Divisi Hepatobilier, Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran Universitas Indonesia/ Rumah Sakit Cipto Mangunkusumo

ASCITES
Akumulasi cairan di

rongga peritoneum

Bacon BR. Cirrhosis and Its Complications. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson
JL, Loscalzo J, ed. Harrisons Principles of Internal Medicine. 18th edition, USA: McGraw-Hill, 2012.
p2592-2602.
Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The
Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
Tarn AC, Lapworth R. Biochemical Analysis of Ascitic (Peritoneal) Fluid: What Should We Measure?
Annals of Clinical Biochemistry. 2010;47: 397-407.

Etiologi
Hipertensi porta

Sirosis hepatis

( tekanan hidrostatik)

Gagal jantung kongestif

Obstruksi outflow vena hepatik
Perikarditis konstriktif
Obstruksi vena kava inferior

tekanan onkotik plasma

Sindroma nefrotik
Malnutrisi

Keganasan (peritoneal)

Ovarium, lambung, kolorektal, dll

Infeksi

TB

Lain-lain

Chylous, pankreatik, bilier, dll

Tarn AC, Lapworth R. Biochemical Analysis of Ascitic (Peritoneal) Fluid: What Should We Measure? Annals of Clinical Biochemistry. 2010;47: 397-407.

Patofisiologi (ascites sirotik)

Sirosis
Hipertensi porta
Vasodilatasi splanchnic

tekanan splanchnic
Pembentukan limfe
ASCITES
Ekspansi volume plasma

pengisian arterial
Aktivasi faktor
antinatriuretik &
vasokonstriktor
Hipertensi porta

Bacon BR. Cirrhosis and Its Complications. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, ed. Harrisons Principles of Internal Medicine. 18th edition,
USA: McGraw-Hill, 2012. p2592-2602.

Gejala
lingkar perut
berat badan

Sesak nafas
Rasa begah

Nyeri perut (menyeluruh)

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210233.

Pemeriksaan Fisik ?

Tanda
Bulging flanks, fluid wave sign
pekak samping, pekak pindah

Pada ascites yang sedikit:

Knee-chest position (perkusi redup pada bagian terendah perut)
Puddle sign (auskultasi pergerakan cairan pada bagian terendah
perut)

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
Simadibrata M. Pemeriksaan Abdomen. In: Setiati S, Alwi I, Sudoyo AW, Setiyohadi B, Syam AF, ed. Buku Ajar Ilmu Penyakit Dalam. 6th edition. Jakarta: Interna Publishing, 2015. p191-196.

Tanda
Stigmata sirosis:
spider angiomata, eritema palmar, muscle wasting.

Kuning
Tanda hipertensi porta:
splenomegali, kolateral di dinding abdomen (caput medussae)

Kondisi lain:
hernia umbilikal, hidrothoraks hepatika, edema perifer.

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
Simadibrata M. Pemeriksaan Abdomen. In: Setiati S, Alwi I, Sudoyo AW, Setiyohadi B, Syam AF, ed. Buku Ajar Ilmu Penyakit Dalam. 6th edition. Jakarta: Interna Publishing, 2015. p191-196.

Penunjang
Fungsi liver
Fungsi ginjal
Elektrolit serum dan urine
Analisis cairan ascites (paracentesis diagnostik)
Pencitraan
Lain-lain: trigliserida (chylous?), bilirubin (kebocoran empedu?),

glukosa (infeksi?), amilase (pankreatitis?), penanda tumor

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.
Tarn AC, Lapworth R. Biochemical Analysis of Ascitic (Peritoneal) Fluid: What Should We Measure? Annals of Clinical Biochemistry. 2010;47: 397-407.

