Ascites

• Swelling of the abdomen
• Weight gain
• Shortness of breath
• Nausea
• Indigestion
• Sense of heaviness
• Bloating
• Sense of fullness
• Vomiting
• Digestive issues
• Constipation
• Back pain
• Difficulty in sitting
• Fatigue
• Swelling in the lower legs

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 accumulate between these layers when there is a build-up of pressure in the veins present in the liver, causing them to function improperly. The increased pressure prevents blood flow into the liver, and over time, the 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.

Liver Cirrhosis

Cirrhosis accounts for 84% of cases of ascites. Liver cirrhosis is a late-stage liver disease in which 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. 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 excessive alcohol intake. Liver cirrhosis results in increased blood pressure in the portal vein, which carries blood from the digestive organs to the liver. When the pressure rises, kidney function declines, causing fluid to build up in the abdomen, resulting in cirrhotic ascites. Cirrhosis of the liver is a result of long-term liver damage that causes liver scarring.

Cancer

Recurrent or late-stage cancer can result in ascites. Cancer can spread to the lining of the peritoneal covering of the organ, causing it to leak, which is known as malignant ascites. Additionally, cancer can spread to the liver itself, causing increased pressure within the liver, which prevents proper kidney function 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, tumor cells present in the lining of the abdomen produce a proteinaceous fluid that leads to ascites.

Heart Failure or Kidney Failure

Ascites can occur when there is increased pressure in the hepatic veins and the veins draining the lining of the organ, usually caused by long-standing venous hypertension. Heart failure or kidney failure can lead to a decline in the blood volume in the arteries, which carry blood throughout the body. This can result in changes in various body systems and cause the blood vessels of the kidneys to constrict, leading to sodium and water retention and ultimately ascites.

Budd–Chiari Syndrome

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.

Pancreatic Ascites

Chronic pancreatitis is the most significant risk factor for the development of pancreatic ascites. It occurs when pancreatic secretions collect in the peritoneum due to pancreatic duct injury. This condition most often follows necrotizing pancreatitis with major pancreatic duct injury or via fistula formation that communicates with the peritoneum.

Other Rare Causes

• Meigs syndrome (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 characterized by an excess of mast cells)

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 the following conditions:

• Non-alcoholic fatty liver disease
• Alcohol use disorder
• Hepatitis B
• Hepatitis C
• Autoimmune hepatitis
• Congestive heart failure
• Kidney failure
• Infections
• Cancer of the organs present in the abdomen
• Genetic liver conditions such as Wilson’s disease

Diagnosing ascites can involve multiple tests that may require you to undergo specific evaluations. Your doctor will perform a physical examination to check for swelling in the abdomen and conduct further assessments. Blood tests may be ordered to measure protein levels. Other imaging and testing methods can include:

• Ultrasound: Abdominal ultrasound is an examination modality that uses sound waves to create images of the organs in the abdomen. Patients may need to fast for eight to twelve hours before the ultrasound to ensure clear imaging. A fat-free meal the evening before may be recommended for liver or pancreas ultrasounds. A handheld probe is used to capture real-time digital images, showing the structure and movement of blood through the abdominal blood vessels. Abdominal ultrasonography can detect as little as 100 ml of ascitic fluid.
• CT scan: A CT scan, or computed tomography, is a specialized form of X-ray that provides cross-sectional views of specific body parts. The scan encircles the body and sends images to a computer for medical professionals to review. An abdominal CT scan allows doctors to view organs and blood vessels in the abdominal cavity. Patients may be asked to fast for two to four hours before the scan and may need to stop certain medications. Drinking a glass of water or oral contrast may also be required for better imaging.
• MRI scan: Magnetic resonance imaging (MRI) uses magnets and radio waves to create images of the body’s interior. This non-invasive technique produces cross-sectional images of the abdomen, enabling healthcare professionals to identify abnormalities in tissues and organs. MRI does not involve radiation, making it a safer alternative to CT scans. Patients will lie on their backs, receive a blanket and pillow, and communicate with a technician via a microphone. The MRI machine may produce loud noises, and it is essential for patients to remain still during the scan.
• Laparoscopy: This surgical diagnostic procedure allows for the examination of abdominal organs through a small incision. It is a low-risk, minimally invasive procedure that uses a laparoscope, equipped with a high-intensity light and a high-resolution camera. The doctor inserts the instrument through the incision to view the inside of the body in real-time and collect tissue samples if necessary. Laparoscopy is typically performed when non-invasive methods like CT and MRI scans are inconclusive.
• Fluid sample (diagnostic paracentesis): A sample of fluid from the abdomen may be taken using a needle. This fluid is sent to a laboratory for analysis to check for signs of disease, such as infection or cancer. Local anesthesia is administered before the procedure. The fluid is evaluated for gross appearance, protein level, albumin, and cell counts (red and white). Additional tests, such as microbiological culture, Gram stain, and cytopathology, may be performed as needed. The serum ascites albumin gradient (SAAG) is a more effective discriminant than older measures for determining the causes of ascites. A high gradient (> 1.1 g/dL) suggests portal hypertension, while a low gradient (< 1.1 g/dL) indicates non-portal hypertensive causes.

