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EASL Update 2025 : Autoimmune Hepatitis

EASL Update 2025 : chronic hepatitis B infection

The Main causes of Non-cirrhotic ascites: 1. Portal Hypertension (Non-Cirrhotic) - Portal vein thrombosis: Blood clot in the portal vein increases portal pressure, leading to ascites. - Splenic vein thrombosis: Can cause localized portal hypertension, often with splenomegaly. - Schistosomiasis: Parasitic infection causing presinusoidal portal hypertension, common in endemic areas. - Nodular regenerative hyperplasia: Abnormal liver nodule formation without fibrosis, leading to portal hypertension. 2. Malignancy-Related - Peritoneal carcinomatosis: Cancer spread to the peritoneum (e.g., ovarian, gastric, or colorectal cancer) causes fluid exudation. - Primary peritoneal mesothelioma: Rare cancer of the peritoneal lining. - Lymphoma: Can obstruct lymphatic drainage, leading to ascites. - Hepatic metastases: Extensive liver metastases can mimic portal hypertension. 3. Infectious Causes - Tuberculosis: Peritoneal tuberculosis can cause exudative ascites, often with fever and weight loss. - Spontaneous bacterial peritonitis: Though more common in cirrhosis, can occur in other conditions. - Fungal or parasitic infections: Less common, but can involve the peritoneum (e.g., histoplasmosis). 4. Hypoalbuminemia - Nephrotic syndrome: Severe proteinuria reduces serum albumin, lowering oncotic pressure and causing ascites. - Protein-losing enteropathy: Loss of protein through the gut (e.g., in Crohn’s disease or celiac disease) leads to low albumin. 5. Lymphatic Disorders - Chylous ascites: Leakage of lymphatic fluid into the peritoneal cavity due to lymphatic obstruction or trauma (e.g., surgery, lymphoma, or congenital lymphangiectasia). - Lymphatic malformations: Rare congenital conditions disrupting lymphatic drainage. 6. Cardiac Causes - Right heart failure: Elevated central venous pressure from heart failure (e.g., tricuspid regurgitation, constrictive pericarditis) leads to ascites. - Constrictive pericarditis: Restricts heart filling, increasing venous pressure. - Pulmonary hypertension: Can cause right-sided heart strain and ascites. 7. Renal and Endocrine Disorders - Chronic kidney disease: Fluid overload or hypoalbuminemia from nephrotic syndrome. - Myxedema: Severe hypothyroidism can cause ascites due to fluid retention and increased capillary permeability. 8. Pancreatic Ascites - Leakage of pancreatic fluid into the peritoneum, often due to pancreatitis, pancreatic duct rupture, or pseudocyst rupture. 9. Biliary Ascites - Bile leakage into the peritoneum from gallbladder or bile duct perforation (e.g., post-cholecystectomy or trauma). 10. Gynecologic Causes - Ovarian hyperstimulation syndrome: Seen in fertility treatments, causing vascular permeability and ascites. - Meigs syndrome: Benign ovarian tumors (e.g., fibroma) with ascites and pleural effusion, resolving after tumor removal. 11. Other Rare Causes - Serositis: Associated with autoimmune diseases like systemic lupus erythematosus or rheumatoid arthritis. - Eosinophilic gastroenteritis: Eosinophilic infiltration of the peritoneum. - Endometriosis: Rarely causes hemorrhagic ascites. - Retroperitoneal fibrosis: Can compress veins or lymphatics, leading to ascites. Diagnostic Notes: - Ascites fluid analysis (e.g., SAAG, serum-ascites albumin gradient) helps differentiate causes: - SAAG ≥1.1 g/dL: Suggests portal hypertension (e.g., portal vein thrombosis). - SAAG <1.1 g/dL: Indicates non-portal hypertension causes (e.g., malignancy, tuberculosis, nephrotic syndrome). - Imaging (e.g., ultrasound, CT) and lab tests (e.g., albumin, cytology, culture) are critical for identifying the underlying cause.

Primary biliary cholangitis and the narrowing gap towards optimal disease control