medigraphic.com
Colegio de Medicina Interna de México.

2022, Number 6

<< Back Next >>

Med Int Mex 2022; 38 (6)

Ascites: Pathophysiology, diagnosis and treatment

Vidal-González D, Moreno-Madrigal LG, Pérez-López KP, Vera-Nungaray SA

Language: Spanish
References: 50
Page: 1223-1232
PDF size: 215.67 Kb.


ABSTRACT

Ascites is the accumulation of fluid in the peritoneal cavity, caused by a wide variety of entities, the most common is liver cirrhosis. In these patients, the development of ascites is the consequence of splanchnic vasodilation, a decrease in the effective circulating volume and activation of the sympathetic nervous system and the renin angiotensinaldosterone system, in addition to a systemic inflammatory process. The diagnostic approach includes, in addition to clinical data suggestive of ascites and its specific causes, imaging studies (abdominal ultrasound is the initial method of choice, and can be complemented with tomography or magnetic resonance imaging) and laboratory studies, such as the serum-ascitic albumin gradient (which allows the distinction between causes related to portal hypertension versus oncological, infectious and other inflammatory ones, nephrotic syndrome, etc.), stains, cultures and cytology, among others. Some molecular biomarkers are under investigation. Management is diverse and depends on the specific cause.


REFERENCES

  1. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history andprognostic indicators of survival in cirrhosis: a systematicreview of 118 studies. J Hepatol 2006; 44: 217-231. doi:10.1016/j.jhep.2005.10.013.

  2. European Association for the Study of the Liver. EASLclinical practice guidelines on the management of ascites,spontaneous bacterial peritonitis, and hepatorenal syndromein cirrhosis. J Hepatol 2010; 53 (3): 397-417. doi:10.1016/j.jhep.2010.05.004.

  3. Zipprich A, Garcia-Tsao G, Rogowsky S, Fleig WE, SeufferleinT, Dollinger MM, et al. Prognostic indicators ofsurvival in patients with compensated and decompensatedcirrhosis. Liver Int 2012; 32: 1407-14. doi: 10.1111/j.1478-3231.2012.02830.x.

  4. Iwakiri Y. The molecules: mechanisms of arterial vasodilatationobserved in the splanchnic and systemic circulationin portal hypertension. J Clin Gastroenterol 2007; 41 (Suppl3): S288-S294. doi: 10.1097/MCG.0b013e3181468b4c.

  5. Gatta A, Bolognesi M, Merkel C. Vasoactive factors andhemodynamic mechanisms in the pathophysiology ofportal hypertension in cirrhosis. Mol Aspects Med 2008;29: 119-129. doi: 10.1016/j.mam.2007.09.006.

  6. Fernandez M, Mejias M, Angermayr B, Garcia-Pagan JC,Rodés J, Bosch J. Inhibition of VEGF receptor-2 decreases thedevelopment of hyperdynamic splanchnic circulation andportal-systemic collateral vessels in portal hypertensive rats.J Hepatol 2005; 43: 98-103. doi: 10.1016/j.jhep.2005.02.022.

  7. Iwakiri Y, Shah V, Rockey DC. Vascular pathobiology in chronicliver disease and cirrhosis – current status and futuredirections. J Hepatol 2014; 61: 912‐924. doi: 10.1016/j.jhep.2014.05.047.

  8. Iwakiri Y, Groszmann RJ. The hyperdynamic circulationof chronic liver diseases: from the patient to the mo-lecule. Hepatology 2006; 43: S121-S131. doi: 10.1002/hep.20993.

  9. Møller S, Hobolth L, Winkler C, Bendtsen F, Christensen E.Determinants of the hyperdynamic circulation and centralhypovolaemia in cirrhosis. Gut 2011; 60: 1254‐1259. doi:

  10. 10.1136/gut.2010.235473.10. Møller S, Iversen JS, Henriksen JH, Bendtsen F. Reducedbaroreflex sensitivity in alcoholic cirrhosis: relationsto hemodynamics and humoral systems. Am J PhysiolHeart Circ Physiol 2007; 292: H2966‐H2972. doi:10.1152/ajpheart.01227.2006.

  11. Stadlbauer V, Wright GA, Banaji M, Mukhopadhya A,Mookerjee R, Moore K, et al. Relationship betweenactivation of the sympathetic nervous system and renalblood flow autoregulation in cirrhosis. Gastroenterology2008; 134 (1): 111-119. doi: 10.1053/j.gastro.2007.10.055.

  12. Møller S, Bendtsen F, Henriksen JH. Determinants of the renin-angiotensin aldosterone system in cirrhosis with specialemphasis on the central blood volume. Scand J Gastroenterol2006; 41: 451‐458. doi: 10.1080/00365520500292962.

  13. Bernardi M, Moreau R, Angeli P, Schnabl B, Arroyo V. Mechanismsof decompensation and organ failure in cirrhosis:From peripheral arterial vasodilation to systemic inflammationhypothesis. J Hepatol 2015; 63 (5): 1272-1284. doi:10.1016/j.jhep.2015.07.004.

