TOPIC

MANAGEMENT OF MALIGNANT ASCITES

Moderator : Dr M.M. Ansari Speakers: Dr Abul Hasan Dr Arun kr. Patel Date : 14/11/11

AIM
The Aim Is To Approach The Patient With Malignant Ascites In Terms Of :
DEFINITION ; CAUSES ; CLINICAL FEATURES ; INVESTIGATIONS ; MANAGEMENT ; COMPLICATIONS ;

DEFINITION
It is the of pathological accumulation of fluid in the peritoneal cavity.

Pathogenesis
Peritoneal carcinomatosis Lymphangitic carcinomatosis Massive hepatic metastasis. Neovascularization Severe malnutrition

CAUSES
Can Be Broadly Classified On The Basis Of :
1. Normal peritoneum:

2. Diseased peritoneum

 Normal peritoneum: * Massive Hepatic Metastasis with resultant portal venous obstruction. * Primary hepatocellular carcinoma.

CAUSES
DISEASED PERITONEUM

Gynaecologic Malignancies: Ovarian Endometrial, Uterine GI Malignancies: Colon Pancreatic Gastric

Diseased peritoneun
Lung ca. Breast Ca. Pseudomyxoma Peritonei Mesothelioma. HIV associated Primary serosal effusion vlymphoma Lymphoma(mc cause of Chylous Ascites) Prostatae ca.(Rare)

CLINICAL FEATURES
PRESENTING COMPLAINTS Abdominal Distension Diffuse Abdominal Pain Bloated Feeling of Abdomen Dyspnoea and Orthopnea (due to elevation of daipharagm) Indigestion and Heart burn (due to inc intra abdominal pressure)

CLINICAL FEATURES
PHYSICAL EXAMINATION SIGNS RELATED TO SECONDARY EFFECTS OF ASCITES Scrotal Edema Pleural effusion (due to defect in the diaphragm and fluid pass into the pleural space) Edema Cardiac apex is shifted upward due to raised diaphragm) Distended neck veins due to inc rt atrial pressure)

CLINICAL FEATURES
PHYSICAL EXAMINATION
Abdominal Distension Fullness of Flanks Umbilicus Flat and Everted Divarication of Recti Muscles Distended Abdominal Veins Shifting dullness (esp. when >1000ml of fluid)

CLINICAL FEATURES contd

Fluid Thrill Puddle Sign Shortness of breath Early satiety nausea and vomiting Difficulty with bending or sitting upright Heart burn

SHIFTING DULLNESS

METHOD OF EXAMINATION BEGIN BY PERCUSSING AT THE UMBILICUS AND MOVING TOWARD THE FLANKS. THE TRANSITION FROM AIR TO FLUID CAN BE IDENTIFIED WHEN THE PERCUSSION NOTE CHANGES FROM TYMPANIC TO DULL. ROLL THE PATIENT ON THEIR SIDE AND PERCUSS AS BEFORE. THE AREA OF TYMPANY WILL SHIFT TOWARDS THE TOP AND THE AREA OF DULLNESS TOWARDS THE BOTTOM.
JAMA 1992;267:2645-2648

SHIFTING DULLNESS

PATIENT OR ASSISTANT

FEEL

TAP

METHOD OF EXAMINATION

HAVE THE PATIENT OR ASSISTANT PLACE THEIR HANDS IN THE MIDLINE

TAP ONE FLANK SHARPLY AND USE THE FINGERTIPS OF THE OPPOSITE HAND TO FEEL FOR AN IMPULSE ON THE OPPOSITE FLANK

PUDDLE SIGN

METHOD OF EXAMINATION PATIENT IS PRONE FOR 3-5 MINUTES AND THEN RISES TO ALL FOURS DIAPHRAGM OF THE STETHOSCOPE IS PLACED OVER MOST DEPENDENT AREA OF THE ABDOMEN BEGIN BY FLICKING A FINGER OVER A LOCALIZED FLANK AREA MOVE THE STETHOSCOPE OVER THE OPPOSITE FLANK SUDDEN INCREASE IN INTENSITY IS A POSITIVE SIGN (NO LONGER USED)
JAMA 1992;267:2645-2648

PHYSICAL EXAMINATION
SIGNS RELATED TO THE CAUSE OF ASCITES LIVER Involvement (Primary /Secondary) 1 Jaundice 2 Edema, 3 Palmar erythema 4 Spider angiomas, 5 Hepatosplenomegaly, 6 Caput Medusae 7 Fetor hepaticus

MALIGNANCY: * Nodule in the umbilicus, the so-called Sister Joseph nodule,( suggests peritoneal carcinomatosis originating from gastric, pancreatic, or hepatic primary malignancy.
* Troisiers sign left-sided supraclavicular node (Virchow node) suggests the presence of upper abdominal malignancy

Two grading systems for ascites have been used in the literature.

