Ascites, Varices & Spontaneous Bacterial Peritonitis
Ascites β pathogenesis
Why fluid accumulates
Sinusoidal portal hypertension
β Hydrostatic pressure in hepatic sinusoids
Hypoalbuminaemia β β oncotic pressure
Leakage of fluid + hepatic lymph into the peritoneal cavity
+ splanchnic hypervolaemia / central hypovolaemia β RAAS β NaβΊ & HβO retention
Ascites
𧫠SAAG, grades & treatment
- SAAG (serum-ascites albumin gradient = serum β ascites albumin): β₯1.1 g/dL β portal hypertension (cirrhosis, alcoholic hepatitis, cardiac); <1.1 β non-portal causes (peritoneal TB/malignancy, nephrotic, pancreatic).
- Grades: I β detected only on USG (<500 mL, puddle sign +); II β moderate (500 mLβ2 L, shifting dullness +); III β tense (>2 L, fluid thrill +).
- Rx: β salt-restricted diet; β‘ diuretics β spironolactone : furosemide in a 100 : 40 mg ratio (up to 400 : 160 mg/day); β’ therapeutic paracentesis.
- Refractory ascites = no response despite maximal diuretics. For large-volume paracentesis (>5 L) give albumin ~8 g per litre removed to prevent post-paracentesis circulatory dysfunction.
Porto-systemic shunts & varices
| Site of shunt | Portal β systemic connection |
|---|---|
| Lower oesophagus (oesophageal varices) | Left gastric vein β azygos vein |
| Rectum (haemorrhoids) | Superior rectal β inferior rectal veins |
| Umbilicus (caput medusae) | Para-umbilical (ligamentum teres) β superficial epigastric veins |
| Bare area of liver | Hepatic β inferior phrenic veins |
| Retroperitoneal | Colonic β body-wall veins |
Management of acute variceal bleeding Emergency
β Resuscitate β restrictive transfusion (target Hb ~7β8 g/dL), protect the airway (high aspiration risk β RSI).
β‘ Control bleeding β pharmacological: terlipressin 2 mg IV 6-hourly β 1 mg 6-hourly until bleeding stops (or vasopressin 20 U in 100 mL D5 over 15 min then 0.1β0.4 U/min); or octreotide (somatostatin analogue β splanchnic vasoconstriction). Add antibiotic prophylaxis.
β’ Endoscopy (urgent): variceal band ligation or sclerotherapy (sodium tetradecyl sulphate).
β£ Balloon tamponade (rescue): SengstakenβBlakemore (3-lumen) / Minnesota (4-lumen).
β€ Salvage: TIPS (transjugular intrahepatic porto-systemic shunt, portal β hepatic vein) β but precipitates encephalopathy.
Prophylaxis: non-selective Ξ²-blockers (propranolol, nadolol) β block Ξ² in the gut β unopposed Ξ± β splanchnic vasoconstriction β β portal pressure.
β‘ Control bleeding β pharmacological: terlipressin 2 mg IV 6-hourly β 1 mg 6-hourly until bleeding stops (or vasopressin 20 U in 100 mL D5 over 15 min then 0.1β0.4 U/min); or octreotide (somatostatin analogue β splanchnic vasoconstriction). Add antibiotic prophylaxis.
β’ Endoscopy (urgent): variceal band ligation or sclerotherapy (sodium tetradecyl sulphate).
β£ Balloon tamponade (rescue): SengstakenβBlakemore (3-lumen) / Minnesota (4-lumen).
β€ Salvage: TIPS (transjugular intrahepatic porto-systemic shunt, portal β hepatic vein) β but precipitates encephalopathy.
Prophylaxis: non-selective Ξ²-blockers (propranolol, nadolol) β block Ξ² in the gut β unopposed Ξ± β splanchnic vasoconstriction β β portal pressure.
Spontaneous bacterial peritonitis (SBP)
Infection of ascitic fluid without an intra-abdominal source. Diagnose on ascitic PMN >250 cells/mmΒ³ (typically a single organism; ascitic protein often low). Rx: 3rd-generation cephalosporin + IV albumin (reduces HRS); secondary prophylaxis with a quinolone. A perioperative decompensation trigger β always exclude it in the acutely unwell cirrhotic.