AscitesAlso known as Portal hypertension-ascites
Ascites is a medical condition that results in the accumulation of fluids within the spaces of your abdomen. Primarily, the condition is caused by cirrhosis of the liver that is foremost a result of drinking excessive amounts of alcohol. Ascites can also be caused by different types of cancer, specifically, it is seen in advanced stages of cancer and recurrent cancer. The condition can also be seen in different heart disorders, infections, low protein levels, and dialysis.
Ascites can be painful in severe cases and may prevent a person from being able to move around comfortably. The condition can cause fluid to move into the chest and surround the lungs which can cause difficulty in breathing.
The most common symptoms of ascites include swelling in the abdomen, weight gain, bloating, sense of heaviness, feeling of fullness, vomiting, shortness of breath, nausea, and indigestion. Treatment of ascites requires a change in lifestyle, modification of diet, and taking diuretics to flush out the excessive fluid. In severe cases, doctors would remove excessive fluid through a needle.
- Adults and children
- Both men and women
- Bladder distention
- Pancreatic pseudocysts
- Large uterine or ovarian tumours
- CT scan
- MRI scan
- Blood tests
- Lifestyle modifications
- Diet changes
- Transjugular intrahepatic portosystemic shunt
- General physician
Symptoms Of Ascites
Ascites can cause several symptoms that can affect your health. It is possible to experience more than one symptom at the same time.
Causes Of Ascites
The abdominal organs are covered by a sheet of tissue called the peritoneum. The peritoneum covers the liver, stomach, kidneys, and bowels. This peritoneal covering has two layers, one outer and one inner layer. Accumulation of fluid between these two layers is called ascites.
Fluids can get accumulated between these layers when there is a build-up of pressure in the veins present in the liver, and they stop working the way they should. The increased pressure prevents the flow of blood into the liver, and over time kidneys are unable to remove the excessive amount of salt from the body. This causes fluid build-up resulting in ascites.
The build-up of pressure is primarily caused by liver cirrhosis, heart failure, kidney failure, cancer or an infection.
Cirrhosis accounts for 84% cases of ascites. Liver cirrhosis is a late-stage liver disease in which the healthy liver tissue is replaced with scarred tissue resulting in permanent damage to the liver. The scar tissue prevents the liver from functioning normally and causes inflammation and cell death of the liver. Cirrhosis can be caused by various diseases such as hepatitis, fat accumulation in the liver, and iron buildup in the body. The leading cause of liver cirrhosis is an excessive amount of alcohol intake.
Liver cirrhosis results in an increase in the blood pressure of the portal vein that carries blood from the digestive organs towards the liver. When the pressure rises, there is a decline in the functioning of the kidneys that causes fluids to build up in the abdomen. This results in cirrhotic ascites.
Cirrhosis of the liver is a result of long-term liver damage which causes liver scarring. Read more about it.
Recurrent cancer or late-stage cancer can result in ascites. Primarily cancer can spread to the lining of the peritoneal covering of the organ and cause it to leak. These are called malignant ascites. Secondly, cancer can spread to the liver itself and cause the build-up of pressure within the liver. This prevents the functioning of the kidney and results in ascites. Cancers such as colon cancer, ovarian cancer, pancreatic cancer, and liver cancer are more likely to cause ascites. In peritoneal cancer, the tumor cells present in the lining of the abdomen produce a proteinaceous fluid that causes ascites.
Heart failure or kidney failure
Ascites can occur when there is increased pressure of the hepatic veins and the veins that drain the lining of the organ. This is usually caused by long-standing venous hypertension. A heart failure or kidney failure can result in the decline of the blood volume of the arteries, vessels that carry blood throughout the body. This can further cause changes in the different body systems and cause the blood vessels of the kidneys to constrict, resulting in sodium and water retention leading to ascites.
Budd–Chiari syndrome is caused by occlusion of the hepatic veins that drain the liver. It presents with the classical triad of abdominal pain, ascites, and liver enlargement.
Chronic pancreatitis is the most significant risk factor for the development of pancreatic ascites. It occurs when pancreatic secretions collect in the peritoneum as a result of a pancreatic duct injury. It most often follows necrotizing pancreatitis with major pancreatic duct injury or via fistula formation which communicates with the peritoneum.
