🔍 Approach to Diagnosing Ascites: A Quick Guide

1️⃣ Start with SAG (Serum-Ascites Albumin Gradient):

• 1.1→ Portal hypertension (High SAAG).

• <1.1→ Non-portal causes (Low SAAG).

2️⃣ High SAAG (Portal HTN) Causes:

• Post-Hepatic: Constrictive pericarditis, CHF, Budd-Chiari, IVC obstruction.
• Intra-Hepatic: Cirrhosis (most common! 🥇), alcoholic hepatitis, schistosomiasis.
• Pre-Hepatic: Portal vein thrombosis.

3️⃣ Low SAAG (Non-Portal HTN) Causes:

• Cancer: Peritoneal carcinomatosis, mesothelioma.
• Infection: TB, fungal, secondary peritonitis.
• Autoimmune: SLE, Familial Mediterranean fever.
• Organ-Specific: Pancreatitis, nephrotic syndrome, Meigs’ syndrome.

💡 Key Takeaway: Always pair SAAG with ascitic fluid

Ref: www.mediconotes.com

Diuretic-resistant Ascites

• Ascites is truly diuretic-resistant in approximately 10 percent of patients with cirrhosis and ascites.

  patients with cirrhosis who have hypotension and/or refractory ascites and who do not respond to dietary modifications, education, discontinuation of beta blockers, and appropriately-prescribed diuretics be treated with oral [midodrine](file:///C:/Users/drzaw/Documents/Medical/References/U%20p%20t%20o%20d%20a%20t%20e%2021.6%20offline%20version/Uptodate%2021.6/contents/mobipreview.htm?2/35/2613?source=see_link) ( [Grade 2C](file:///C:/Users/drzaw/Documents/Medical/References/U%20p%20t%20o%20d%20a%20t%20e%2021.6%20offline%20version/Uptodate%2021.6/contents/._grade_6?title=Grade%202C) ). We start with 5 mg orally three times daily and adjust the dose every 24 hours (maximal dose 17.5 mg three times daily) to achieve an increase in systolic blood pressure of approximately 10 to 15 mmHg.

  We suggest that patients with diuretic-resistant ascites undergo serial paracentesis and follow a sodium-restricted diet (2 g per day) rather than undergo TIPS as initial therapy ( [Grade 2B](file:///C:/Users/drzaw/Documents/Medical/References/U%20p%20t%20o%20d%20a%20t%20e%2021.6%20offline%20version/Uptodate%2021.6/contents/._grade_5?title=Grade%202B) ). However, serial paracenteses should be viewed as a bridge to more definitive therapy (ie, liver transplantation or TIPS).

• Exceptions are patients who are not candidates for transplant or TIPS. With respect to the latter, spontaneous or otherwise problematic hepatic encephalopathy, alcoholic hepatitis, MELD score >18, advanced age, or parenchymal renal disease are all relative contraindications to TIPS.