AscitesLast updated: October 20, 2020
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)
Progressive abdominal distension
Fluid wave test: wave produced by tapping one side of the abdomen in a patient in supine position; this wave will be transmitted to the other side via ascitic fluid.
Shifting dullness: change of resonance from dull to tympanic resonance when patient changes from supine to lateral decubitus position.
Abdominal pain may be present
Abdominal wall hernias (e.g., umbilical, inguinal, or incisional hernias)
Peripheral or generalized edema
Symptoms associated with increased abdominal distension
Signs of underlying disease
Subtypes and variants
Definition: ascitic fluid with RBC > 50,000 mm3
Etiology: : may be spontaneous (e.g, malignant mass eroding into vessels) or iatrogenic (e.g., following paracentesis or biopsy in patients with cirrhosis)
Dilutional hyponatremia as a result of overhydration despite normal or increased sodium concentration (see electrolyte imbalance of sodium)
Ultrasound (best initial test): Reliable detection even of smaller quantities of ascitic fluid: lower limit of detection approx. 30 mL
Isodense areas of fluid in the lower region of the abdomen
- Fluid can also be found around the liver , spleen, and flanks (e.g., perihepatic, posterior subhepatic, rectouterine pouch)
Ultrasound-guided diagnostic paracentesis
Indications: first diagnosed ascites, worsening ascites or suspected complication.
Ascitic fluid analysis
Remember, eggs, like“EGGsudates” (exudates) are high in protein.
Treatment of the underlying disease (e.g., using anticoagulation in case of a thrombosis or tuberculostatics in case of a tubercular peritonitis)
- Regular weight control
- Water restriction or avoiding overhydration
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!
- 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
Indication: inadequate response to diuretics, frequent recurrence, or when diuretic therapy is contraindicated
We list the most important complications. The selection is not exhaustive.
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