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Bloody ascites is also associated with hepatocellular carcinoma or any malignancy-associated ascites. Pink or bloody fluid is most often caused by mild trauma, with subcutaneous blood contaminating the sample. Turbidity or cloudiness of the ascites fluid suggests that infection is present and further diagnostic testing should be performed. If the patient is deeply jaundiced, the fluid might appear brown. Uncomplicated cirrhotic ascites is usually translucent and yellow. Valuable clinical information can often be obtained by gross examination of the ascites fluid ( Table 2). An abdominal ultrasound can guide the procedure if the fluid is difficult to localize or if initial attempts to obtain fluid are unsuccessful. Insertion of the paracentesis needle is most commonly performed in the left or right lower quadrant, but it can also be performed safely in the midline. A low platelet count or elevated prothrombin time is not considered a contraindication, and prophylactic transfusion of platelets or plasma is almost never indicated. This is particularly true in the case of a significant gastrointestinal hemorrhage.Ĭomplications from abdominal paracentesis are rare, occurring in less than 1% of cases. It is common for hospitalized cirrhotic patients to have infected ascites fluid (spontaneous bacterial peritonitis, SBP) even if no symptoms are present. Cirrhotic patients should, however, undergo paracentesis in the case of unexplained fever, abdominal pain, or encephalopathy or if they are admitted to the hospital for any cause. Our opinion is that for a highly functional outpatient with documented cirrhosis, the new development of ascites does not routinely require paracentesis. In a patient with well-established cirrhosis, the exact role of a diagnostic paracentesis is less clear. If a noncirrhotic patient develops ascites, diagnostic paracentesis with ascites fluid analysis is an essential part of the medical evaluation. The validity of this grading system has yet to be established. More recently, a different grading system has been proposed, from grade 1 to grade 3. An older system has graded ascites from 1+ to 4+, depending on the detectability of fluid on physical examination. Two grading systems for ascites have been used in the literature ( Table 1). If the physical examination is not definitive, abdominal ultrasonography can be used to confirm the presence or absence of ascites. If ascites is present, typical findings include generalized abdominal distention, flank fullness, and shifting dullness. The accuracy of detecting ascites depends on the amount of fluid present and the body habitus of the patient: ascites may be more technically difficult to diagnose in obese patients. Physical examination findings are equally variable. If a large amount of fluid is present, the patient might complain of abdominal fullness, early satiety, abdominal pain, or shortness of breath. If trace ascites is present, the patient may be asymptomatic and fluid can be detected only on physical or radiologic examination. The symptoms of ascites vary from patient to patient and largely depend on the quantity of fluid. This explains why cirrhotic patients with ascites demonstrate urinary sodium retention, increased total body sodium, and dilutional hyponatremia, a challenging concept for many physicians.
#Excess abdominal fluid free
In the late stages of cirrhosis, free water accumulation is more pronounced than the sodium retention and leads to a dilutional hyponatremia. The ultimate effect is sodium and water retention. Mechanisms involved include the renin-angiotensin system, sympathetic nervous system, and antidiuretic hormone (vasopressin). Progressive vasodilation leads to the activation of vasoconstrictor and antinatriuretic mechanisms, both in an attempt to restore normal perfusion pressures. The precise agent(s) responsible for vasodilation is a subject of wide debate however, most the recent literature has focused on the likely role of nitric oxide. These vasodilators affect the splanchnic arteries and thereby decrease the effective arterial blood flow and arterial pressures. As portal hypertension develops, vasodilators are locally released. Development of portal hypertension is the first abnormality to occur. If observed for 10 years, approximately 60% of patients with cirrhosis develop ascites requiring therapy.Ĭirrhotic ascites forms as the result of a particular sequence of events. Common Causes of Ascites Extraperitoneal CausesĪscites is the most common major complication of cirrhosis and is an important landmark in the natural history of chronic liver disease.