* An old system which grades ascites from 1+ to 4+, depending on the detectability of fluid on physical examination.

* More recently, the International Ascites Club has proposed a system of grading from 1 to 3.

The older system 1+ is minimal and barely detectable. 2+ is moderate. 3+ is massive but not tense. 4+ is massive and tense.

The International Ascites Club grading (2003) Grade 1: mild ascites detectable only by US. Grade 2: moderate ascites manifested by moderate symmetrical abdominal distension. Grade 3: large or gross ascites with marked abdominal distension.

INVESTIGATIONS

INVESTIGATIONS
Includes:

1 .Imaging studies. 2. Abdominal Paracentesis 3.Laparoscopy. 4. Immunohistochemistry

Imaging

CHEST X ray Non specific *Elevation of diaphragm *Sympathetic pleural effusions

ABDOMINAL X ray NON SPECIFIC

Diffuse abdominal haziness Bulging of flanks Indistinct psoas margins Poor definition of organs Separation of small bowel loops Centralization of floating bowel

 Direct signs
Hellmersign Dogs ear or Mickey Mouse Medial displacement of cecum and ascending colon

Lateral displacement of properitoneal fat line

USG
As small as 50-100 mL "lollipop appearance of small bowel loops

Multiple septa- pseudomyxoma peritonei.

Tethering of bowel along post .abd. wall with loculated fluid in between -malignancy

CT SCAN
Parietal perotineum thickening and contrast enhancement. Peritoneal nodule Sepatations Lymph node

CT SCAN contd..
CAN DIFFERENTIATE MALIGNANT FROM BENIGN. Lymph nodes Focal liver lesions. Pancreatic lesions. Malignant ascites -- fills greater and lesser sac

Abdominal Paracentesis

Paracentesis is a Surgical procedure involving needle aspiration of fluid from Peritoneal cavity.

Indications
(1) Evaluation for a patient with known malignancy, developing clinically apparent ascites of recent onset. (2) To diagnose metastatic cancer

Absolute Contraindications
1. Previous abdominal surgeries with suspected adhesions. 2. Distended bowel/ bowel obstruction/ ileus 3.Abdominal wall cellulitis at the proposed site of puncture. 4. Pregnancy. 5. Uncooperative patient.

Relative Contraindications
Bleeding diathesis a)PT > 21 seconds, b)INR> 1.6, c)Platelet counts< 50,000 )

Procedure

Using sterile technique, prep and drape the site of insertion.

Procedure cont..
The preferred site is approximately 2cms below the umbilicus in the midline. The alternate site is either lower quadrant ,approximately 5cms cephalad and medial to the anterior superior iliac spine. Positioning of the patient depends on the amount of fluid to be aspirated. Pt with large quantity of fluid can go with supine position with 30-45 degree head end elevation

Diagnostic paracentesis

 Anaesthetize: Draw up 1% lidocaine and first administer just below epidermis (attempt to raise a wheal) with a 25-gauge needle. Using the z technique. Change to a 22-gauge needle and then anesthetize down to the peritoneum. The Z-technique involves retracting skin downward by two centimeters before the needle is inserted and advanced.

Procedure contd..

This technique prevents direct overlap of the skin insertion and peritoneal insertion sites, theoretically minimizing the risk fluid leak..

Complications.
Local complications: abdominal wall haematoma persistent ascitic fluid leak localized infection. Intraperitoneal: visceral and vessel injury. Catheter fragment left in the abdominal wall or peritonealcavity. Introduction of infection

Complications contd..
Systemic : Haemodyanamic compromise by overzealous removal of fluid.(colloid or dextran infusion should be considered for paracentesis of more than 5 lts). Dilutional hyponatremia. Hepatorenal syndrome

Differentrial diagnosis
Chylous ascites: the most common cause is malignant lymphoma Diagnosis is based on Paracentesis shows high plasma triglyceride ratio(2-8 folds) or total ascitic triglyceride of greater than 110 mg/ml.

