Ascites

• Bile ascites (bile peritonitis): Spontaneous rupture of the common bile duct
• Renal
  –Nephrotic syndrome
  –Urinary ascites (due to bladder rupture)
  –Obstructive uropathy: Congenital ascites may be seen with bilateral hydronephrosis
• Peritoneal dialysis
• Cardiac
  –Congestive heart failure
  –Chronic constrictive pericarditis
  –Inferior vena cava web
  –Erythroblastosis fetalis
• Peritonitis
  –Tuberculous peritonitis
  –Schistosomiasis (Mansoni)
  –Tularemia
  –Abscess
• Gastrointestinal disorders
  –Infarcted bowel
  –Bowel perforation
  –Pancreatitis, ruptured pancreatic duct
  –Protein-losing gastroenteropathy
• Chylous ascites
  –Collection of lymph within the abdominal cavity; secondary to lymphatic obstruction from trauma, surgery, tumor, tuberculosis, or filariasis
• Gynecologic
  –Ovarian tumors, cyst torsion or rupture
• Malignancy
  –Leukemia, lymphoma, neuroblastoma
• Systemic lupus erythromatosus
• Ventriculoperitoneal shunt
• Hypothyroidism

Workup and Diagnosis

• History and physical exam
  –Clinical hallmark of ascites is abdominal distension
  –Five classic signs of ascites: Flank bulging, flank dullness, shifting dullness, fluid wave, puddle sign
  –Only appreciated when there is considerable fluid
  –Respiratory distress may develop with tense ascites
  –Umbilical herniation can be seen with large ascites
  –Peripheral edema or anasarca may accompany severe hypoalbuminemia

• Urinalysis and urine electrolytes (for proteinuria)
• CBC with diff (lymphopenia in lymphatic obstruction)
  
• Serum electrolytes (for sodium management)
• True liver function tests
  –Examines the synthetic function of the liver
  –Serum albumin, vitamin K, and coagulation factors
• Abdominal ultrasound detects small volume of ascites
  
• KUB may show centrally floating intestines

• Paracentesis: Milky fluid indicates chylous ascites, fluid analysis will reveal elevated protein and triglycerides and lymphocytosis (fluid serous in a fasting patient)
  –Bile may indicate perforation of common bile duct
  –High creatinine: Seen with bladder rupture
  –Ascitic fluid analysis for cell count, cytology, protein, LDH, amylase, lipase, creatinine, pH, culture, Gram stain, bile, lipids, and sudan red staining for fat

Treatment

• Treatment is directed at underlying cause
• Bed rest, fluid, sodium restriction is the first line
• Diuretics: Careful use in selected cases
• Chylous ascites
  –High-protein, low-fat diet supplemented with medium-chain triglycerides
  –Parenteral nutrition may be needed to decrease lymph flow and supplement nutrition
  –Laparotomy may be indicated for failed dietary management, to seal leak site
• Surgical intervention: Bile or urine ascites
• Therapeutic paracentesis: May be repeated to relieve respiratory distress or impending umbilical rupture
• Portacaval shunt or a peritoneovenous shunt (LeVeen) for intractable ascites
  –Shunt between peritoneal cavity and superior vena cava
• Transjugular intrahepatic portosystemic shunt (TIPSS) for cirrhosis while awaiting transplantation

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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