What is Ascites?

Ascites refers to an abnormal build-up of fluid in the abdomen, specifically in a part called the peritoneal cavity. This condition is the most common issue related to liver cirrhosis, developing in about half of the patients within 10 years of being diagnosed with said disease. Ascites generally indicates the shift from a managed stage of cirrhosis to a more severe, unmanaged one. This can lead to increased chances of death due to complications such as spontaneous bacterial peritonitis and hepatorenal syndrome, where the mortality rates can range from 15% in one year to 44% in five years.

In normal, healthy individuals, very small amounts of free fluid exists in the peritoneal cavity; some women may have about 20 ml during their menstrual cycle.

What Causes Ascites?

In the US, the main reason people develop ascites, a condition in which excess fluid fills the abdomen, is cirrhosis, an advanced liver disease. This is responsible for about 80% of cases. Other causes include cancer (10%), heart failure (3%), tuberculosis (2%), undergoing dialysis (1%), pancreatic disease (1%), and other conditions (2%).

Interestingly, nearly 19% of patients with cirrhosis might experience what’s called hemorrhagic ascites, where their excess abdominal fluid is bloody. This can happen on its own, and in most instances (72%), it’s likely because of bloody lymph, a vital bodily fluid, and in 13% of cases, hepatocellular carcinoma, a type of liver cancer. This bloody fluid can also develop after a medical procedure known as paracentesis.

Several other conditions and lifestyle habits can cause ascites, including:

– Chronic use of alcohol
– Intravenous drug use
– Being overweight
– High cholesterol
– Type 2 diabetes
– Nephrotic syndrome, a kidney disorder
– Severe malnutrition
– Pancreatic ascites, a specific type relating to the pancreas
– Ovarian lesions, which are abnormal tissue growths.

Risk Factors and Frequency for Ascites

Patients suffering from cirrhotic ascites, or fluid buildup in the abdomen due to severe liver disease, face a fairly high risk. Around 50% of these patients unfortunately do not survive past 3 years. The outlook becomes even grimmer if the condition becomes stubborn and doesn’t improve with treatment, dropping the survival rate to less than 50% in one year. When it comes to the amount of this fluid in a healthy body, males usually have very little. On the other hand, females generally have about 20 mL, although this can vary depending on where they are in their menstrual cycle.

Signs and Symptoms of Ascites

Ascites is a medical condition characterized by an abnormal accumulation of fluid in the abdomen, which causes it to gradually swell. This process can either be painless or accompanied by abdominal discomfort and can lead to additional symptoms such as:

Weight gain
A feeling of fullness after eating just a little food (early satiety)
Shortness of breath
Fever
Abdominal tenderness
Confusion

Ascites can be caused by different health problems. For example, if the ascites is due to cancer, it might also cause weight loss. If it’s caused by heart failure, patients could report difficulty breathing, particularly when lying down (orthopnea), and swelling of the legs and feet (peripheral edema). In particularly unusual type of ascites, known as chylous ascites, diarrhoea, poor nutrition, swollen lymph nodes and night sweats might be reported.

During a medical examination, a doctor might find several signs that a person has ascites, such as:

A dull sound when the sides of the abdomen (flanks) are tapped
A wave-like motion across the abdomen when one side is tapped (fluid wave)
Fluid in the lungs (pleural effusions)
Symptoms associated with the underlying cause of the ascites, such as those of cirrhosis or heart failure

If cirrhosis is the cause, the doctor might see red spider-like veins on the skin (spider angioma), redness on the palms of the hands (palmar erythema), or veins visible through the skin on the abdomen. Other signs of advanced liver disease include yellowing of the skin and the whites of the eyes (jaundice), muscle wasting, enlarged breasts in men (gynecomastia), and white spots on the nails (leukonychia). If a small lump (nodule) is found at the belly button, this could be a sign that cancer is causing the ascites.

In cases of heart failure, signs might include distended neck veins (jugular venous distension), lung congestion, or leg and ankle swelling (peripheral edema).

Testing for Ascites

Abdominal paracentesis is a procedure that analyzes the fluid in the abdomen (ascitic fluid) to determine the cause of fluid build-up or “ascites”. It’s fast and cost-effective method.

The fluid is tested to count the number of blood cells, both total and a type known as polymorphonuclear neutrophils (PMN), and to check for bacteria.

The protein and albumin levels in the ascitic fluid are compared to the albumin level in the blood. Based on those results, a ‘serum-ascites albumin gradient’ (SAAG) is calculated. Ramarkably, if the SAAG is 1.1 g/dL or more, it suggests with 97% accuracy that the patient has portal hypertension, a condition associated with liver diseases and heart problems. If the SAAG is less than 1.1 g/dL, it suggests that the cause of the ascites is not portal hypertension, but other conditions such as cancerous growths in the abdomen, pancreas inflammation, or kidney diseases.