Pancreatic Ascites

Pancreatic ascites, which is characterized by a very high amylase in the ascitic fluid (greater than 1000 IU/L)

 A history of chronic pancreatitis is common, as this is the etiology of the pancreatic ascites in approximately 80% of cases acute pancreatitis in 8.6%, trauma in 3.6%.

Differential diag contd..

Budd chiari synd a rare disease caused by obstruction of the hepatic venous outflow or the inferior vena cava (IVC) above the hepatic vein. It often occurs secondary to intrinsic vascular thrombosis, hepatic tumor invasion/compression, or associates with an idiopathic obstructing membrane. The clinical signs of ascites, abdominal pain and hepatomegaly are the typical triad of BCS.

AASLD RECOMMENDATION
1.Paracentesis should be performed ,ascitic fluid should be obtained from inpatients & outpatients with clinically apparent new-onset ascites 2. Since bleeding is uncommon ,prophylactic use of FFP or platelets is not recommended. 3. Initial evaluation of ascitic fluid should include cell count ,differential, total protein & SAAG. 4. If infection is suspected, ascitic fluid should be cultured at the bedside in blood culture bottles. 5. Other studies can be ordered based on pretest probability of disease.

LAB STUDIES
ASCITIC FLUID ANYALYSIS(DIAGNOSTIC PARACENTESIS) Ascitic Fluid should be analyzed for APPEARANCE CELL COUNT TOTAL PROTEINS SAAG(SERUM ASCITIC ALBUMIN GRADIENT) CYTOLOGY CULTURE IMMUNOHISTOCHENISTRY

Gross Appearance of Ascitic Fluid

Color Translucent or yellow Appearance Normal/sterile

Brown
Cloudy or turbid Pink or blood tinged Grossly bloody Milky ("chylous")

Hyperbilirubinemia GB or biliary perforation Infection

Mild Trauma Malignancy Cirrhosis Thoracic duct injury Lymphoma

INVESTIGATIONS CONTD..
CELL COUNT
WBCS <500/mm3 and NEUTROPHILS<250/mm3: NORMAL NEUTROPHILS>250/microL: suggests SBP LYMPHOCYTES PREDOMINANCE: ABDOMINAL TB OR MALIGNANCY

INVESTIGATIONS

TOTAL PROTEINS
PROTEINS<2.5g/dl: TRANSUDATE PROTEINS>2.5g/dl: EXUDATE

INVESTIGATIONS

CYTOLOGY
58-75% HELPING FOR DETECTING MALIGNANT ASCITES

CULTURE AND GRAM STAIN

MORE IMPORTANT IN SBP

Papinacolou stain showing malignant cells in peritoneal fluid.

MALIGNANT ASCITES
* GROSS APPEARANCE: Straw - coloured Chylous Haemorrhagic Mucinous * Protein: >2.5gm/dl (SAAG<1.1g/dL) * RBC >10000mcrio ml- -20% * WBC PER MICRO LITRE> 1000

Serum ascites albumin gradient(SAAG)

Rather than total protein content of ascites fluid, it is better to characterize ascites by serum ascites albumin gradient. It is observed that gradient correlate directly with portal pressure. A gradient of >1.1g/dl is characteristic of uncomplicated cirrrhotic ascites and differentiate ascites due to portal hypertension from not due to portal hypertension.

 The sensitivity and specificity of SAAG to differentiate b/w cirrrhotic and non cirrhotic cause of ascites is 95%. Calculation: SAAG is calculated by subtracting the albumin concentration of the ascitic fluid from the albumin concentration of a serum specimen obtained on the same day.

Types of Ascites according to the level of the serum-ascites albumin gradient

High Gradient ( > or = 1.1 g/dl) Low Gradient ( < 1.1 g/dl)

Cirrhosis Alcoholic Hepatitis Cardiac Failure Fulminant Hepatic Failure Portal-vein Thrombosis

Peritoneal Carcinomatosis Pancreatic ascites Biliary ascites Peritoneal Tuberculosis Nephrotic Syndrome Serositis Bowel obstruction or infarction

Errors in SAAG Timing of collection Serum albumin < 1.1

Arterial hypotension
Chylous ascites Serum hyperglobulinemia

CORRECTION IN SAAG
[SAAG X (0.16) X S.globulin (g/dl)] + 2.5

LAPROSCOPY
IN SOME PATIENTS FOR DIRECT VISUALIZATION TO TAKE BIOPSIES OF LIVER PERITONEUM INTRA ABDOMINAL LYMPHNODES

 IMMUNOHISTOCHEMISTRY

Positive staining with prostate specific antigen of the peritoneal fluid.

