LAPORAN PAGI

ASCITES

Disusun Oleh:
Benny Yohanis Gae
12/329227/KU/14996
Kelompok 16304
IDENTITAS

 Nama : Ny T
 Usia : 58 thn
 Alamat : Sukuharjo, Kab. Sleman
 Agama : Islam
 Ruang : IGD
 Tgl masuk : 1 Mei 2018
 Fotopolos abdomen dengan
keterangan klinis Limfoma
Malignant curiga pembesaran
limfonodi para aorta

PEMERIKSAAN
PENUNJANG
  Tampak gambaran ground glass oppacity
FOTO POLOS ABDOMEN di proyeksi cavum abdomen, floating sign
(+)
3 POSISI, KONDISI CUKUP :
 Tampak pre-peritoneal fat line dan psoas
line bilateral tegas
 Tampak renal outline bilateral samar
 Tampak distribusi udara usus normal,
fecal material prominent
 Tak tampak distensi sisterna usus halus
maupun colon, tampak udara di proyeksi
cavum pelvis
 Tak tampak penebalan dinding usus
maupun pneumatisasi intestinal
 Tak tampak gambaran coil spring, air fluid
level, step ladder appearence, maupun
string of pearl sign
 Tak tampak gambaran udara bebas di
proyeksi subdiafragma bilateral pada
posisi semierect, dan tak tampak
gambaran udara bebas di tempat tertinggi
pada proyeksi supine maupun LLD,
football sign (-), riglers sign (-)
 Tampak sisterna tulang yg tervisualisasi
normal
 Tampak gambaran ground glass
oppacity di proyeksi cavum abdomen,
floating sign (+)
 Tampak pre-peritoneal fat line dan
psoas line bilateral tegas
 Tampak renal outline bilateral samar
 Tampak distribusi udara usus normal,
fecal material prominent
 Tak tampak distensi sisterna usus halus
maupun colon, tampak udara di
proyeksi cavum pelvis
 Tak tampak penebalan dinding usus
maupun pneumatisasi intestinal
 Tak tampak gambaran coil spring, air
fluid level, step ladder appearence,
maupun string of pearl sign
 Tak tampak gambaran udara bebas di
proyeksi subdiafragma bilateral pada
posisi semierect, dan tak tampak
gambaran udara bebas di tempat
tertinggi pada proyeksi supine maupun
LLD, football sign (-), riglers sign (-)
 Tampak sisterna tulang yg tervisualisasi
normal
 Tampak gambaran ground glass
oppacity di proyeksi cavum abdomen,
floating sign (+)
 Tampak pre-peritoneal fat line dan psoas
line bilateral tegas
 Tampak renal outline bilateral samar
 Tampak distribusi udara usus normal,
fecal material prominent
 Tak tampak distensi sisterna usus halus
maupun colon, tampak udara di
proyeksi cavum pelvis
 Tak tampak penebalan dinding usus
maupun pneumatisasi intestinal
 Tak tampak gambaran coil spring, air
fluid level, step ladder appearence,
maupun string of pearl sign
 Tak tampak gambaran udara bebas di
proyeksi subdiafragma bilateral pada
posisi semierect, dan tak tampak
gambaran udara bebas di tempat
tertinggi pada proyeksi supine maupun
LLD, football sign (-), riglers sign (-)
 Tampak sisterna tulang yg tervisualisasi
normal
ASCITES

 Derived from the Greek word “askos”, meaning bag or sac

 Defined as the accumulation of fluid in the peritoneal cavity
 It is a common clinical finding, with many extra-peritoneal and
peritoneal causes, but most common from liver cirrhosis
  It is a potential space between the parietal peritoneum
and visceral peritoneum, the two membranes separate the
organs in the abdominal cavity from the abdominal wall.
 Derived from the coelomic cavity of the embryo.
 Largest serosal sac in the body and secretes
approximately 50 ml of fluid per day
 The fluid is mostly water with electrolytes, antibodies,
white blood cells, albumin, glucose and other
biochemicals.
 Reduce the frictionbetween the abdominal organs as they
move around during digestion.