Additional tests may be needed if a specific diagnosis is suspected. For example, if secondary peritonitis (inflammation of the inner wall of the abdomen) is suspected, doctors will test for lactate dehydrogenase (LDH) and glucose level. If pancreatic ascites (fluid in the abdomen due to pancreas problems) is suspected, they measure the level of an enzyme called amylase. If tuberculosis is strongly suspected, a mycobacterial culture is performed. Other analytes, such as lactate and pH, don’t typically provide relevant information.

Imaging techniques can also provide useful information. A chest x-ray, for instance, may show abnormalities in the diaphragm, while an ultrasound proves very effective in detecting ascites. It can identify even small amounts of fluid build-up in specific areas of the abdomen like Morison’s pouch. Finally, a CT scan can help detect both ascites and possible masses in the abdomen.

Treatment Options for Ascites

The treatment plan for ascites, which is the build-up of fluid in the abdomen, depends on the underlying cause of this fluid retention. The main objectives of ascites therapy are lessening the amount of this fluid and reducing leg swelling—but without draining too much fluid from the bloodstream.

Treatment often involves a combination of limiting salt intake and taking diuretics (water pills).

For patients with a type of ascites linked to conditions like cirrhosis, it’s recommended to stop drinking alcohol, limit daily salt intake, and take certain diuretics. If the cause of the liver condition can be treated—such as autoimmune hepatitis, chronic hepatitis B, hemochromatosis, or Wilson disease—specific therapy should be offered for these diseases. In some cases, people whose ascites is due to conditions other than alcohol use or hepatitis B may be more suited for a liver transplant than long-term medical treatment.

Another type of ascites usually appears in patients with non-ovarian cancers that have spread to the peritoneum (the lining of the abdomen). These patients often benefit from having the fluid drained out in an outpatient procedure. In cases of ovarian cancer, removing the tumor surgically and undergoing chemotherapy might be beneficial.

Tuberculosis-related ascites is treated with anti-TB drugs, whilst ascites linked to issues with the pancreas or a recent operation on the spleen or lymph nodes can often get better on their own.

Ascites caused by a Chlamydia infection in the peritoneum can be treated with antibiotics, while ascites related to lupus may improve with steroid therapy.

Over time, various pumps have been created to help with the ascites, but none have proved very reliable—they often get blocked, stop working or leak.

For those with severe ascites, a procedure to drain the fluid, called a therapeutic paracentesis, is often used to relieve symptoms. This should be followed up with supplements of albumin, a type of protein, to prevent low blood pressure. If albumin isn’t available, another substance called Terlipressin can be used.

For patients who don’t respond to diuretics, a treatment known as a transjugular intrahepatic portosystemic shunt can be used. This procedure creates a new connection between blood vessels in the liver, helping to reduce pressure and fluid build-up.

Liver Failure
Diseases affecting the bile ducts
Liver disease caused by excessive alcohol consumption
Scarring of the liver, also known as cirrhosis
Heart condition where the heart’s muscle becomes stretched and thin (Dilated Cardiomyopathy)
Liver cancer
High blood pressure in the liver (Portal hypertension)
Liver infection caused by a virus, known as viral hepatitis
Kidney disease causing high levels of protein in urine and low levels of protein in the blood, known as Nephrotic syndrome

What to expect with Ascites

The outlook for patients with ascites – which is a buildup of fluid in the abdomen – depends on what caused it and how long the patient has had it. Conditions that come on suddenly and respond well to treatment generally have a better outlook. On the other hand, conditions that don’t respond to treatment typically have a less favorable outlook.

Possible Complications When Diagnosed with Ascites

Spontaneous bacterial peritonitis is a condition that can lead to various complications, especially if a procedure called paracentesis is done. Some of these complications include:

Infection
Imbalance of electrolytes (minerals) in the body
Perforation (hole) in the bowel
Bleeding
Leakage of fluid through the wall of the abdomen
Injury to the kidneys

Recovery from Ascites

People with ascites, a condition where there’s too much fluid in the abdomen, need constant check-ups to see if their treatment is working. This means keeping track of their body weight and the amount of sodium in their urine, especially if they are taking a drug called furosemide.

The main aim of their treatment is to reduce swelling and make sure they can do some daily activities without any issues.

It’s also suggested for these patients to eat a diet low in sodium.

Preventing Ascites

It’s suggested to reduce the amount of alcohol consumed. Getting vaccinated against Hepatitis B can also be beneficial. It’s recommended to limit your sodium (salt) intake to no more than 2000 milligrams per day.