  14. Sztrymf B, Rabiller A, Nunes H, Savale L, Lebrec D, Le PapeA, et al. Prevention of hepatopulmonary syndrome and hyperdynamicstate by pentoxifylline in cirrhotic rats. Eur RespirJ 2004; 23: 752-8. doi: 10.1183/09031936.04.00080404.

  15. Runyon BA, AASLD Practice Guidelines Committee. Managementof adult patients with ascites due to cirrhosis: Anupdate. Hepatology 2009; 49 (6): 2087-2107. doi: 10.1002/hep.22853.

  16. Bhardwaj R, Vaziri H, Gautam A, Ballesteros E, KarimeddiniD, Wu GY. Chylous ascites: A review of pathogenesis,diagnosis and treatment. J Clin Transl Hepatol 2018; 6 (1):105-113. doi: 10.14218/JCTH.2017.00035.

  17. Gordon FD. Ascites. Clin Liver Dis 2012; 16 (2): 285-299.doi: 10.1016/j.cld.2012.03.004.

  18. Akriviadis EA, Runyon BA. Utility of an algorithm indifferentiating spontaneous from secondary bacterialperitonitis. Gastroenterology 1990; 98 (1): 127-133. doi:10.1016/0016-5085(90)91300-u.

  19. Krowka MJ. Pulmonary manifestations of chronic liverdisease. Clin Pulmonary Med 2000; 7 (1): 24-29.

  20. Piano S, Tonon M, Angeli P. Management of ascites andhepatorenal syndrome. Hepatol Int 2018; 12 (suppl 1):122-134. doi: 10.1007/s12072-017-9815-0.

  21. Rajwani K, Fortune BE, Brown RS. Critical care managementof gastrointestinal bleeding and ascites in liver failure.Semin Respir Crit Care Med 2018; 39 (5): 566-577. doi:10.1055/s-0038-1672200.

  22. Runyon BA. Introduction to the revised American Associationfor the Study of Liver Diseases Practice Guidelinemanagement of adult patients with ascites due to cirrhosis2012. Hepatology 2013; 57 (4): 1651-1653. doi: 10.1002/hep.26359.

  23. Miyashita H, Okamoto K, Kobayashi T, Wakabayashi Y,Kitaura S, Ikeuchi K. Bacterial peritonitis in a patient withmalignant ascites caused by pancreatic carcinoma: Casereport and review of literature. J Infect Chemother 2019;25 (6): 473-476. doi: 10.1016/j.jiac.2019.01.007.

  24. Brink JA, Wagner BJ. Pathways for the spread of diseasein the abdomen and pelvis. En: Hodler J, Kubik-Huch RA,Von Schulthess GK. Diseases of the Abdomen and Pelvis2018-2021: Diagnostic Imaging - IDKD Book. 1st ed. Suiza:Springer International Publishing; 2018: 57-65.

  25. Krugmann J, Schwarz CL, Melcher B, Sterlacci W, Vieth M,Rösch S, Lermann J. Diagnostic impact of ascites cytology in941 patients: malignancy rates and time of detection in ovariancancer relative to other tumor types. Arch Gynecol Obstet2020. DOI: https://doi.org/10.1007/s00404-020-05553-y.

  26. Ackerman Z. Ascites in nephrotic syndrome: Incidence,patients’ characteristics, and complications. J Clin Gastroenterol1996; 22 (1): 31-34. doi: 10.1097/00004836-199601000-00009.

  27. Allah MH, Salama ZA, El-Hindawy A, Al Kady N. Role ofperitoneal ultrasonography and ultrasound-guided fineneedle aspiration cytology/biopsy of extravisceral massesin the diagnosis of ascites of undetermined origin. ArabJ Gastroenterol 2012; 13 (3): 116-124. doi: 10.1016/j.ajg.2012.08.004.

  28. Conangla-Planes M, Serres X, Persiva O, Augustín S. Imagingdiagnosis of portal hypertension. Radiologia 2018; 60 (4):

  29. 290-300. doi: 10.1016/j.rx.2017.12.010.29. Salman MA, Salman AA, Hamdy A, Abdel SRM, Ewid M,Abouregal TE, et al. Predictive value of omental thicknesson ultrasonography for diagnosis of unexplained ascites,an Egyptian centre study. Asian J Surg 2020; 43 (1): 13-19.doi: 10.1016/j.asjsur.2019.03.004.

  30. Bosques-Padilla FJ, Torre-Delgadillo A, De Ariño-Suárez M,Castañeda-Román J, Dehesa-Violante M, Trejo-Estrada R.Guías clínicas de diagnóstico y tratamiento de la ascitis.Fisiopatología y diagnóstico de la ascitis. Rev GastroenterolMex 2009; 74 (4): 387-391.