Paracentesis

http://www.em.emory.edu/ultrasound/ImageWeek/Procedures/abdomen%20paracentesis.html

Paracentesis Diagnostik
Warna
Serum-ascites albumin gradient (SAAG)
Total protein
Cell count
Kultur bakteri

Bacon BR. Cirrhosis and Its Complications. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, ed. Harrisons Principles of Internal Medicine. 18th edition, USA: McGraw-Hill, 2012. p2592-2602.
Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis. Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.
Tarn AC, Lapworth R. Biochemical Analysis of Ascitic (Peritoneal) Fluid: What Should We Measure? Annals of Clinical Biochemistry. 2010;47: 397-407

Paracentesis Diagnostik
Warna
Jernih, kekuningan, kehijauan, atau berwarna empedu.
Darah: keganasan atau prosedur invasif

Serum-ascites albumin gradient (SAAG)

Total protein
Cell count
Kultur bakteri

Bacon BR. Cirrhosis and Its Complications. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, ed. Harrisons Principles of Internal Medicine. 18th edition, USA: McGraw-Hill, 2012. p2592-2602.
Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis. Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.
Tarn AC, Lapworth R. Biochemical Analysis of Ascitic (Peritoneal) Fluid: What Should We Measure? Annals of Clinical Biochemistry. 2010;47: 397-407

Paracentesis Diagnostik
Warna

Serum-ascites albumin gradient (SAAG)

Albumin serum () albumin cairan ascites.
SAAG (1,1 g/dL) hipertensi porta

Total protein
Cell count
Kultur bakteri

Bacon BR. Cirrhosis and Its Complications. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, ed. Harrisons Principles of Internal Medicine. 18th edition, USA: McGraw-Hill, 2012. p2592-2602.
Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis. Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.
Tarn AC, Lapworth R. Biochemical Analysis of Ascitic (Peritoneal) Fluid: What Should We Measure? Annals of Clinical Biochemistry. 2010;47: 397-407

Bagaimana membedakan etiologi

ascites dari analisanya ?

DD/ 3 Penyebab Tersering Ascites

Warna

SAAG Protein
(cutoff (cutoff
1,1 g/dl) 2,5 g/dl)

Cell count

Tekanan vena
hepatika
WHVP

FHVP

HVPG

Sirosis

Clear straw

PMN>250/mm3

Kardiak

Clear straw

PMN>250/mm3

WBC<100/mm3,
MN, PMN

Keganasan

/ TB

Kemerahan
(blood-stained)

WHVP = Wedged Hepatic Venous Pressure, FHVP = Free Hepatic Venous Pressure, HVPG = Hepatic Venous Pressure Gradient.

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.

Pencitraan
BNO polos: diffuse ground glass appearance
USG, CT scan: Ruang di sekeliling hepar

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.

Tatalaksana Umum Ascites

Paracentesis diagnostik (pertama kali datang atau jika timbul gejala/tanda SBP)
Jika tense ascites paracentesis
Diet garam (2000 mg atau 80- 120 mmol/ hari)

Diuretik.
Stop diuretik jika pre-koma, hipokalemia/hiperkalemia, hiponatremia berat, azotemia, alkalosis
Dosis diuretik dapat disesuaikan dengan BB. BB 0,5kg/hari (1kg/hari jika dengan edema perifer)
Hindari NSAIDs/ obat nefrotoksik.

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.

Grading Ascites (Inkomplikata)

& Saran Tatalaksana
Grade

Definisi

Tatalaksana

Ascites ringan, hanya terdeteksi USG

Ascites sedang, distensi abdomen sedang

Restriksi garam & diuretik

Ascites besar, distensi abdomen jelas

Paracentesis + restriksi garam &

diuretik (kecuali jika ascites refrakter)

European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal
Syndrome in Cirrhosis. Journal of Hepatology 2010 (53): p397-417.

Diuretik pada Ascites

Spironolakton saja
Pada temuan ascites pertama
Mulai dengan dosis 50-100 mg/hari, 100mg setiap 4-7 hari (maks. 400mg/hari)
Jika respons klinis kurang, atau hiperkalemia + furosemide

Kombinasi
Terutama pada ascites berulang
Spironolakton 100 mg + Furosemide 40 mg ( bertahap, maks. 160 mg/hari)

Perlu pemantauan (lab) lebih ketat

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.

Diuretik pada Ascites

Komplikasi:
Ureum & kreatinin
Ensefalopati
Hipo-/hiperkalemia
Hipotensi postural
Ginekomastia nyeri
Keram otot

Follow-up: BB, elektrolit, kreatinin serum

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.