Frequently asked questions

Ascites refers to an abnormal build-up of fluid in the abdomen, specifically in a part called the peritoneal cavity.

Ascites is responsible for about 80% of cases of excess fluid filling the abdomen.

Signs and symptoms of Ascites include: - Abnormal accumulation of fluid in the abdomen, causing gradual swelling - Painless or accompanied by abdominal discomfort - Weight gain - Feeling of fullness after eating just a little food (early satiety) - Shortness of breath - Fever - Abdominal tenderness - Confusion In addition, depending on the underlying cause of Ascites, there may be specific symptoms: - Ascites due to cancer may also cause weight loss - Ascites caused by heart failure may result in difficulty breathing, particularly when lying down (orthopnea), and swelling of the legs and feet (peripheral edema) - Chylous ascites, a rare type of Ascites, may be accompanied by diarrhea, poor nutrition, swollen lymph nodes, and night sweats During a medical examination, a doctor may find the following signs of Ascites: - Dull sound when tapping the sides of the abdomen (flanks) - Wave-like motion across the abdomen when one side is tapped (fluid wave) - Presence of fluid in the lungs (pleural effusions) - Symptoms associated with the underlying cause of Ascites, such as those of cirrhosis or heart failure Specific signs related to the underlying cause of Ascites may also be observed: - Cirrhosis may present with red spider-like veins on the skin (spider angioma), redness on the palms of the hands (palmar erythema), visible veins on the abdomen, yellowing of the skin and eyes (jaundice), muscle wasting, enlarged breasts in men (gynecomastia), and white spots on the nails (leukonychia) - In cases of cancer-related Ascites, a small lump (nodule) at the belly button may be found - Heart failure may be indicated by distended neck veins (jugular venous distension), lung congestion, or leg and ankle swelling (peripheral edema)

Ascites can be caused by various health problems, including cirrhosis (80% of cases), cancer (10% of cases), heart failure (3% of cases), tuberculosis (2% of cases), undergoing dialysis (1% of cases), pancreatic disease (1% of cases), and other conditions (2% of cases). Additionally, several lifestyle habits and conditions such as chronic alcohol use, intravenous drug use, being overweight, high cholesterol, type 2 diabetes, nephrotic syndrome, severe malnutrition, pancreatic ascites, and ovarian lesions can also cause ascites.

The doctor needs to rule out the following conditions when diagnosing Ascites: - Cancerous growths in the abdomen - Pancreas inflammation - Kidney diseases

The types of tests that are needed for Ascites include: - Abdominal paracentesis: This procedure analyzes the fluid in the abdomen to determine the cause of fluid build-up. It involves testing the fluid for blood cell count, including polymorphonuclear neutrophils (PMN), and checking for bacteria. The protein and albumin levels in the ascitic fluid are compared to the albumin level in the blood to calculate the serum-ascites albumin gradient (SAAG). - Additional tests: Additional tests may be needed based on suspected diagnoses. For example, if secondary peritonitis is suspected, doctors will test for lactate dehydrogenase (LDH) and glucose level. If pancreatic ascites is suspected, the level of amylase is measured. If tuberculosis is suspected, a mycobacterial culture is performed. - Imaging techniques: Imaging techniques such as chest x-ray, ultrasound, and CT scan can provide useful information. A chest x-ray may show abnormalities in the diaphragm, while an ultrasound can detect even small amounts of fluid build-up. A CT scan can help detect both ascites and possible masses in the abdomen.

The treatment for ascites depends on the underlying cause of the fluid retention. It often involves a combination of limiting salt intake and taking diuretics. For patients with ascites linked to conditions like cirrhosis, it is recommended to stop drinking alcohol, limit salt intake, and take certain diuretics. Specific therapy should be offered for liver conditions that can be treated. In some cases, a liver transplant may be more suitable than long-term medical treatment. Other treatment options include draining the fluid through outpatient procedures, surgical removal of tumors, chemotherapy, anti-TB drugs, antibiotics, steroid therapy, therapeutic paracentesis, and transjugular intrahepatic portosystemic shunt for patients who do not respond to diuretics.

The side effects when treating Ascites can include: - Infection - Imbalance of electrolytes (minerals) in the body - Perforation (hole) in the bowel - Bleeding - Leakage of fluid through the wall of the abdomen - Injury to the kidneys

The prognosis for ascites depends on the underlying cause and how long the patient has had it. If the condition is sudden and responds well to treatment, the outlook is generally better. However, if the condition does not respond to treatment, the prognosis is less favorable.

A gastroenterologist or hepatologist.