1/

WHERE does ascites come from?
HOW do diuretics treat ascites?
ARE you ready for a #tweetorial?

#livertwitter #medtwitter #MedEd
2/
First, ascites is:
1⃣Fluid in the belly
2⃣Awful
3⃣A cruel trick the liver plays on the heart and kidney

Throw back to my "what is #cirrhosis?" tweetorial
https://twitter.com/ebtapper/status/1185513443199246336?s=20
3/

The first 'lesion' in ascites formation is the fibrotic liver.

Fibrotic liver:
⬆️sinusoidal hydrostatic pressure
⬆️lymph formation

"Mo sinusoidal pressure, mo lymph"
- Ernest H. Starling MD, personal communication
4/

Lymph production in #cirrhosis is:
1⃣Proportional to portal pressure
2⃣Massive. Nearly 10 times normal
Thoracic duct flow goes from 120cc/hr to up to 1.2L/hr!

😀Fig2: Splenorenal shunt surgery ⬇️lymph production

🥸Fig3: Drain the thoracic duct & eliminate ascites
4/Lymph production in #cirrhosis is:Proportional to portal pressureMassive. Nearly 10 times normalThoracic duct flow goes from 120cc/hr to up to 1.2L/hr!Fig2: Splenorenal shunt surgery lymph productionFig3: Drain the thoracic duct & eliminate ascites
4/Lymph production in #cirrhosis is:Proportional to portal pressureMassive. Nearly 10 times normalThoracic duct flow goes from 120cc/hr to up to 1.2L/hr!Fig2: Splenorenal shunt surgery lymph productionFig3: Drain the thoracic duct & eliminate ascites
4/Lymph production in #cirrhosis is:Proportional to portal pressureMassive. Nearly 10 times normalThoracic duct flow goes from 120cc/hr to up to 1.2L/hr!Fig2: Splenorenal shunt surgery lymph productionFig3: Drain the thoracic duct & eliminate ascites
5/

As portal hypertension worsens (as the HVPG rises past 10mmHg), the lymphatics are stressed, then overwhelmed, and ascites develops
5/ As portal hypertension worsens (as the HVPG rises past 10mmHg), the lymphatics are stressed, then overwhelmed, and ascites develops
5/ As portal hypertension worsens (as the HVPG rises past 10mmHg), the lymphatics are stressed, then overwhelmed, and ascites develops
6/

But WHERE does the ascites actually come from?

The weeping liver!

Check this 1955 paper out:

Method: clamped IVC in dogs
Result: Ascites beaded on the liver surface. Covering the liver with a bag collects all the ascites, keeps the gut dry
7/

Hold up!

We dont yet understand where the extra fluid is coming from

The secret lies between two seemingly conflicting facts:

People with #cirrhosis and ascites have:
1. Peripheral fluid overload
2. Low central blood volume
8/

The reason for low central blood volume in #cirrhosis:

1⃣Despite ⬆️lymph return, 🫀is underfilled
2⃣All the blood is trapped in vasodilated gut arteries
3⃣Arterial vasodilation is proportional to disease severity
8/The reason for low central blood volume in #cirrhosis:Despite lymph return, is underfilledAll the blood is trapped in vasodilated gut arteries Arterial vasodilation is proportional to disease severity
8/The reason for low central blood volume in #cirrhosis:Despite lymph return, is underfilledAll the blood is trapped in vasodilated gut arteries Arterial vasodilation is proportional to disease severity
8/The reason for low central blood volume in #cirrhosis:Despite lymph return, is underfilledAll the blood is trapped in vasodilated gut arteries Arterial vasodilation is proportional to disease severity
9/

If blood is trapped, return to the heart is low, and so is delivery to the pesky kidney

As a result:
1⃣ALL THE TOOLS are revved: Renin, aldosterone, ADH, norepi
2⃣Renal tubules respond: sodium & free H20 excretion plummets
3⃣Plasma volume increases
9/If blood is trapped, return to the heart is low, and so is delivery to the pesky kidneyAs a result:ALL THE TOOLS are revved: Renin, aldosterone, ADH, norepiRenal tubules respond: sodium & free H20 excretion plummets Plasma volume increases
9/If blood is trapped, return to the heart is low, and so is delivery to the pesky kidneyAs a result:ALL THE TOOLS are revved: Renin, aldosterone, ADH, norepiRenal tubules respond: sodium & free H20 excretion plummets Plasma volume increases
10/

Interim summary:

#cirrhosis
+ Portal hypertension
+ Arterial vasodilation
+ ⬆️plasma volume
+ Starling forces

= Ascites
QED
11/

NOW

how do diuretics work?

1⃣The peritoneum absorbs 0.5-1L/day
2⃣Diuretics do NOT speed this up
3⃣Diuretics drop plasma volume!
11/NOWhow do diuretics work?The peritoneum absorbs 0.5-1L/dayDiuretics do NOT speed this upDiuretics drop plasma volume!
11/NOWhow do diuretics work?The peritoneum absorbs 0.5-1L/dayDiuretics do NOT speed this upDiuretics drop plasma volume!
11/NOWhow do diuretics work?The peritoneum absorbs 0.5-1L/dayDiuretics do NOT speed this upDiuretics drop plasma volume!
12/

1⃣Diuretics work by Starling forces!
They⬇️pressure gradient between portal & hepatic veins (HVPG)

How?
2⃣They drop HVPG proportional to⬇️plasma volume

How?
3⃣Spironolactone addresses the cause: high aldo
12/Diuretics work by Starling forces! Theypressure gradient between portal & hepatic veins (HVPG)How?They drop HVPG proportional toplasma volumeHow?Spironolactone addresses the cause: high aldo
12/Diuretics work by Starling forces! Theypressure gradient between portal & hepatic veins (HVPG)How?They drop HVPG proportional toplasma volumeHow?Spironolactone addresses the cause: high aldo
12/Diuretics work by Starling forces! Theypressure gradient between portal & hepatic veins (HVPG)How?They drop HVPG proportional toplasma volumeHow?Spironolactone addresses the cause: high aldo
13/

Final summary
1⃣Ascites=a trick the liver plays on the 🫀/kidney
2⃣Sinusoidal htn⬆️⬆️lymph production
3⃣Arterial vasodilation traps blood in the gut
4⃣Cardiac return suffers
5⃣RAAS en fuego
6⃣⬆️Plasma volume
7⃣Ascites forms
8⃣Diuretics⬇️plasma volume; spiro⬇️RAAS
/End

This concludes a #tweetorial on ascites formation/treatment. Thank you for reading. I hope you enjoyed.

🙏to @jaumebosch9 and @BloomPringle for their input

If interested, please see below for my 'ascites' menu
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