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Ascites

Dr. Prasad Kasbekar
Oncologist

verified

People with a swollen stomach or abdomen and those suffering from liver cirrhosis often come across a word at their doctor’s clinic, i.e., ascites. A medical term of significance, ascites is used to describe the fluid build-up between abdominal organs and peritoneal cavity (abdominal lining). Usually seen for liver diseases, it is primarily caused by the leakage of serous fluid (that surrounds red blood cells (RBCs)) in the body. Here is everything you should know about ascites, i.e. causes, diagnosis, symptoms, treatment and complications.

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Types

There are no known types of ascites.

Stages

There are no known stages of ascites.

Symptoms

The symptoms of ascites gradually develop and depend on the cause of the disease. Usually, a person reports symptoms when fluid gets accumulated in the abdomen:


  • Abdominal pain

  • Abdominal bloating

  • Shortness of breath

  • Abdominal swelling

  • Weight gain

  • Liver failure (in severe cases)

Causes And Risk Factors

Causes

The improper functioning of the liver places a pressure on the blood vessels, which compels body fluids to come out in the peritoneal cavity, thus leading to ascites. Characterized by fluid build-up in the abdomen, ascites can be attributed to a wide range of factors such as –


  • High pressure in the blood vessels of the liver (portal hypertension), which causes fluid leakage in the surrounding tissues

  • Low albumin levels in the body

  • Severe liver damage because of hepatitis, long-term alcohol abuse (leading to liver cirrhosis) or clots in the veins of the liver

  • Cancer of the liver, uterus, pancreas, colon and ovaries

  • Scarring of the tissue covering the heart

  • Inflammation of the pancreas

  • Kidney dialysis (in certain cases) causes ascites

  • Tuberculosis


Risk Factors

There are multiple common risk factors responsible for the development of ascites, which can then lead to liver cirrhosis. Some risk factors that can lead to this condition are hepatitis B, hepatitis C, and alcohol abuse for an extended time period. Disease conditions such as kidney failure and congestive heart failure lead to the buildup of fluid, which can cause ascites. Another risk factor in the development of ascites is cancer of organs in the abdomen.

Prevention

There is no defined manner in which ascites can be prevented.

Diagnosis

Usually, to determine the extent of abdominal swelling, the first step of diagnosis involves physical examination. It is then followed by various laboratory tests to determine the functioning of the different organs in the body. The diagnostic tests involve:


  • LFT (liver function test) – AST (aspartate aminotransferase) and ALT (alanine aminotransferase), albumin and alkaline phosphatase (ALP); there are six known tests to confirm your liver function.

  • RFT (renal/kidney function test) – BUN (blood urea nitrogen) and creatinine

  • Electrolyte analysis (sodium, potassium and chloride)

  • Urine analysis

  • Abdominal ultrasound/sonography



  • Ascites is diagnosed by appropriate ascitic fluid analysis. Diagnostic tests such as blood cell count, polymorphonuclear neutrophils (PMN) count and total nucleated cell count, and a bacterial cell culture performed by the inoculation of blood culture bottles are the initial test for diagnosing ascites.



  • To determine the serum ascites albumin gradient (SAAG), albumin and ascitic fluid proteins are measured in the sample. If the gradient is greater or equal to 1.1 g/dl, the patient is experiencing portal hypertension, which is an important result observed in alcoholic hepatitis, massive hepatic metastasis, heart failure, cirrhosis, Budd–Chiari syndrome, idiopathic portal fibrosis and portal vein thrombosis. If the gradient value is <1.1 g/dL, it indicates that the patient is not experiencing portal hypertension. Usually, this gradient value occurs in peritoneal tuberculosis, serositis, pancreatitis, nephrotic syndrome and peritoneal carcinomatosis. 

  • If secondary peritonitis is suspected, additional tests such as LDH and glucose levels are performed. The amylase levels of >1000 U/L indicates pancreatic ascites. For strongly suspected tuberculosis, a mycobacterial culture test is mandatory. Other parameters, such as lactate levels and pH of ascitic fluid, provide additional information.

  • Chest X-ray test results may provide insights into the elevated diaphragm. CT scan helps determine any mass present, which may lead to the diagnosis of ascites. Ultrasound is the most reliable test to detect ascites.

