Written and peer-reviewed by physicians—but use at your own risk. Read our disclaimer.

banner image

amboss

Trusted medical answers—in seconds.

Get access to 1,000+ medical articles with instant search
and clinical tools.

Try free for 5 days

Ascites

Last updated: October 20, 2020

Summarytoggle arrow icon

Ascites is the abnormal accumulation of fluid in the peritoneal cavity and a common complication of diseases presenting with portal hypertension (e.g., liver cirrhosis, acute liver failure) and/or hypoalbuminemia (e.g., nephrotic syndrome). Other conditions resulting in ascites include chronic heart failure, visceral inflammation (e.g., pancreatitis), and malignant tumors. Clinical features include progressive abdominal distension, shifting dullness, and a positive fluid wave test. Ascites may be associated with abdominal pain in rare cases. An adequate clinical assessment should be followed by imaging (e.g., ultrasound), which helps to identify even very small quantities of ascitic fluid in the peritoneal cavity. If the onset of ascites is spontaneous or the origin is unclear, an abdominal paracentesis and ascitic fluid assessment may be performed (i.e., to determine the appearance, composition). Management involves treating the underlying condition in addition to sodium restriction and diuretic therapy. Severe or refractory ascites may require therapeutic abdominal paracentesis. A severe complication is spontaneous bacterial peritonitis.

  • The etiology can be determined using the serum-ascites albumin gradient (SAAG) based on Starling's law.
  • Calculation: SAAG = (albumin levels in serum) - (albumin levels in ascitic fluid)
Etiology Pathophysiology

High SAAG ascites

≥ 1.1 g/dL (obsolete term: transudate)

Low SAAG ascites

< 1.1 g/dL (obsolete term: exudate)

  • Production of protein-rich fluid from tubercles

References:[1][2][3][4][5][6][7]

References:[3][8][9]

References:[10]

Criteria for analyzing ascitic fluid

Ascites due to portal hypertension (SAAG ≥ 1.1 g/dL)

(Previously referred to as transudate)

Ascites due to other causes (SAAG < 1.1 g/dL)

(Previously referred to as exudate)

Color
  • Clear, sometimes opalescent
  • Cloudy
  • Bloody
  • Milky
  • Dark brown
Cell count and differentiation
  • ↓ Cell count
Protein concentration

Remember, eggs, like“EGGsudates” (exudates) are high in protein.

References:[1][2]

General measures

  • Treatment of the underlying disease (e.g., using anticoagulation in case of a thrombosis or tuberculostatics in case of a tubercular peritonitis)
  • Sodium restriction
  • Regular weight control
  • Water restriction or avoiding overhydration

Diuretic therapy

  • Indications
    • Portal hypertensive ascites: usually responsive; may be treated in the same way as ascites caused by liver cirrhosis (see treatment of cirrhosis).
    • Non-portal hypertensive ascites (exudate): usually not effective; therefore it is essential to focus on treating the underlying disease!
  • Approach
  • Regular control of potassium and creatinine during diuretic therapy

Diuretics should be used with precaution in cases of severe hyponatremia, hepatic encephalopathy, or deterioration of renal function!

Treatment of refractory ascites

References:[1][2]

We list the most important complications. The selection is not exhaustive.

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

  1. Cárdenas A, Gelrud A, Chopra S. Chylous, bloody, and pancreatic ascites. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/chylous-bloody-and-pancreatic-ascites.Last updated: December 15, 2015. Accessed: March 20, 2017.
  2. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  3. Shah R. Ascites. In: Roy PK, Ascites. New York, NY: WebMD. http://emedicine.medscape.com/article/170907-overview#showall. Updated: August 24, 2016. Accessed: February 12, 2017.
  4. Moore KP, Wong F, Gines P, et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology. 2003; 38 (1): p.258-266. doi: 10.1053/jhep.2003.50315 . | Open in Read by QxMD
  5. Lai M. Budd-Chiari syndrome: Epidemiology, clinical manifestations, and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/budd-chiari-syndrome-epidemiology-clinical-manifestations-and-diagnosis?source=see_link§ionName=CLINICAL+MANIFESTATIONS&anchor=H2#H2.Last updated: November 2, 2016. Accessed: February 12, 2017.
  6. Such J, Runyon BA. Pathogenesis of ascites in patients with cirrhosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/pathogenesis-of-ascites-in-patients-with-cirrhosis?source=see_link.Last updated: December 16, 2015. Accessed: February 12, 2017.
  7. Cabral FC, Krajewski KM, Kim KW, Ramaiya NH, Jagannathan JP. Peritoneal lymphomatosis: CT and PET/CT findings and how to differentiate between carcinomatosis and sarcomatosis. Cancer Imaging. 2013; 13 : p.162-170. doi: 10.1102/1470-7330.2013.0018 . | Open in Read by QxMD
  8. Runyon BA. Malignancy-related ascites. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/malignancy-related-ascites?source=see_link§ionName=ETIOLOGY+AND+PATHOGENESIS&anchor=H2#H2.Last updated: December 9, 2016. Accessed: February 12, 2017.
  9. Runyon BA. Evaluation of adults with ascites. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/evaluation-of-adults-with-ascites#H25272225.Last updated: April 22, 2015. Accessed: February 12, 2017.
  10. Ascites. http://www.medbullets.com/step2-3-gastrointestinal/21668/ascites. Updated: April 11, 2016. Accessed: February 12, 2017.
  11. Herold G. Internal Medicine. Herold G ; 2014
  12. Kim JJ, Tsukamoto MM, Mathur AK, et al. Delayed Paracentesis Is Associated With Increased In-Hospital Mortality in Patients With Spontaneous Bacterial Peritonitis. Am J Gastroenterol. 2014; 109 (9): p.1436-1442. doi: 10.1038/ajg.2014.212 . | Open in Read by QxMD
  13. Runyon BA. American Association for the Study of Liver Disease (AASLD) Practice Guideline: Management of Adult Patients with Ascites Due to Cirrhosis, Update 2012. undefined. 2012 . doi: 10.1002/hep.00000 . | Open in Read by QxMD
  14. Angeli P, Bernardi M, Villanueva C, et al. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018; 69 (2): p.406-460. doi: 10.1016/j.jhep.2018.03.024 . | Open in Read by QxMD
  15. Soriano G, Castellote J, Álvarez C, et al. Secondary bacterial peritonitis in cirrhosis: A retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010; 52 (1): p.39-44. doi: 10.1016/j.jhep.2009.10.012 . | Open in Read by QxMD
  16. Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations.. Eur J Gastroenterol Hepatol. 2016; 28 (3): p.e10-8. doi: 10.1097/MEG.0000000000000548 . | Open in Read by QxMD
  17. Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology. 1988; 8 (5): p.1104-9. doi: 10.1002/hep.1840080521 . | Open in Read by QxMD
  18. Hou W, Sanyal AJ. Ascites: Diagnosis and Management. Med Clin North Am. 2009; 93 (4): p.801-817. doi: 10.1016/j.mcna.2009.03.007 . | Open in Read by QxMD
  19. Rudralingam V, Footitt C, Layton B. Ascites matters. Ultrasound. 2016; 25 (2): p.69-79. doi: 10.1177/1742271x16680653 . | Open in Read by QxMD