PERITONEAL CAVITY AND FLUID

 Abdominal distention (which may be painful)
 Nausea
 Vomitting
 Dyspnea
 Peripheral edema

CLINICAL PRESENTATION
ASCITES CLASSIFICATION (BASED ON ETIOLOGY)
Portal Hypertension
 Pre-Sinusoid
 Thrombosis vena porta or
splenchnic
 schistosomiasis
 Sinusoid
 Cirrhosis** (81%)
 Liver Disease (ie. Alcoholic
hepatitis, acute liver failure)
 Malignancy (HCC or metastasis)
 Pasca Sinusoid
 Hepatic Veno-occlusive Disease
(e.g. Budd Chiari)
 CHF** (3%)
 Constrictive Pericarditis
Peritoneal Disease
 Malignant Ascites** (10%)
 Infectious Peritonitis (e.g:
TB, fungal)
 Peritoneal Dialysis
Hypoalbuminemia
 Nephrotic Syndrome
 Protein-Losing Enteropathy
 Severe malnutrition
Pancreatitis
Obstruction or infarction of Gut
Leakage post Operation
ASCITES CLASSIFICATION

Exudative
Transudative
 Peritoneal
 Sirosis hepatis carcinomatosis
 Alcoholic hepatitis  Pancreatitis
 Heart failure  Abscess
 Hipoproteinemia  Nephrotic Syndrome
 Trombosis v. porta  Peritonitis (e.g. TB)
 Peritoneal dialysis  Ischaemic bowel
 malignancy  Bowel obstruction
GRADING OF ASCITES

Grade I • Only detectable by USG

• Moderate symmetrical distension

Grade II
of the abdomen

Grade III • Marked abdominal distension

 Imaging Serology
Ultrasound CBC with diff

CT Comprehensive
Metabolic Panel
(CMP)
Coagulation

DIAGNOSTIC EVALUATION
USG

• Simple ascites is anechoic

• Exudative, hemorrhagic or
neoplastic ascites contains
floating debris
• Septation  inflammatory or
neoplastic cause (loculated
ascites)
CT Scan
CT Ascites

Most sensitive to small

amount of fluid in the
peritoneum  biasanya lebih
mudah dilihat di Morison
pouch dan pelvis
Transudat  densitas mirip
dengan air (-10 s.d. +10 HU)
Eskudat  > 15 HU
Haemoperitoneum  higher
~45 HU
MX: PARACENTESIS

Indications Basic tests

 Diagnostic  General appearance
 New-onset  Cell count & differential
 Suspicion for spontaneous or  Total protein
secondary bacterial
peritonitis  Albumin
 Therapeutic Additional tests
 Respiratory compromise  Gram stain/culture, LDH, glucose,
amylase, cytology, bilirubin
 Abdominal pain/pressure
 Serum-Ascites Albumin Gradient
(SAAG)
Cell count & differential
SAAG = (serum albumin) – (ascites  *best test to assess for
albumin) infection
 PMN > 250/mm3 suggests
 ≥1.1 g/dL  portal HTN infection
 <1.1 g/dL  unlikely portal
HTN
Utilization of Glucose, LDH, Total Protein:
Helps distinguish cardiac from hepatic etiology
Ascitic Fluid Total protein <2.5 g/dL
Suggests hepatic etiology
Ascitic Fluid Total protein ≥2.5 g/dL
Suggests cardiac etiology
ANALYSIS
MANAGEMENT
 General :
 Salt restriction 6-8 g/d
 water restriction 1000 ml/d
 Moderate Volume:
 Spironolacton 50-200 mg/d
 Combined with furosemid 20-40 mg/d
(perifer edema)
 Target diuresis :loss weight 300-500
g/d in non perifer edema or 800-1000
g/d in perifer edema
 Massive Volume:
 Parasentecis therapeutic with albumin
1,5 g/kg
 Max spironolaton 400 mg/d with
furosemid 160 mg/d
 Ascites Refracter:
 Non adequat respon with hi dose
diuretic or refracter after paracentesis
 Consider another paracentesis with
albumin
 TIPS (transjugular intrahepatic
portosystemic shunt)
  Chen, M., et al. 2011. Lange Clinical Medicine: Basic Radiology
2nd Ed. New York: McGraw-Hill
 Herring, W. 2016. Learning Radiology: Recognizing the Basics 3rd
Ed. Philadelphia: Elsevier
 Sutton, D., et al. 2003. Textbook of radiology and Imaging 7th Ed
Vol. 1. Philadelphia: Elsevier
 https://radiopaedia.org/articles/ascites diakses pada 2 Mei
2018

REFERENCE