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Ascites

Last updated: July 27, 2021

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Ascites is the abnormal accumulation of fluid within the peritoneal cavity and is a common complication of portal hypertension (e.g., due to liver cirrhosis, acute liver failure) and/or hypoalbuminemia (e.g., due to nephrotic syndrome). Other conditions resulting in ascites include chronic heart failure, inflammation of abdominal viscera (e.g., pancreatitis), and malignancies. Clinical features include progressive abdominal distention, shifting dullness, and a positive fluid wave test. Abdominal pain may be present in ascites due to an acute inflammatory etiology. Diagnostics are aimed at identifying the underlying etiology and determining whether the ascitic fluid is infected. They include imaging (e.g., with abdominal ultrasound or CT abdomen and pelvis), which is used to identify free intraperitoneal fluid and possibly the underlying cause, and diagnostic paracentesis with ascitic fluid analysis. The serum-ascites albumin gradient (SAAG), or the difference between albumin levels in serum and ascitic fluid, is essential to determine the underlying etiology. A high SAAG indicates that the ascites is secondary to portal hypertension. An ascitic fluid neutrophil count ≥ 250 cells/mm3 indicates spontaneous bacterial peritonitis (SBP), which should be urgently managed with empiric antibiotic therapy. Management of ascites involves identifying and managing the underlying cause as well as dietary sodium restriction and diuretic therapy. Additionally, tense ascites and refractory ascites require therapeutic paracentesis. Liver transplant is a treatment option for patients with cirrhosis who develop ascites. Transjugular intrahepatic portosystemic shunts (TIPS) and peritoneovenous shunts are advanced treatment options for refractory ascites, which carries a high risk of mortality.

  • The etiology can be determined using the serum-ascites albumin gradient (SAAG) based on Starling's law.
  • 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

Remember, exudative ascitic fluid is high in protein, like eggs.

References:[1][2][3]

References:[2]

Chylous ascites

Bloody ascites

Diagnostics are used to confirm the presence of ascites, assess its severity, determine the underlying etiology, and evaluate for complications. [5]

Imaging [6][7]

Abdominal ultrasound (initial study of choice)

CT abdomen (and pelvis) [5]

  • Indications: to work up for the underlying cause as needed; examples include [5][6]
  • Findings

Laboratory studies [6]

The choice of laboratory studies should be guided by the pretest probability of the suspected underlying etiology.

Diagnostic paracentesis [5][6][10]

Indications

  • All patients with new-onset ascites (to identify the underlying etiology) [4][5][10]
  • To detect spontaneous bacterial peritonitis (SBP) or other peritoneal infections in the following situations:
    • Clinical suspicion
    • Hospitalization for any cause in patients with cirrhosis and ascites (to identify occult SBP) [4][6][11]

Occult SBP is common in patients with ascites and cirrhosis and delays in diagnosis result in increased mortality. [12]

Ascitic fluid analysis [6][10]

Routine studies

Differential diagnoses of ascites based on SAAG and ascitic fluid total protein [5]
Ascites due to portal hypertension Ascites due to other causes
SAAG
  • ≥ 1.1 g/dL
  • < 1.1 g/dL

Ascitic fluid total protein levels

Additional studies (based on the pretest probability of the underlying etiology)

The International Ascites Club classifies the severity classification of ascites as follows: [2]

  • Mild ascites (grade 1): ascites only detectable by ultrasound
  • Moderate ascites (grade 2): moderate abdominal distention
  • Large ascites (grade 3): marked abdominal distention

Approach [5][6][10]

Medical and supportive therapy [6][10][17]

This section details only the management of ascites due to portal hypertension (e.g., cirrhosis, heart failure, some patients with malignancy-related ascites). See “Treatment of cirrhosis” for management of cirrhosis and its complications. Medical and/or supportive management of other etiologies can be found in the articles dedicated to these conditions.

Salt and fluid restriction

  • Dietary sodium restriction: 2 g/day or 88 mEq/d (2 g of sodium = 5 g of salt)
    • Recommended for all patients
    • Advise patients to restrict the amount of salt in home-cooked meals and to avoid precooked and prepackaged food.
    • Consider referral to a nutritionist for counselling.
  • Fluid restriction: 1 L/day (only if serum Na+ < 125 mEq/L)

Diuretics

Combination diuretic therapy is associated with more rapid ascites reduction and a lower risk of potassium imbalance than monotherapy. [6][17]

Diuretics should be used with caution in patients with severe hyponatremia, hepatic encephalopathy, and/or renal function deterioration.

Empiric antibiotic therapy [6][10]

Antibiotic therapy for patients with cirrhosis and ascites is recommended in the following situations:

Monitoring [6]

  • Monitor weight, blood pressure, nutritional status, serum electrolytes, and renal function.
  • Goals of diuretic therapy
    • Patients without peripheral edema: weight loss of up to 0.5 kg/day
    • Patients with significant peripheral edema
      • No limit to daily weight loss goal until edema is resolved [6][17]
      • Once edema has resolved, daily weight loss should not exceed 0.5 kg/day
  • Discontinue or adjust the dosage of diuretics if adverse effects develop (e.g., hyponatremia, hyperkalemia, renal dysfunction)

Therapeutic paracentesis [6][17][18]

  • Indications
  • Important considerations
    • Consider performing the procedure under ultrasound guidance to minimize the risk of complications.
    • A predetermined limit to the removed volume is usually not necessary. [19]
    • Administer albumin in patients undergoing large-volume paracenteses (> 5 L). [6][18]

Fresh frozen plasma is not routinely recommended before paracentesis in patients with increased INR, as procedure-related hemorrhage is uncommon. [6]

Advanced therapies [6][10][16][17]

21% of patients who develop refractory ascites die within 6 months. Do not delay referral for surgical management. [6]

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

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