Thursday, January 25, 2018

Moderate Ascites : An approach to management

Hi everyone ! This is just a general proforma on how to manage Moderate ascites occuring due to Liver Cirrhosis.
Hope you find this helpful.

Moderate Ascites

Ix :

- Complete hemogram
- LFT : complete ; look for Liver dysfunction. Important parameters for Alcoholic liver disease : AST / ALT ratio > 2 and GGT levels raised.
- Creatinine BUN : for Pre renal AKI / Hepatorenal Syndrome
- Electrolytes : Sodium , Potassium , Calcium.
- Urine Routine and Microscopy

Ascitic fluid analysis -
∆ Biochem : SAAG ( Serum Ascites Albumin Gradient) , Ascitic fluid Proteins , ADA.
∆ Path :  Cell count. ( > 250 per micro litte suggests Spontaneous Bacterial Peritonitis).
∆ Micro : Microscopy and Culture.

USG
AFP (Alpha feto protein) for HCC screen.

Rx
- Bed rest and admit the patient
- Salt reduced to < 2g/day
- Fluid restricted - less than 1 L per day
- Spironolactone 100 mg per day +/- Frusemide 40 mg. ( Gen Frusemide added on day 4)
- Monitor output , input , girth , weight
- Ideal Weight loss - 0.5 - 1 kg/day
- If not - amp up doses of diuretics by day 3/4
- Max doses = Spironolactone 400 mg
Lasix = 160 mg
- Therapeutic Paracentesis indicated if - Tense Ascites , Child B Cirrhosis , creatinine < 3.
5-10 L in an hour can be removed  + IV albumin 6-8 gm/L

If failure to respond to Max dose of diuretics - that is 400 mg Spironolactone and 160 mg Frusemide , it is termed as Refractory Ascites and needs further evaluation and Paracentesis.

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Basis for using Spironolactone as preferred drug in Cirrhotic Ascites : Ascites occurs in these patients  Largely due to lack of degradation of Steroids by liver, and activation of Renin Angiotensin Aldosterone system.

Basis for SAAG ratio :
Difference between Serum and Ascitic fluid Albumin.
i.e. SAAG = Serum protein - Ascitic fluid protein
If the difference is more than 1.1 it indicates the Ascitic fluid was not very proteinaceous and in fact had low protein compared to serum , i.e. , it's a Transudative Ascites. Most important of which is Liver Cirrhosis (Where the Serum proteins are low themselves as well, so is the total Ascitic fluid protein.)

If the difference is less than 1.1 it indicates the Ascitic fluid was highly protein rich and it's an Exudative Ascites.

Let me know if you'd like anything clarified.
Hope this helps !
Happy Studying!
Stay awesome :)

~ A.P. Burkholderia

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