Ascites

The term ascites comes from Greek, askítes, which can be translated as “baglike”. Ascites appears when the abdominal cavity is filled with an abnormal quantity of fluid. Usually, this fluid is serous and has a pale yellow color. The abdominal or peritoneal cavity is right below the chest cavity. The diaphragm is the one that separates the abdominal cavity from the chest cavity.

Ascites appears when the quantity of liquid accumulated in the peritoneal cavity exceeds 25 ml. This condition appears most of the time because of cirrhosis, but there are also other causes that can produce it. For example, those suffering from a severe liver disease or metastatic cancer can also develop ascites. This condition can be diagnosed usually with blood tests, an ultrasound scan of the abdomen and also the direct removal of the fluid by using a needle. Fortunately, this condition can be treated and the doctors can recommend several solutions to treat it.

What Are The Signs Of Ascites?

Depending on the cause of the fluid that accumulated inside the abdominal cavity, the symptoms of ascites can appear suddenly or slowly. When the ascites is mild, having less than 400 ml of fluid in the cavity, then the patient may not have any symptoms. Once the fluid quantity increases, then the first sign would be the increase in size and girth of the abdominal cavity.

Usually, many symptoms do not lead the patients straight to the emergency room. However, as soon as one of the symptoms below appears, you should definitely talk to your doctor:

  • diminished appetite
  • sudden weight gain
  • a distended (swollen) abdomen – this is a common sign for many patients
  • nausea and vomiting
  • abdominal pain
  • bloating – appears when the ascites becomes larger
  • shortness of breath because of the increased pressure on the diaphragm
  • heartburn

What Can Cause Ascites?

Ascites is most often caused by liver disease or cirrhosis. It appears when the pressure in the liver blood flow is increased. This increased pressure forces the fluid into the abdominal cavity. This accumulation of fluid causes ascites. Therefore, the liver damage is considered the biggest risk factor that leads to ascites. If we were to determine the biggest causes that can damage the liver, these are:

  • cirrhosis
  • hepatitis B or C
  • a history of alcohol use

Apart from the above-mentioned causes, the ascites can be also stimulated by other factors like salt and water retention. Due to these factors, the sensors in the kidneys may perceive the circulating blood volume as low. This happens because the ascites depletes the volume from the blood and signals the kidneys to absorb more water and salt in order to compensate for the volume loss.

The risk of ascites may be increased by many other factors such as:

  • ovarian, pancreatic, liver, or endometrial cancer
  • heart or kidney failure
  • pancreatitis
  • tuberculosis
  • hypothyroidism

When ascites appears as a result of cancers, then we are talking about malignant ascites. Usually, the advanced cancers of the organs in the abdominal cavity can cause this type of ascites. On the other hand, long-standing pancreatitis can also lead to pancreatic ascites. Usually, the prolonged alcohol abuse determines chronic pancreatitis. Other causes for pancreatic ascites can be also the trauma of the pancreas or acute pancreatitis.

What Are The Types Of Ascites?

Traditionally, if we take into consideration the amount of protein found in the fluid, there are two types of ascites: transudative or exudative.

If we were to consider the amount of albumin in the ascitic fluid compared to the serum albumin from the blood, then the classification is the following:

  • Ascites related to portal hypertension (cirrhosis, congestive heart failure, Budd-Chiari) which is generally greater than 1.1.
  • Ascites caused by other reasons (malignant, pancreatitis) which is lower than 1.1.

How Is Ascites Diagnosed?

Ascites is usually considered a nonspecific symptom for other diseases. Therefore, the diagnosis is based on the physical examination combined with the detailed medical history. The doctor starts with the physical examination and looks at the patient both from the lying position but also by standing up. When the quantity of fluid is greater than 500 ml, the condition can be easily determined by bulging flanks and fluid waves performed by the doctor. When the quantity of fluid is smaller, then it is easier to determine it by an ultrasound. There are cases when the patient is having a CT scan done for other conditions and the doctors see also the ascites developing in his body.

On the other hand, the medical history contains valuable clues for the cause that has lead to ascites. Therefore, the doctor may ask questions about the previous diagnosis of liver disease, viral hepatitis infection and many other risk factors (alcohol abuse, cancer history, and even medication history). In addition, another useful procedure is the complete blood count because it offers clues to the underlying conditions. Clotting panel abnormalities may represent a liver dysfunction and inadequate production of clotting proteins.

If all the above options do not give a clear result in regards to ascites, then the analysis of the fluid may be necessary in order to obtain further diagnostic data. This procedure, called paracentesis, involves inserting a needle into the abdominal cavity and extracting the fluid for a more detailed analysis. This can be done only by trained physicians and only after the area on the abdomen has been sterilized. The quantity of fluid extracted is not very big. Usually, around 20cc of fluid are enough to do an adequate testing. The larger quantities are extracted when it is necessary to relieve the symptoms associated with the abdominal crisis.

Can Ascites Be Treated?

The ascites can be treated as soon as the cause that led to this condition is accurately determined. For instance, the malignant ascites can be treated by chemotherapy and resection of cancer. On the other hand, the ascites related to heart failure can be treated once the heart failure is treated with medicines and dietary restrictions.

However, as ascites is often provoked by cirrhosis, the treatment is focused mainly on this area.

First of all, the patients suffering from cirrhosis should start with a strict diet. Limiting the sodium intake and prescribing diuretics should be the first step. A limit of 2 mg of sodium per day is very easy to accomplish and this is a solution widely recommended for patients dealing with ascites. When this sodium intake limitation is combined with diuretics, the effects are even greater. A nutrition expert is the best person to implement this type of solution that is very helpful for patients with ascites.

As mentioned above, one of the first medicines recommended for ascites are diuretics. They are excellent for the kidneys because they help to eliminate the salt and water from the body. The recommended diuretic regimen in the setting of liver-related ascites is a combination of spironolactone and furosemide. Single daily dose of 100 milligrams of spironolactone and 40 milligrams of furosemide is the usual recommended initial dosage.

When the above solutions fail, then a large amount of fluid needs to be removed. This procedure is called therapeutic paracentesis and consists of a needle carefully placed into the abdominal area, under sterile conditions. This procedure is extremely useful when it is necessary to remove a few liters of fluid.

When the patients do not respond to aggressive medical treatment, then the surgery is necessary to reduce ascites. This procedure is called transjugular intrahepatic portosystemic shunts (TIPS). It consists of a procedure done through the internal jugular vein under local anesthesia by placing a shunt between the portal venous system and the systemic venous system (veins returning blood back to the heart), thereby reducing the portal pressure. However, it can lead to some complications such as hepatic encephalopathy and sometimes even death.

How To Prevent Ascites

In fact, ascites can be prevented. However, the risk factors that lead to this condition can be controlled and thus diminish the possibility of developing this condition. Therefore, some of the actions that people should focus on are the following:

  • Moderate alcohol consumption. It is a known fact that the alcohol excess is the one that causes cirrhosis which might lead to ascites.
  • Get vaccinated for hepatitis B.
  • Practice safe sex. Hepatitis can be spread sexually.
  • Avoid intravenous drug use. Hepatitis can be transmitted through shared needles.
  • Be aware of the potential side effects of your medications. The nonsteroidal anti-inflammatory drugs such as ibuprofen, Advil, etc., may diminish the blood flow to the kidneys. Therefore, they limit the salt and water excretion which inevitably causes ascites.

References:

https://en.wikipedia.org/wiki/Ascites

http://www.medicinenet.com/ascites/article.htm

http://www.healthline.com/symptom/ascites

https://medlineplus.gov/ency/article/000286.htm

https://patient.info/doctor/ascites

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