Ascites is the abnormal accumulation of free fluid within the peritoneal cavity (the space between abdominal organs and abdominal wall). It often signals underlying health problems, particularly liver disease, but can also result from conditions affecting the heart, kidneys, lymph nodes or cancer.
This blog will provide an up-to-date and in-depth look at ascites, including its features, types, causes, risk factors, symptoms, investigations, and management as per the guidelines outlined by the World Health Organization (WHO).
Now, let's come to the point that what is Ascites?
Ascites typically denotes excessive accumulation of free fluid in the peritoneal cavity. It manifests as abdominal swelling, which can lead to discomfort, pain, and other severe complications. Ascites is primarily associated with liver cirrhosis and other chronic liver diseases, but it can also develop due to other medical conditions.
Types of Ascites
Ascites can be classified into different types based on the underlying cause and the nature of the fluid.
Typically ascites is of 2 types - Transudative ascites & Exudative ascites.
1. Exudative Ascites: If the ascites protein concentration is >25gm/l as well as serum-ascites albumin gradient of less than 11gm/l, it is known as exudative ascites. This occurs due to inflammation, infection, or cancer. The fluid in exudative ascites is rich in proteins and may contain other inflammatory markers. Conditions like tuberculosis or malignancies can cause this type of ascites.
2. Transudative Ascites: If the ascites protein concentration is <25gm/l as well as serum-ascites albumin gradient of more than 11gm/l, it is known as transudative ascites. This type results from increased pressure in the blood vessels related to cirrhosis or heart failure. The fluid in exudative ascites is usually low in protein and other solutes.
Some other types of ascites are also found as follows :
Chylous Ascites: Rarely, lymphatic system disruption leads to chylous ascites, where the peritoneal cavity fills with lymphatic fluid rich in triglycerides. This can occur due to cancer, trauma, or lymphatic obstruction.
Haemorrhagic Ascites: In this type, blood is present in the peritoneal cavity which can result from trauma, ruptured tumor or severe liver diseases.
Causes and Risk Factors of Ascites
The development of ascites is often a sign of severe illness, most commonly liver disease.
The key causes include:
1. Cirrhosis: It is the most common cause of ascites. Cirrhosis leads to portal hypertension, where the increased pressure in the portal vein causes fluid to leak into the abdominal cavity.
2. Heart Failure: When the heart is unable to pump efficiently, fluid may build up in various parts of the body, including the abdomen, leading to ascites.
3. Kidney Disease: Conditions like nephrotic syndrome can cause significant protein loss in the urine, leading to low protein levels in the blood and fluid accumulation in the abdomen.
4. Malignancies: Cancers, particularly those affecting the liver, pancreas or peritoneum can cause exudative ascites.
5. Infections: Tuberculosis and spontaneous bacterial peritonitis (SBP) are important infectious causes of ascites.
Risk Factors for developing ascites include:
- Chronic alcohol use leading to liver damage
- Hepatitis B and C infections
- Obesity and metabolic syndrome, which can result in fatty liver disease
- Long-term heart disease
- Malnutrition
- Meigs’ syndrome
- Hypothyroidism
Signs and Symptoms
The symptoms of ascites can vary depending on the underlying causes, the amount of fluid accumulation, and the speed at which fluid builds up.
Common signs and symptoms include:
- Abdominal distension with fullness in the flanks
- Abdominal pain or discomfort
- Shortness of breath
- Nausea and reduced appetite
- Periorbital and pedal oedema
- Clubbing
- Weight gain
In severe cases, ascites may lead to complications such as bacterial infections, kidney dysfunction, or hernias.
Clinical Examination
To diagnose and understand the cause of ascites, the following investigations are to be employed:
Physical Examination: A healthcare provider will find the following findings:
In general -
- Hepatic facies
- Confusion, disorientation, disturbed sleep pattern
- Periorbital oedema
- Lymphadenopathy
- Raised JVP and cyanosis
- Clubbing of fingers
- Stigmata of CLD
- Palmar erythema
- Pedal oedema
- Signs of nutritional deficiency
In the abdomen -
- Abdominal distension
- Fullness in the flanks
- Dilated superficial abdominal veins
- Eversion of the umbilicus
- Abdominal striae
- Shifting dullness on percussion
- Fluid thrill (if the ascites is marked)
Associated features -
- Herniae
- Divarication of the recti and scrotal oedema
- Pleural effusion
- Splenomegaly
- Hepatomegaly
Investigations:
1. Ascitic fluid analysis
The ascitic fluid is analyzed to determine its nature (transudate or exudate) of ascites which include :
- Appearance
- Ascitic albumin
- White cell count (250*10^6/L strongly suggests SBP)
- Cytology for malignant cells
- Microscopy and culture
- Ascitic amylase (increased in ascites)
2. Serum albumin & total protein
3. USG of the whole abdomen
4. Liver function tests (if CLD is suspected)
5. CBC with ESR (to detect any infection)
6. Chest x-ray
7. CT scan or MRI (to detect any growth ot mass)
Let's learn about different appearances of ascitic fluid in different disease conditions.
- Cirrhosis: Clear, straw-coloured or light green
- Malignant disease: Bloody
- Infection: Cloudy
- Biliary communication: Heavy bile staining
- Lymphatic obstruction: Milky-white (chylous)
Management of Ascites
Managing ascites focuses on treating the underlying causes, controlling symptoms, and preventing complications. WHO guidelines suggest a comprehensive approach:
1. Sodium and Water Restriction
- Daily sodium intake <100 mmol
- No added salt
- Restriction of water intake to 1-1.5 L/day
- Sodium retaining drugs (NSAIDs, corticosteroids) should be avoided
2. Pharmacological Management
- Diuretics: Medications like spironolactone (100-400 mg/day) and furosemide are used to increase fluid excretion through urine. Monitoring of electrolytes and kidney function is necessary when using diuretics.
- Antibiotics: Antibiotics such as cefotaxime or ciprofloxacin are prescribed if SBP is suspected or diagnosed.
3. Paracentesis
For patients with large or refractory ascites, therapeutic paracentesis can be performed to remove large volumes of fluid, providing symptomatic relief. 3-5 litres daily is safe, provided the circulation is supported by giving IV colloid such as human albumin or other plasma expander.
4. Liver Transplantation
5. Peritoneo-venous (LeVeen) Shunt
6. Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS)
Management of Complications
- Spontaneous Bacterial Peritonitis (SBP): Timely diagnosis and treatment with antibiotics are critical.
- Hepatorenal Syndrome: This is a serious complication that may require vasoconstrictor drugs like terlipressin, along with albumin infusions and, in some cases, dialysis.
Ascites is a serious medical condition that requires prompt attention to the underlying cause and effective management of symptoms. The WHO emphasizes a comprehensive, multidisciplinary approach that includes lifestyle changes, medication, and sometimes surgical intervention. Early diagnosis and appropriate treatment can significantly improve outcomes for patients suffering from ascites, particularly those with liver disease.
For more personalized advice or guidance on ascites, it's important to consult a healthcare professional who can tailor treatment plans to your specific needs.