Liver and intrahepatic bile ducts - nontumor
General concepts

Author: Anthony W.H. Chan, FRCPA (see Authors page)

Revised: 12 October 2016, last major update September 2016

Copyright: (c) 2002-2016,, Inc.

PubMed Search: Ascites [title] liver and intrahepatic bile ducts

Cite this page: Ascites. website. Accessed April 23rd, 2017.
Definition / General
Essential Features
  • Pending
Combination of these factors, which reinforce each other:
  • Elevated hydrostatic pressure due to portal hypertension
  • Reduced osmotic pressure due to hypoalbuminemia
  • Renal retention of sodium and water due to activation of renin-angiotensin-aldosterone system (RAAS)
  • Decreased effective circulatory volume due to ascites
  • Ascitic fluid cell count and differential
    • Polymorphonuclear leukocyte (PMN) count > 250 cells / mm3 in the absence of an intra abdominal, surgically treatable source of infection indicates spontaneous bacterial peritonitis (Hepatology 1982;2:399), which complicates about 12% of cirrhotic patients with ascites (Dig Liver Dis 2001;33:41)
  • Serum ascites albumin gradient (SAAG) (Am J Gastroenterol 2009;104:1401)
    • > 1.1 g / dL indicates portal hypertension
    • < 1.1 g / dL indicates nonportal hypertension causes including malignancies, tuberculous peritonitis and nephrotic syndrome
  • Cytology
    • Only positive in peritoneal carcinomatosis (sensitivity of 96.7% if 3 samples from different paracentesis procedures) (Hepatology 1988;8:1104)
    • Almost always negative in cirrhotic patients, even those known to have hepatocellular carcinoma (Cytojournal 2009;6:16)
  • First line (Hepatology 2013;57:1651)
    • Cessation of alcohol when present
    • Sodium restriction
    • Dual diuretics (usually spironolactone and furosemide)
    • Discontinue nonsteroid anti inflammatory drugs
    • Evaluation for liver transplantation
  • Second line
    • Discontinue beta blockers, angiotension converting enzyme inhibitors and angiotension receptor blockers
    • Serial therapeutic paracentesis
    • Transjugular intrahepatic portosystemic stent shunt (TIPSS)
    • Evaluation for liver transplantation
  • Third line
    • Peritoneovenous shunt
Clinical Images
Images hosted on other servers:

Severe ascites due to cirrhosis

Cytology Description
  • Ascites fluid cytology is almost always negative in patients with cirrhosis, even those known or suspected to have hepatocellular carcinoma (Cytojournal 2009;6:16)
Cytology Images
Images hosted on other servers:

Ascites fluid cytology

Various images in patients with ascites, all interpreted as negative