Perjalanan Ascites Sirotik

Ascites inkomplikata

Ascites + hiponatremia

Ascites refrakter

Sindrom hepatorenal

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.

Hiponatremia
Bedakan hiper- atau hipovolemik
Balans Na negatif berkepanjangan, kehilangan cairan ekstraselular

Na serum , tanpa ascites/edema hiponatremia hipovolemik .

Terapi: normal saline & penyebabnya (stop diuretik)

Restriksi cairan 1000 ml/hari untuk mencegah Na serum semakin

Hindari Na terlalu cepat (>8-10 mmol/hari) osmotic

demyelination syndrome

European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal
Syndrome in Cirrhosis. Journal of Hepatology 2010 (53): p397-417.

Ascites Refrakter ?
Diuretic Intractable ?

Ascites Refrakter
Diuretic-resistant = tidak respons terhadap dosis maksimal diuretik +

restriksi garam
Diuretic-intractable = Terjadi komplikasi terkait terapi diuretik
Pilihan terapi:
Large-volume paracenteses (LVPs)
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Peritoneovenous shunting (LeVeen Shunt)
Transplantasi hepar

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.

Sindrom Hepatorenal
Gagal ginjal pada penyakit hati berat, tanpa adanya

kelainan patologis pada ginjal.

Klasifikasi:
Tipe 1: Penurunan fungsi ginjal progresif ( kreatinin serum

hingga >2,5 mg/dL) dengan cepat (<2minggu)

Tipe 2: Tidak terjadi progresivitas kegagalan ginjal (stabil)

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.

Sindrom Hepatorenal
Kriteria Diagnosis:
Sirosis + ascites
Kreatinin serum >1,5 mg/dL
Tidak ada perbaikan kreatinin serum setelah 2 hari lepas diuretik dan pemberian
albumin (1g/kgBB/hari hingga maks. 100g/hari)
Tidak syok/ hipovolemik
Tidak dalam terapi obat nefrotoksik/ vasodilator
Tidak ada penyakit parenkim ginjal (proteinuria, mikrohematuria, USG abnormal)

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.

Sindrom Hepatorenal
Penilaian kecukupan cairan, stop diuretik
Albumin 1,5 - 1g/kgBB, maks 100 gram

Stop obat nefrotoksik

Vasokonstriktor (terlipressin 1 mg IV setiap 6 jam)

Terapi kuratif hanya TRANSPLANTASI HATI.

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.

Spontaneous Bacterial Peritonitis (SBP)

Diagnosis= PMN >250/mm3 (dihitung mikroskopik)
Penyebab tersering = bakteri aerob gram negatif

Jika protein cairan ascites < 1,5 g/dL risiko SBP

antibiotik profilaksis.
Ceftriaxone (IV, 7 hari) pada perdarahan sal.cerna &

penyakit hati berat

Lebih ringan: kuinolon per oral

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.

Spontaneous Bacterial Peritonitis (SBP)

Terapi antibiotik empiris segera setelah diagnosis.
Lini 1: Cefotaxime 3-4 gr/hari, selama 5 hari.
Atau amoksisilin/klavulanat atau kuinolon (kecuali pada penerima profilaksis

kuinolon risiko resisten)

Jika 2-3 hari setelah mulai AB, PMN tidak berhasil turun sampai <25% semula

gagal terapi ganti AB

SBP teratasi risiko SBP rekuren AB profilaksis norfloxacin (400 mg/hari p.o),

atau ciprofloxacin (750mg per minggu p.o)/ kotrimoksazol (960 mg/hari p.o)

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.
American Association for The Study of Liver Disease. Management of Adult Patients with Ascites Due To Cirrhosis: Update 2012.

Prognosis
Buruk jika ascites pada sirosis
Variabel prognostik:
Renal water excretion
rerata tekanan arterial (MAP)

skor Child-Pugh
Kreatinin serum

Tsao GG. Ascites. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, ed. Sherlocks Diseases of The Liver and Biliary System. 12th edition. Blackwell Publishing Ltd, 2011. p210-233.
European Association for The Study of The Liver. EASL Clinical Practice Guidelines on The Management of Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome in Cirrhosis.
Journal of Hepatology 2010 (53): p397-417.