Other rare causes:
Meigs syndrome (It is the triad of benign ovarian tumors with ascites and pleural effusion)
Vasculitis (swelling and redness of the blood vessels)
Hypothyroidism (decreased production of thyroid hormones)
Mastocytosis (a condition in which mast cells are formed in excess)
Risk Factors Of Ascites
Usually, a patient experiences ascites along with other medical conditions or as a consequence of another disease. You are more likely to have ascites in case of the following conditions:
Non-alcoholic fatty liver disease
Alcohol use disorder
Congestive heart failure
Cancer of the organs present in the abdomen
Genetic liver conditions such as Wilson’s disease
Diagnosis Of Ascites
Diagnosing ascites can take multiple tests that may require you to go through some particular tests. Your doctor will carry out a physical examination where they'll check the swelling in the abdomen and carry out an examination. You can also be asked to take blood tests that will measure the protein levels in your blood. Other imaging and testing methods can include:
Abdominal ultrasound is an examination modality that uses sound waves that helps in creating an image of the organs present in the abdomen. For an ultrasound, the patient may be asked to fast for the next eight to 12 hours before the ultrasound. This is done to prevent undigested food from blocking the sound waves and preventing a clear picture. You can also be asked to consume a fat-free meal the evening before your test in case of a liver or pancreas ultrasound. A doctor or health provider uses a handheld probe and moves it over the abdomen to take the ultrasound. This in turn creates a digital image on the screen that can be viewed by the doctor. This imaging modality is painless and images are captured in real-time. It will show the structure and movement of blood through the blood vessels of the abdomen. Abdominal ultrasonography can detect as little as 100 ml of ascitic fluid.
A CT scan is also known as computed tomography. It is a specialized form of X-ray and shows the cross-sectional view of a specific body part. The CT scan circles around the body and sends images to the computer where they can be viewed by a medical professional. An abdominal CT scan can help the doctor view the organ and blood vessels present in the abdominal cavity. CT scan provides multiple images of the body and allows medical professionals to make an accurate diagnosis. Your doctor may ask you to fast for two to four hours before the CT scan and stop certain medications. You can also be asked to drink a glass of water or oral contrast that can help in getting a better view of the stomach and bowel.
Magnetic resonance imaging or MRI is a testing modality that uses magnets and radio waves to create images of the inside of the body. This non-invasive technique uses magnets and radio waves to create cross-sectional images of the abdomen that allows healthcare professionals to view any abnormality present inside the tissues and organs of the abdomen. An MRI uses no radiation and is considered to be a safer alternative to a CT scan. You will be asked to lie on your back and given a blanket and pillow while a technician will communicate with you via a microphone. The MRI machine makes loud noises that can be disturbing. The scan requires the patient to be completely still as the machine is sensitive towards movements.
It is a surgical diagnostic procedure that allows the examination of the organs presents inside the abdomen. This is a low-risk and minimally invasive procedure that is carried out via a small incision. It uses an instrument called a laparoscope that has a high-intensity light and a high-resolution camera at the front. The doctor will insert the instrument through a small incision in the abdomen and move the rod along with the camera that will further send images to the video monitor. Your doctor will be able to view the inside of the body in real-time and also collect tissue samples if needed. It is usually performed when non-invasive methods such as CT scan and MRI scan are unable to help with the diagnosis.
Fluid sample (diagnostic paracentesis)
Your doctor may take a sample of fluid present inside your abdomen through a needle. The fluid will be sent back to the laboratory, where it will be checked for the signs of disease such as infection or cancer. This test can help in pointing towards the cause of ascites. You will be given local anesthesia before this procedure.
The fluid is then reviewed for its gross appearance, protein level, albumin, and cell counts (red and white). Additional tests will be performed if indicated such as microbiological culture, Gram stain (to check for bacteria), and cytopathology (examination of cells and fluids of the body).
The serum ascites albumin gradient (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites. A high gradient (> 1.1 g/dL) indicates the ascites are due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive as a cause.
Ascites exist in three grades:
Grade 1: Mild, only visible on ultrasound and CT
Grade 2: Detectable with flank bulging and shifting dullness
Grade 3: Directly visible, confirmed with the fluid wave/thrill test
Prevention Of Ascites
It is not always possible to prevent ascites. However, you can reduce your risk of developing ascites by reducing the risk factors of some causes. This can be done by:
Living a healthy lifestyle and eating a balanced diet that is low in added fats and salts.
Managing body weight and getting regular exercise are also great ways of preventing your chances of having ascites.
Limiting alcohol consumption alcohol abuse is a leading cause of ascites.