Classification

Ascites can be classified into 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.

It is not always possible to prevent ascites. However, you can reduce your risk of developing ascites by addressing the risk factors associated with some causes. This can be achieved by:

• Living a healthy lifestyle and eating a balanced diet that is low in added fats and salts.
• Managing body weight and engaging in regular exercise to lower the chances of developing ascites.
• Limiting alcohol consumption, as alcohol abuse is a leading cause of ascites.
• Avoiding undercooked fish or meat to reduce the risk of infection, especially if you have cirrhosis.
• Consulting 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, ensure you consult your doctor before starting any new medications.

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 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 kidneys 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
   This 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 intravenous albumin infusions of 6-8 g/L of ascitic fluid removed.
5. Ultrafiltration
   If the person exhibits 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 do not improve, the patient may require a liver transplant. Ascites from liver or kidney failure may require surgery. If the underlying cause of the ascites is a bacterial or viral infection, your doctor will treat you with other therapies to address 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 prioritize people for transplantation. The MELD Score has been validated as a predictor of survival in patients with cirrhosis, alcoholic hepatitis, and acute liver failure.

Ascites can be a significant issue if not managed correctly. Individuals diagnosed with it should implement lifestyle modifications for their betterment. These include:

• Take the prescribed medications on time to manage your medical condition.
• Label your medications and set an alarm to ensure you take them daily at the same time.
• Follow all the instructions provided by your doctor, including the dietary guidelines.
• Adhere to the treatment plan established by your doctor, as incorporating necessary lifestyle changes can help manage your condition and promote faster recovery.
• Eat a balanced diet and limit alcohol or foods that may worsen your risk of developing ascites.

Note: The food you consume plays a vital role in your overall well-being and health. Your physician may refer you to a dietician who can create a customized plan based on your medical condition and suggest ways to make your diet more compatible with your disease.

Ascites can lead to several complications, including:

• Abdominal problems: The fluid buildup may lead to pain and discomfort, causing difficulty in breathing. These symptoms can interfere with a patient's ability to carry out day-to-day tasks such as walking and eating.
• Infection: The accumulated fluid can become infected, resulting in a condition called spontaneous bacterial peritonitis. This may cause fever and stomach pain, requiring immediate medical attention. Long-term antibiotics or IV antibiotics may be prescribed to prevent recurrence of the infection.
• Accumulation of fluid in the lungs: Abdominal fluid can fill the lungs, especially on the right side, leading to symptoms such as chest discomfort, shortness of breath, cough, and hypoxemia (lack of oxygen in the blood). This condition may require thoracentesis, a procedure to drain the fluid from around the lungs.
• Ascites-related hernia: Ascites can increase abdominal pressure, potentially leading to a hernia, where an internal organ pushes through a weak spot in the muscle or tissue. This is particularly common in umbilical or inguinal hernias.
• Kidney failure: Worsening liver cirrhosis may lead to kidney failure. Treatment options will be discussed by your doctor based on your clinical condition. Severe ascites can result in hepatorenal syndrome (HRS), where impaired kidney function occurs alongside advanced liver disease. Individuals with HRS do not have an identifiable cause of kidney dysfunction, and the kidneys themselves are not structurally damaged.

If you have ascites, these therapies can help you control the condition. They are:

• Exercising: 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.
• Diet changes: Choose a diet that is low in salts and follow the protein guidelines provided by your doctor. The recommendations will depend on the severity of the condition and the treatment regimen you are on. It is important to follow your doctor's advice, as your diet influences your health.
• Yoga: Opting for simple exercises such as yoga can help you avoid stress and anxiety, which can further benefit your health.

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:

Diet Modifications

• Your doctor may recommend you to a dietician who will help you plan a sodium-restricted diet.
• Check food labels and avoid consuming any food with high sodium content.
• Use salt substitutes and incorporate fresh ingredients with no added salts.
• Avoid salt substitutes containing potassium if you are taking medications for ascites, as they can increase potassium levels.

Stop Alcohol Intake

• If you have ascites, consuming large amounts of alcohol can be extremely detrimental to your liver's health.
• Your liver will have to work harder to remove toxins from your body since alcohol does not metabolize easily.
• Drinks such as wine and beer contain high amounts of phosphorus that can lead to heart diseases and even death if your liver cannot filter excessive potassium.
• Consult your doctor about what types of drinks you can consume without jeopardizing your health and the frequency of consumption.
• Most people are 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.

Lifestyle Modifications

• Maintain a healthy weight and consider recording your weight daily to track fluid retention.
• Engage in daily exercise to improve your health. Consult your doctor about suitable exercises.