Positive prostatic acid phosphatase staining of the peritoneal fluid.

Treatment

 Goal: to relieve the symptoms With little or no discomfort: dont treat Before intervening, discuss prognosis, benefits, risks

When to treat?
With these symptoms:
Dyspnea Abdominal pain Fatigue Anorexia Early satiety Reduced exercise tolerance

TREATMENT contd..
THERAPEUTIC PARACENTESIS DRAINAGE PROCEDURES Catheter drainage Shunt Drainage CHEMOTHERAPY(CYTOREDUCTIVE) LAPROSCOPIC HIPEC

THERAPEUTIC PARACENTESIS
International ascites club recommend if <5L is removed synthetic plasma expander can be used and as good as albumin ( some hepatologist suggests no albumin/plasma expander if <5L). Compared to albumin, artificial plasma expander cause more activation of RAS , causes more hyponatraemia and results in longer hospital stay.

 20% albumin should be infused after paracentesis of >5L at dose of 8g/L of ascites drained ( 100ml of 20% albumin= 20gm, so 3L of ascites fluid removal needs 3x8=24 gm of albumin replacement = 125ml but we tend to round it to 100ml)

 So if >10L remember to give an extra 100ml of albumin 25% albumin can be given if the patient is hypervolemic while 5 percent albumin can be given if dehydration is suspected.

SURGICAL TREATMENT
CATHETER DRAINAGE PERITONEO-VENOUS SHUNT TRANSJUGULAR INTRAHEPATIC PORTOSYSYTEMIC STENT SHUNT(TIPS),

CATHETER DRAINAGE
TEMPORARY :
PIGTAIL

PERMANENT:
PIGTAIL TENCHKHOFF TUNNELED PERITONEAL CATHETER(PLEUR-X)

Tunneled peritoneal catheter

Procedures are performed using general surgical aseptic technique with overnight fasting sonographically large pocket of ascites in right lower abdomen was localized a location lateral to that access was preferred to facilitate medially directed tunnel. 18 gauge sheathed needle was passed in peritoneal cavity and confirmation done by aspiration. Guide wire passec through that needle. Serial dilatation done under flouroscopic guidance.

Photograph shows catheter placement with guidance to identify fluid in right lower quadrant. Note lateral position of selected site for placement of 18-gauge Longdwell needle (insert); .

Method used to ease insertion of polymeric silicone peritoneal catheter. Photograph shows coaxial catheter system as it is pieced together. Coaxial system is used to prepare soft polymeric silicone peritoneal catheter for insertion into peritoneal cavity. Amplatz guidewire (Davis; Cook, Bloomington, IN) (arrowhead) is inserted through a long 5-French catheter (thin straight arrows); this combination is then inserted through polymeric silicone peritoneal catheter (thick straight arrow) to provide stiffness and reduce friction created by polymeric silicone catheter as it is pushed through peel-away sheath (curved arrow).

Lateral-to-medial placement of tunnel. Photograph shows tunneling technique. Image of patient undergoing final placement of cuffed portion (straight arrow) of catheter. Special tunneling device (curved arrow) is used.

Uses for Intraperitoneal Access Devices

Provide repeated access to the peritoneal cavity the administration of IP therapies
Provide for relief/palliation of symptomatic ascites at diagnosis or in end of life care Provide access for initial diagnosis or recurrence (cytology)

Benefits to the Patient from a Paracentesis Catheter Relief of symptoms (i.e. pain, SOB, anorexia) Decreases number of repeated paracentesis
Decrease amount of visit to hospital and clinics Care can be provided in the home Increases the patient and families QOL

Complications of Paracentesis Catheter

Post-insertion Complications: Pain at the exit site usually resolves in 5-7 days
Bleeding into the peritoneum Potential for bowel perforation assess for severe abdominal pain, fever, tense abdomen and bowel sounds

Peritonitis assess for fever, N&V, severe abdominal pain, cloudy peritoneal fluid

Other Catheter Complications

Infection Leakage around site Non-function catheter (blockage)

Catheter dislodgment
Hypotension Bleeding,Decreased Albumin Decreased Fluid Volume

SHUNTS

PERITONEOVENOUS SHUNTS
LE-VEEN SHUNT A conduit implanted subcutaneously connecting the peritoneal cavity with sup. venacava via Rt.Int.Jugular vein Pressure sensitive unidirectional valve .