Avoiding undercooked fish or meat to reduce the chances of getting an infection in case you have cirrhosis.
Talking to your doctor and following their advice for managing your condition.
If you are at a higher risk of developing ascites due to pre-existing conditions, make sure to consult your doctor before taking new medications.
Specialist To Visit
You should visit a doctor if you are experiencing symptoms such as a distended, swollen abdomen, sudden weight gain, difficulty in breathing when lying down, reduced appetite, abdominal pain, bloating, nausea, vomiting, heartburn, fluid retention that is causing swelling in your feet or ankles, and shortness of breath. These symptoms might indicate the possibility of ascites. You can consult the following doctors for diagnosis:
A hepatologist is a medical doctor who diagnoses, treats, and manages problems associated with your liver, gallbladder, bile ducts, and pancreas.
A gastroenterologist is a doctor who treats digestive disorders.
If you are noticing any of the symptoms, seek advice from our world-class medical professionals.
Treatment Of Ascites
There are different treatment modalities for ascites which include:
1. Lifestyle changes
Some common lifestyle changes that can help in the treatment of ascites include avoiding alcohol and limiting salt intake in your diet. You should not have more than 1500 mg/day of sodium or as directed by the doctor. You will also be asked to limit the intake of some types of fluids.
2. Water pills
These are also known as diuretic pills are used to flush out the extra fluid from the body. The most commonly used diuretic pills are furosemide and spironolactone, which help the kidney remove excess sodium and water. These pills are most effective for ascites and reduce the pressure around the liver.
Use of spironolactone may be limited by hyponatremia, hyperkalemia and painful gynecomastia (tenderness in the breasts). If gynecomastia is distressing, amiloride may be substituted for spironolactone. Furosemide is usually combined with spironolactone in a ratio of 40:100; maximal daily doses of spironolactone and furosemide are 400 mg and 160 mg, respectively.
Your doctor may ask you to monitor your blood chemistry while on the medications and reduce your salt and alcohol intake.
3. Pharmacologic therapy
It is used for refractory ascites and includes the addition of midodrine or clonidine, alpha-adrenergic agonists, to diuretic therapy. These agents constrict the vessels counteracting splanchnic dilation of the vessels.
4. Therapeutic paracentesis
This procedure is carried out by medical professionals. They use a long and thin needle to remove the accumulated excessive fluid from around the abdomen. The needle will be inserted through the skin and into the abdominal cavity. After the procedure, you will be asked to maintain a low salt and fluid diet to prevent the fluid from getting recollected. This procedure is usually recommended in patients with severe or recurrent ascites that do not show improvement with diuretics.
Patients undergoing large-volume paracentesis should receive i/v albumin infusions of 6-8 g/L of ascitic fluid removed.
If the person exhibits a resistance or poor response to diuretic therapy, ultrafiltration or aquapheresis may be needed to achieve adequate control of fluid retention and congestion. The use of such mechanical methods of fluid removal can be beneficial in people with diuretic resistance and may restore responsiveness to conventional doses of diuretics
6. Transjugular intrahepatic portosystemic shunt (TIPS)
Severe cases of ascites may require a permanent tube called a stent (wire mesh) which will be inserted inside the body. This will be inflated inside the body and will form a channel or shunt that will bypass the liver. This will help in rerouting the blood flow from around the liver and hence decrease the need for regular drainage. This may be recommended when the diuretics fail to show any improvement in the patient's symptoms.
7. Liver transplantation
In the case of severe liver disease where the ascites don't improve, the patient may require a liver transplant. Ascites from liver or kidney failure may require surgery. In case the underlying cause of the ascites is a bacterial or viral infection, your doctor will treat you with other therapies to treat the cause and relieve the symptoms.
Ascites that are refractory to medical therapy are considered an indication for liver transplantation. In the United States, the MELD score is used to prioritise people for transplantation. The MELD Score has been validated as a predictor of survival in patients with cirrhosis, alcoholic hepatitis, and acute liver failure.
Home-care For Ascites
Ascites can be a real problem if not managed correctly. Individuals diagnosed with it should make lifestyle modifications for their betterment. These include:
Make sure you take the prescribed medications on time to manage your medical condition.
Label your drugs and set the alarm to make sure you have the medicines every day at the same time.
Follow all the instructions given to you by your doctor. Follow the diet given to you by your doctor.
Stick to the right treatment plan, as decided by your doctor, and incorporating the necessary lifestyle changes can help you take care of your condition and recover faster.
