ASITES

Uchti Akbar, S. Ked

Asites
 Causes Of Ascites
CAUSE % OF TOTAL NUMBER
OF PATIENTS

Cirrhosis (with or without infection) 85

Miscellaneous portal hypertension-related 8
( including 5 % with two causes including
5 portal hypertension)
Cardiac ascites 3
Peritoneal carcinomatosis 2
Miscellaneous nonportal hypertension- 2
related
Klasifikasi asites :
1. Serum ascitic albumin gradient (SAAG)
1a. SAAG > 1.1 ( hipertensi portal / transudat ) 1b.
SAAG < 1.1 ( exudat / non portal hipertensi )
Clasiffication Of Ascites by serum Ascites Albumin Gradient
HIGH GRADIENT LOW GRADIENT > 1.1
G/DL (11 g/L) < 1.1 G/DL (11 g/L) (Transudat )
( Exudat )

Cirrhosis Peritoneal carcinomatosis

Alcoholic hepatitis Tuberculous peritonitis
Cardiac ascites pancreatic ascites
Mixedascites Bowel obstruction or infarction
Massive liver metastases Biliary ascites
Fulminant hepatic failure Nephrotic syndrome
Budd-Chiari syndrome Postoperative lymphatic leak
Portal vein thrombosis serositis in connective tissue disease
Veno-occlusive disease
Myxedema
Fatty liver of pregnancy
Klasifikasi Infeksi Cairan Asites
Spontaneous ascitic fluid infection

2. Infeksi : Spontan Bacterial Peritonitis (SBP)

Monomicrobial non neutrositic asites
Polimicrobial bacterascites Peritonitis
Sekunder
Cultur negative neutrositic ascites (CNNA)
 Perforation Laparotom
Peritonitis y
ye
Free Air Or
s
Extravasation Of
Contrast Medium
no
Evidence For
Fulfillment Of At Least 2 Of The ye
Following: Loculated
s Infection
- Total Protein > 1 g/dl
(U/S.CT,etc)
- Glucose < 50 mg/dl Non-Perforation
- LDH > Upper limit of normal Secondary
Bacterial Peritonitis
no
no
ASCITIC FLUID No Evidence For
PMN COUNT > Loculated
Ascites PMN<Baseline
250 Infection
After 48 Hours of ye (U/S.CT,etc)
Therapy With Antibiotic s
Spontaneous Continu
Bacterial e
Peritonitis Antibioti
no c
Ascitic Fluid Bile- ye Ascitic Fluid Bilirubin >6 mg/dl Biliary
ye
Stained s And Ascitic Fluid / serum Perforatio
s
Bilirubin > 1.0 n
 Classification of Malignancy-Related Ascites

Peritoneal carcinomatosis
Massive liver metastases
Peritoneal carcinomatosis with massive liver metastases
Hepatocellular carcinoma
Malignant lymph node obstruction
Malignant Budd-Chiari syndrome (tumor emboli in
hepatic veins)
 Gut Flora
? Altered Altered Flora
Permeability Bacteria In
Mesenteric Lymph
Nodes
Bacteria Abdominal
?
Lymphatics
Lymphatic
Bacteria in Thoracic Rupture
Lymphatics
Bacteria in Thoracic Duct
Respiratory Tract Infection Lymph Urinary Tract Infection
Complement Deficiency Reticuloendthelial
Bacteremia System Dysfunction

Bacteria in hepatic
lymph
Bacterascites
Poor Opsonic Good Opsonic
Activity Moderate Opsonic Activity Activity
SBP Sterile
Nonneutrocytic
CNNA Ascites
Patogenesis
1. Peningkatan tekanan hidrostatik
2. Penurunan tekanan onkotik Hipoalbumin
3. Pembendungan limfe
4. Reabsorpsi sodium dan air (pada
hiperaldosteron dan RAAS)
Mekanisme Terjadinya
Asites
Transudasi
 Teori Underfilling

Hipertensi porta Hipoalbuminemia

Transudasi

Penurunan volume intravaskular

Ginjal mereabsorpsi air dan garam melalui mekanis neurohormonal

 Teori Overfilling

Penurunan aktivitas hormon natriutikPeningkatan aktifitas hormon ADH

Reabsorpsi air dan garam oleh ginjal

Ekspansi cairan plasma

 Teori Vasodilatasi Perifer

Sirosis Hati

Hipertensi porta

Vasodilatasi arteriolar splangnikus

Tekanan intrakapiler dan koefisien

filtrasi meningkat Volume efektif darah
arteri menurun

Pembentukan cairan limfe lebih

Aktivasi ADH, sistem
Besar daripada aliran balik
simpatis, RAAS

Terbentuk asites Retensi air dan garam

Pemeriksaan Fisik
Inspeksi
Pemeriksaan Penunjang
USG
Paracentesis Diagnostik
1. Gambaran makroskopik
2. Gradien SAAG
3. Hitung sel
4. Biakan kuman
5. Pemeriksaan Sitologi
Penatalaksanaan
Tirah baring
Diet rendah garam
Diuretika
Pengobatan penyakit dasar
Terapi paracentesis
 Indications for Empirical Antibiotic Therapy
Of Suspected Spontaneous Ascitic Fluid
Infection
Ascitic fluid neutrophil count > 250 / mm3
(0.25 x 10 0/L) Convincing symptoms or signs of
infection
Kenapa asites diobati ?
1. Gangguan aktivitas, 2. Gangguan
pernafasan
3. Hernia abdominalis, 4. Hidrothoraks
5. Spontan Bacterial Peritonitis 6. Hepatorenal
sindrom
7. Varises esofagus 8. Komplikasi diet
( dispepsia )
 Treatment Of Subtypes of Ascitic Fluid Infection
Diagnosis Treatment
Spontaneus bacterial 5 days of intravenous antibiotic to which the
organism peritonitis is highly susceptible (eg. cefotaxime 2
g every 8 hours empirically followed by more narrow spectrum
therapy after susceptibility results are available
Monomicrobial non- 5 days of intravenous antibiotic to which the organism
is neutrocytic bacterascites highly susceptible, if patients is symptomatic or
persistently culture-possitive. Not all patients with
bacterascites require treatment
Culture-negative 5 days of intravenous thirdgeneration
cephalosporin (eg. neutrocytic ascites cefotaxime 2 g q8h )
Secondary bacterial Surgical intervention plus approximately 2 weeks
peritonitis of intravenous cephalosporin (eg. cefotaxime 2 g q8h) plus
an antianaeobic drug such as metronidazole
Polimicrobial intravenous third generation cephalosporin (eg.
Bacterascites cefotaxime 2 g q8h ) plus antianaerobic drug such
as metronidazole. Duration is determined by clinical
response and serial ascitic fluid PMN counts and cultures.
THANK YOU