 2g/day.
  • Therapeutic paracentesis: Large-volume paracentesis in tense ascites.
  • Management of underlying cause: E.g., treating liver disease, heart failure.
  • Transjugular intrahepatic portosystemic shunt (TIPS): In refractory cases.
Complications
  • Spontaneous bacterial peritonitis (SBP): Infection of the ascitic fluid without an obvious intra-abdominal source.
  • Hydrothorax.
  • Herniation due to increased intra-abdominal pressure.

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