Definition and Overview

Ascites is a term used to describe a medical condition characterised by the abnormal accumulation of fluid in the abdominal cavity. It is associated with many underlying diseases, such as liver cirrhosis and cancer, among others.

Patients require immediate treatment for this condition because ascites can cause serious health problems and complications that may affect key bodily functions.

Causes of Condition

There are many possible causes of abnormal fluid accumulation in the peritoneal cavity. These include:

  • Liver disease - Liver disease, especially liver cirrhosis and those in the advanced stages, are the most common causes of ascites.

  • Cancer - Ascites that manifest due to cancer are called malignant ascites. They are common symptoms of advanced cancers of the colon, pancreas, stomach, breast, lungs, and ovaries.

  • Pancreatitis - Patients who have been suffering from chronic pancreatitis (inflammation of the pancreas) are also at risk of developing pancreatic ascites. The condition is closely linked to long-term alcohol abuse, but can also be caused by acute pancreatitis or physical trauma to the pancreas.

  • Kidney failure - Kidney failure leads to general and widespread fluid retention in the body, which can result in the development of ascites.

  • Internal or external obstruction of portal vessels - This can occur when a tumour presses down on a vessel or a blood clot forms inside the vessel. This causes the pressure inside the vessels to rise, leading to ascites formation.

Risk factors include:

Many experts believe that ascites develop primarily due to portal hypertension, a condition characterised by increased blood pressure in the liver. However, other factors such as salt and water retention may also play a role.

Key Symptoms

Ascites symptoms include:

  • Abdominal pain

  • Bloating

  • Discomfort

  • Shortness of breath

  • Abnormally large belly

  • Indigestion

  • Nausea

  • Vomiting

  • Heartburn

  • Hernia

  • Leg swelling

  • Bruising

  • Gynaecomastia

  • Hematemesis

Examining the abdomen will also show a fluid wave or fluid thrill, a wave-like effect that ripples toward the other side of the abdomen.

Aside from these symptoms, ascites can also cause some serious complications, including the following:

  • Infections, such as spontaneous bacterial peritonitis (SBP)

  • Hepatorenal syndrome

Ascites are diagnosed by first measuring the amount of fluid involved and looking at the patient’s medical history to determine what causes them to form. If there is no outward sign of abnormal fluid accumulation, an ultrasound can be performed to detect smaller amounts of fluid. In many cases, ascites are detected incidentally during an ultrasound or computed tomography (CT) scan performed for other medical reasons.

To assist in the diagnosis and help determine the most appropriate treatment, patients may also undergo a complete metabolic panel as well as a complete blood count.

Patients suffering from ascites may undergo a procedure called paracentesis, which allows doctors to take a sample of the fluid in the abdomen for further testing. It involves inserting a needle into the abdominal cavity to take a small amount (around 20cc) of the fluid.

Who to See and Types of Treatments Available

A primary care physician, family doctor, or general practitioner can treat patients suspected of having ascites. However, depending on the cause of the condition, patients may also be placed under the care of specialists, such as hepatologists and gastroenterologists.

Treatment options for ascites include:

  • Diet changes - Patients with ascites due to cirrhosis or liver issues need to make some changes in their diet, such as limiting sodium intake to less than 2 grams per day.

  • Diuretics - Patients need to take diuretics for salt restriction. These work by increasing the amount of salt excreted from the kidneys to combat salt and water retention associated with ascites.

  • Therapeutic paracentesis - A paracentesis procedure can also help relieve the symptoms of abdominal ascites by reducing the amount of fluid in the abdomen. In this case, a larger amount of fluid (up to five litres) is removed. This is also called large volume paracentesis and is especially helpful for those suffering from malignant ascites.

  • Surgery - Patients can also undergo a surgical procedure called transjugular intrahepatic portosystemic shunt (TIPS) that aims to normalise portal blood pressure. The procedure is performed under local anaesthesia and involves placing a shunt between the portal venous system and systemic venous system through the main jugular vein in the neck.

  • Liver transplant - If the patient is suffering from severe liver damage, a liver transplant may also be considered. However, a transplant surgery entails a long and complicated process. The patient will be placed under the care of transplant specialists while awaiting the procedure.

The long-term prognosis for patients with ascites depends primarily on the underlying cause of the condition. In general, however, the prognosis is poor for malignant ascites and quite fair for ascites caused by cirrhosis as long as the underlying liver issue is properly managed. So far, ascites caused by heart failure has the best prognosis as long as the patient receives proper treatment.

References:

  • Gines P, Cardenas A, Arroyo V, Rodes J. “Management of Cirrhosis and Ascites.” N Engl J Med. 2004; 3350: 1646-1654. http://www.nejm.org/doi/pdf/10.1056/NEJMra035021

  • Runyon BA. “Care of patients with ascites.” N Engl J Med. 1994; 330: 337-342. http://www.nejm.org/doi/full/10.1056/NEJM199402033300508

  • Gerbes AL. “Medical treatment of ascites in cirrhosis.” Journal of Hepatology. 1993; 17(2): S4-S9. http://www.journal-of-hepatology.eu/article/S0168-8278(05)80447-7/abstract

  • Moore KP, Aithal GP. “Guidelines on the management of ascites in cirrhosis.” Gut. 2006 Oct; 55(Suppl 6): vi1-vi12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860002/

  • Herrine SK. “Ascites.” Merck Manual. http://www.merckmanuals.com/home/liver-and-gallbladder-disorders/manifestations-of-liver-disease/ascites

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