Eat a balanced diet and cut back on alcohol or foods that worsen your risk of developing ascites.
Note: The food you eat plays a vital role in your general well-being and good health. Read about tips to reap the benefits of a healthy diet.
Your physician may recommend you to a dietician who can make a customized plan for you depending on your medical condition and suggest ways to make your diet more compatible with your disease.
Complications of Ascites
Ascites can lead to several complications, including:
The fluid buildup may lead to pain discomfort and cause difficulty in breathing. These symptoms can interfere with a patient's ability to carry out day-to-day tasks such as walking and eating
The accumulated fluid can become infected and cause a condition called spontaneous bacterial peritonitis. This may result in fever and stomach pain that would require immediate medical attention. You may be prescribed long-term antibiotics or IV antibiotics to prevent the recurrence of the infection.
Accumulation of fluid in the lungs
Abdominal fluid can fill the lungs, especially on the right side which can cause symptoms such as chest discomfort, shortness of breath, cough, and hypoxemia (lack of oxygen in the blood). This will require thoracentesis, a procedure to drain the fluid from around the lungs.
Ascites cause an increase in abdominal pressure which can lead to a hernia, a condition in which an internal organ pushes through a weak spot in the muscle or tissue. This can especially occur in the case of an umbilical or inguinal hernia.
Worsening of liver cirrhosis may lead to kidney failure. The treatment options for the same will be discussed by your doctor depending on your clinical condition.
Severe form of ascites can lead to hepatorenal syndrome (HRS) in which the impairment in the kidney function can lead to advanced liver disease. Individuals with hepatorenal syndrome do not have any identifiable cause of kidney dysfunction and the kidneys themselves are not structurally damaged.
Alternative Therapies for Ascites
If you have ascites, these therapies can help you control the condition. They are:
Leading a healthy lifestyle and doing light exercises daily such as walking can help in managing your medical condition. Talk to your doctor about what kind of exercises would suit your condition.
Choose a diet that is low on salts and follow protein guidelines given by your doctor. The guidelines of what you are supposed to eat will depend on the severity of the condition and the treatment regimen that you are on. It is important to follow the advice of your doctor since your diet influences your health.
Opting for simple exercises such as yoga can help you avoid stress and anxiety that can further help your health.
Living with Ascites
Being diagnosed with ascites can be scary and can cause difficulty in carrying out day to day tasks. However, modern science has opened the doors to several possibilities that can allow you to live a healthy life and prevent fluid from accumulating again. Along with your medical treatments, it is important to incorporate lifestyle changes that will help you cope with your disease. Here are a few tips that you can follow:
Your doctor may recommend you to a dietician who will help you plan a sodium-restricted diet. You should also check food labels and avoid consuming any food that has a high content of sodium. Instead of consuming products high in sodium, you can use salt substitutes and incorporate fresh ingredients that have no added salts. However, avoid using any salt substitutes with potassium in case you are taking medications for ascites since they can increase potassium levels.
Stop alcohol intake
If you have ascites, drinking a large amount of alcohol can be extremely detrimental to the health of your liver. Your liver will have to work harder to remove toxins from your body since alcohol doesn't metabolize out of your system. Drinks such as wine and beer contain large amounts of phosphorus that can lead to heart diseases and even death if your liver is unable to filter out excessive potassium. Talk to your doctor about what kind of drink you can intake without putting your health at risk and the frequency of drinking. Most people would be advised to eliminate alcohol from their diet completely.
For most adults, moderate alcohol use is probably not harmful. However, alcoholism, or alcohol dependence, causes long-term problems. Read more about alcohol addiction.
You will be advised to maintain a healthy weight and perhaps record your weight every day to keep a track of fluid retention in the body. Exercising daily will help you improve your health. Ask your doctor about the kind of exercises you can do.
Frequently Asked Questions
- Aithal GP, et al. Guidelines on the management of ascites in cirrhosis. 2020 Aug.
- Chalasani NP, et al. Ascites: A common problem in people with cirrhosis. 2021 Apr.
- Chiejina M, Kudaravalli P, Samant H. Ascites. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
- European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. 2010 Jun.
- Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 144.
- National Institute of Diabetes and Digestive and Kidney Diseases website. Cirrhosis, Updated March 2018. Accessed November 11, 2020.
- Sola E, Gines SP. Ascites and spontaneous bacterial peritonitis. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 93.