Le veen shunt

Shunts with pumps

DENVER SHUNT---AN ADDITIONAL
SUBCUTANEOUS PUMP PROMOTES FLOW EVEN WHILE PT IS NOT SUPINE. CORDIS HAKIM SHUNT WITH A VALVE UNITANTE CHAMBER ASSEMBLY

Denver shunt

CORDIS HAKIM SHUNT(assembly description)

a)valve unit-antechamber assembly b)metal U shaped connector c)venous catheter d)peritoneal canula

 indicated ---malignant ascites with no mailgnant cells

in ascitic fluid

 Peritoneo-venous shunting has been cited in the literature as providing several physiologic benefits: Increases intravascular and effective blood volume. Retains nutrients and improves nutritional status. Increases renal blood flow. Increases diuresis. Relives massive, refractory ascites. Results in weight loss and girth reduction. Improves mobility & respiration.

 AVOIDED IN

--MANY MALIGNANT CELLS t/t of primary pathology with repeated paracentesis. --HIGH PROTEIN CONC.>4.5g/dl ( HIGHER CHANCES OF SHUNT BLOCKAGE)

C/I Mental status

ABSOLUTE RELATIVE COMA Severe encephalopathy 80-120 75-100 1000-1500 4-7 minor Moderate

BILIRUBIN(mo >120-170 l/l) Platelets PT Previous g.i bleed Cardiac failure <50-75 <8 major Severe Fibrinogen(g/l) <1000

Peritonael inf.

Persistent

Resolving

 1) Place tip at atrial-cavo junction.

2) Insure a smooth, non-kinked path.

3) Wipe with a heparin solution just prior to insertion into vein.

4) Secure ligatures firmly without reducing the catheters ID. Value: Eliminates early occlusion due to obstructed fluid pathway. Reduces risk of late occlusion due to fibrin sheath formation. Reduces risk of venous catheter tip thrombosis. Reduces risk of SVC thrombosis.

Pre- and Peri-Operative Issues and Techniques Ascitic Fluid

Drain at least half the fluid. Consider replacing part of the drained volume with saline or other appropriate solution.

PERITONEOSAPHENOUS SHUNT
Abdominal incision Mc burneys point Groin incision 4cm below Ing.lig Venous catheter chanelled upto IVC above the diaphragm

 Early Post-Operative Management and Techniques Monitoring Monitor hemodynamic status and blood values. Value: Provides for evaluation of the level of coagulapathy and hemodilution. Patient Position Supine: Maximum flow of ascites into the venous circulation. Partially Sitting Up: Reduced flow of ascites. Full Upright Sitting: Further reduces or stops flow. Value: Reduces risk of clinical DIC. Reduces risk of fluid overload.

Drug Administration 1) Diuretics as appropriate. 2) Pain medication as appropriate. 3) Consider possible mini-heparin or enteric aspirin for patients with viscous or fibrinous fluid. Value: Aids in the resolution of ascites. Increases patient comfort. Reduces risk of early shunt thrombosis

 Long-Term Maintenance Issues and Techniques Pumping the Shunt For long-term patency the shunt should be properly pumped on a daily basis. Proper Pumping Technique: 1) Lie down in a supine position. 2) Firmly grasp pump chamber between thumb and middle finger. 3) Firmly and completely compress the chamber with the index finger of the other hand. 4) Slowly release the compression of the chamber. (Important: with single valve shunts, percutaneously occlude the venous catheter during pump chamber release.) 5) Repeat the pumping sequence 20 times.

Regular, Daily Schedule: 1) Pump the shunt 20 times in the morning. 2) Pump the shunt 20 times in the evening. Value: Flushes fluid through the shunt. Twenty consecutive compressions provides an exchange of fluid through the pump chamber. Limits the accumulation of fibrin and other debris within the shunt. Helps avoid the formation of an occlusive fibrin sheath at the venous tip. Helps avoid late occlusion due to thrombus formation.