Treatment

The aim of the treatment is to drain out the fluid and treat the root of the problem, which includes three important strategies, namely,


  1. Lifestyle modifications: They are primarily aimed at removing excess fluid from the body by inculcating certain lifestyle changes such as



  • Limiting excessive intake of alcohol

  • Reducing the amount of salt consumption through your diet (eating not >1500 mg salt per day)

  • Cutting down on fluid intake



  1. Medications: Your doctor may prescribe medications depending on the severity of the condition and susceptibility to various infections. The commonly recommended medicines to treat this condition are listed below:



  • Diuretics: They are known as water pills, and they help in removing excess fluid from the body.

  • Antibiotics: If you suffer from bacterial infections, in addition to ascites, your doctor might recommend antibiotics.



  1. Surgical interventions: If the condition is not improved by lifestyle changes and use of medications or the person is suffering from severe abdominal pain because of ascites, your doctor might go for surgery to treat ascites. These treatment options include



  • Paracentesis: It involves the insertion of a tube into the stomach to remove excess fluid.

  • Trans jugular intrahepatic portosystemic shunt (TIPS): In this approach, a special shunt is paced in the stomach to improve blood flow to the liver and thus drain the excess fluid that cause ascites.


Liver transplantation: People suffering from end-stage liver disease or liver failure require liver transplantation to improve their condition.

Lifestyle/management

Lifestyle changes an essential component of managing ascites:


  • The salt amount in your diet should be restricted because it is important to reduce your salt intake to treat ascites. Recommended nutritional limit for sodium intake is <2000 mg or less per day.  

  • Use of water pills (diuretics) is necessary to manage ascites. However, for your salt intake, taking water pills is not an alternative solution. Both these interventions are required to treat ascites.

  • Alcoholic beverages should be limited or avoided in all cases because it reduces the risk of developing ascites.

  • Nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen damage the kidneys, causing water retention in the body. Hence, these drugs should be limited or avoided if they are not required.

Prognosis And Complications

Prognosis

The prognosis of ascitic patients depends on the disease cause and severity. Patients with the acute stage of ascites are more responsive towards managing and providing a favorable prognosis. However, patients with chronic ascites are challenging to respond to and manage.

Complications

If left untreated, ascites may lead to many other health complications because of the excess force exerted by fluid build-up in the stomach. This in turn causes


  • Compression of internal organs

  • Protein malnutrition

  • Sudden increase in blood pressure

  • Kidney failure is a complication of liver cirrhosis. The incidence of this condition is low; however, this condition can lead to severe complications.

  • Hepatic encephalopathy

  • Other health problems because of liver cirrhosis. 

  • Abdominal pain one of the complications of ascites. This can happen when there is fluid build-up in the abdominal cavity. Abdominal pain causes discomfort or the inability to eat, perform daily activities or walk.

  • Infection is a complication that can occur because of infection in the fluid build-up in the gut. This condition is referred to as spontaneous bacterial peritonitis. The symptoms of spontaneous bacterial peritonitis are fever and abdominal pain. This condition is diagnosed by considering the abdominal cavity sample. The treatment of spontaneous bacterial peritonitis is IV antibiotics.

  • Hepatic hydrothorax is a condition in which there is an excess fluid build-up in the lungs. This can lead to the symptoms of cough, chest discomfort, shortness of breath or hypoxemia.

Alternative Treatments

Alternative treatments include


  • Surgery - Surgery is performed to place a shunt between smaller veins and central vein in the body. This helps in increasing the blood flow to the organs of the body and improve kidney function.

  • A liver transplant is recommended for patients with chronic liver failure.

  • Despite using diuretics and a limited salt diet, paracentesis is a method that is used to remove excess fluid overload in your body.

References


  1. Stat Pearls. Ascites [Updated on November 18, 2020] Available at https://www.ncbi.nlm.nih.gov/books/NBK470482/. Accessed on April 7, 2021. (https://www.ncbi.nlm.nih.gov/books/NBK470482/)

  2. Cleveland Clinic. Ascites [Internet] Available at https://my.clevelandclinic.org/health/diseases/14792-ascites#prevention. Accessed on April 7, 2021. (https://my.clevelandclinic.org/health/diseases/14792-ascites#prevention)

  3. Vaz AM, et al. 2017; bcr2017220500. 

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