  31. Oey RC, Van Buren HR, De Man RA. The diagnostic workupin patients with ascites: current guidenlines and futureprospects. Neth J Med 2016; 74 (8): 330-335.

  32. European Association of the Study of the Liver. EASL clinicalpractice guidelines for the management of patients withdecompensated cirrhosis. J Hepatol 2018; 69: 406-460.https://doi.org/10.1016/j.jhep.2018.03.024.

  33. Garbuzenko DV, Arefyev NO. Current approaches to themanagement of patients with cirrotic ascites. World JGastroenterol 2019; 25 (28): 3738-3752. doi: 10.3748/wjg.v25.i28.3738.

  34. Khan FY, Ahmed MS, Lutf AQ, Alsamawi M. Clinical patternof ascites due to malignancy in Qatar. J Clin Diagn Res2008; 2: 617-621.

  35. Sangisetty SL, Miner TJ. Malignant ascites: A review ofprognostic factors, pathophysiology and therapeuticmeasures. World J Gastrointest Surg 2012; 4 (4): 87-95.doi: 10.4240/wjgs.v4.i4.87.

  36. Suceveanu AJ, Todescu D, Mazilu L, Manousos FG, Hulea R,Voinea F, et al. Modern tools for diagnosis in tuberculousascites. En: Rodrigo L. Ascites - Physiopatology, Treatment,Complications and Prognosis. 1st ed. Londres, Reino Unido:InTech; 2017: 33-46.

  37. Serman F, Saavedra M, Feldman R, Concha C, Vitar C, BustosA, et al. Tuberculosis peritoneal con presentación clínicacomo cáncer ovárico avanzado: revisión de la literatura. RevChil Obstet Ginecol 2016; 81 (5): 411-420. http://dx.doi.org/10.4067/S0717-75262016000500011.

  38. Del Valle-Ruiz SR, López-Espejo JB, Martín-Pérez JL, Miluy-Guerrero M, Sánchez-De la Villa G. Tuberculosis peritonealcomo causa de ascitis de origen no filiado. Cirugía Española2010; 87 (5): 323-324. DOI: 10.1016/j.ciresp.2009.02.008.

  39. Somasekar RDR, Prabhakaran R, Amudhan A, GnanasekarM, Sivakumar K, Raman Senthilkumaran G, et al.Primary early surgical management of pancreatic ascitescompicating chronic pancreatitis-a single centre experience.J Clin Diagn Res 2018; 12 (2): 1-7. DOI:10.7860/JCDR/2018/29907.11176.

  40. Schindler P, Kupcinskas J, Juzenas S, Skieceviciene J, SaltenieneV, Schulz C, et al. Expression of MicroRNAs in theascites of patients with peritoneal carcinomatosis andperitonitis. Cancer Cytopathol 2018; 126: 353-363. doi:10.1002/cncy.21966.

  41. Jiménez-Alesanco A, Marcuello M, Pastor-Jiménez M,López-Puerto L, Bonjoch L, Gironella M, et al. Acutepancreatitis promotes the generation of two differentexosome populations. Sci Rep 2019; 9: (1): 18997. https://doi.org/10.1038/s41598-019-56220-5.

  42. Tasneem H, Shahbaz H, Sherazi BA. Causes, managementand complications of ascites: a review. Int Current PharmaceutJ 2015; 4 (3): 370-377.

  43. Ge PS, Runyon BA. Treatment of patients with cirrhosis.N Engl J Med 2016; 373: 767-777. DOI: 10.1056/NEJMra1504367.

  44. Lenz K, Buder R, Kapun L, Voglmayr M. Treatment andmanagement of ascites and hepatorenal syndrome: anupdate. Ther Adv Gastroenterol 2015; 8 (2): 83-100. doi:10.1177/1756283X14564673.

  45. El Sayed MI, Ahmad H. Up to date treatment of ascites inliver cirrhosis. Sohag Medical J 2019; 23 (2): 94-100.

  46. Kasztelan-Szczerbinska B, Cichoz-Lach H. Refractory ascitesthecontemporary view on pathogenesis and therapy. PeerJ2019; 7: 1-22. doi: 10.7717/peerj.7855.

  47. Hodge C, Badgwell BD. Palliation of malignant ascites. JSurg Oncol 2019; 120 (1): 67-73. doi: 10.1002/jso.25453.

  48. Kietpeerakool C, Rattanakanokchai S, Jampathong N,Srisomboon J, Lumbiganon P. Management of drainagefor malignant ascites in gynaecological cancer. CochraneDatabase Syst Rev 2019; 12: 1-34. doi: 10.1002/14651858.CD007794.pub3.

  49. Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A.Review article: the diagnosis approach and current managementof chylous ascites. Aliment Pharmacol Ther 2017;46: 816-824. doi: 10.1111/apt.14284.

  50. Vaid U, Kane GC. Tuberculous peritonitis. Microbiol Spectr2017; 5 (1): 1-6. doi: 10.1128/microbiolspec.TNMI7-0006-2016.




2020     |     www.medigraphic.com