Occlusion Issues and Resolution Techniques Determine Location of the Occlusion: 1) Place the patient in a supine position. 2) Pump the shunt according to the proper technique. If the pump chamber is rigid and resists compression, the occlusion is within either the pump chamber or the venous catheter. If the pump chamber compresses readily but does not refill and resume its normal shape, the occlusion is within the peritoneal catheter. 3) Consider performing a shuntogram. 4) Consider using Doppler ultrasound.

Options for Resolving Venous Catheter Occlusions: 1) Firmly pump the shunt several times. 2) Replace the venous catheter. 3) Reposition the venous catheter. 4) Replace shunt. 5) Consider thrombolytic therapy. Options for Resolving Pump Chamber Occlusions: 1) Firmly pump the shunt several times. 2) Replace the venous catheter. 3) Replace shunt. 4) Consider thrombolytic therapy. Options for Resolving Peritoneal Catheter Occlusions: 1) Reposition catheter. 2) Replace catheter

COMPLICATIONS
SYSTEMICHYPOKALEMIA ----PYROGEN REACTION ----HEMODILUTION ----BLEEDING ----INFECTION ----HEPATIC/RENAL FAILURE LOCAL---WOUND COMPLICATIION ---POSITION OF SHUNT DISLODGEMENT

COMPLICATIONS
Immediate ---CAPSULE RUPTURE ---INTRA-ABDOMINAL BLEED ---CARDIAC PERFORATIONS ---PORTAL/CAVAL LACERATIONS ---HEMOBILIA Late ---STENOSIS/DISPLACEMENT

 Intraperitoneal Hyperthermic Chemotherapy(hipec)

 Laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC) could represent a good therapeutic tool for patients in whom medical therapies have failed and peritoneovenous shunting is contraindicated. LHIPEC with Cisplatin 25 mg/m2/L and Doxorubicin 7 mg/m2/L. A dramatic reduction of ascites was documented in the postoperative period and the patient experienced complete abdominal symptom relief. LHIPEC could be a good therapeutic option to palliate malignant ascites from mesothelioma in cases not eligible for a radical treatment

NEWER APPROACHES
OCTREOTIDE MONOCLONAL ANTIBODIES TRIFUNCTIONAL ANTIBODIES INTRAPERITONEAL IMMUNOTHERAPY

CONTD..
ANP+TERLIPRESSIN ANP LEADS TO INCREASED GFR AND NATRIURESIS

TERLIPRESSIN----SPLANCHNIC VASONCONSTRICTOR COUNTERS THE HYPOTENSIVE EFFECT OF ANP

SBP
The most common complication is spontaneous bacterial peritonitis or SBP DEFINED AS infection of previously sterile ascitic fluid without an apparent intra-abdominal source of infectioin. The diagnosis of SBP is estabilished with PMN count in ascitic fluid higher than 250cells/mm3. Pathogenesis is believed to be due to colonization of ascitic fluid from an episode of bacteremia.

 The infection is blood borne and 90% monomicrobial. polymicrobial are associated with repeated paracentesis. The most common organism are gram negative Enterobacteriaceae specifically most common is E.coli. Clinically Abrupt onset of Fever, Chills, Generalizd Abdominal Pain, Rebound Tenderness in diagnosed case of ascitis.

 Low ascitic fluid albumin (<1g/dl) predisposes SBP. Ascitic Fluid analysis shows wbcs >500/mm3l and Eutrophil>250/mm3. third generation Cephalosporins 2g tid started empirically for 5 days till c/s report is available. Recurrence is common. Ciprofloxacin 750 mg once weekly can be given prophylactically.

SUMMARY
Malignant ascites is associated with a poor prognosis. Determination of the SAAG helps determine whether diuretics with or without dietary modifications are likely to be effective. Paracentesis can relieve symptoms. In selected patients, placement of a permanent catheter may be warranted.

Key take-home points

1. Malignant ascites is due to increased portal pressures, direct secretion into the abdomen, or a combination of these two mechanisms. 2. Calculation of the serum-ascites albumin gradient (SAAG) helps determine whether diuretic therapy is likely to be of benefit; a gradient of >1.1 g/dl is associated with portal hypertension. 3. Intermittent physical removal of fluid, either with intermittent paracentesis or placement of an intraperitoneal catheter, relieves discomfort in selected patients.

THANKS