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Ascites – Causes, Symptoms and Treatment

Ascites is the pathological accumulation of fluid in the abdominal cavity. It most commonly results from liver cirrhosis, heart failure, or malignant disease.

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Ascites is the pathological accumulation of fluid in the abdominal cavity. It most commonly results from liver cirrhosis, heart failure, or malignant disease.

What is Ascites?

Ascites refers to the abnormal buildup of fluid within the peritoneal cavity – the space between the abdominal organs and the lining of the abdominal wall. Under normal conditions, only a small amount of fluid is present in this space to allow smooth organ movement. In ascites, several liters of fluid can accumulate, leading to visible abdominal distension and significant discomfort.

Causes

Ascites is a symptom rather than a disease in itself, and it always points to an underlying condition. The most common causes include:

Liver cirrhosis: The leading cause, accounting for approximately 75% of all cases. Scarring of the liver raises pressure in the portal venous system (portal hypertension), causing fluid to leak into the abdomen.
Malignant disease (malignant ascites): Peritoneal metastases or primary peritoneal tumors can produce ascites.
Heart failure: Reduced cardiac output leads to fluid backflow and accumulation.
Kidney disease: Conditions such as nephrotic syndrome cause significant protein loss, reducing oncotic pressure.
Inflammation: Peritonitis or tuberculosis affecting the peritoneum.
Pancreatitis: Inflammation of the pancreas can also trigger ascites.

Symptoms

The symptoms of ascites depend on the volume of fluid accumulated. Common signs and symptoms include:

Progressive abdominal enlargement and a sensation of fullness or tightness
Unexplained weight gain
Shortness of breath, particularly when lying flat (due to upward displacement of the diaphragm)
Early satiety and loss of appetite
Nausea and digestive discomfort
Swelling of the legs (peripheral edema)
Visibly rounded or distended abdomen with fluid shifting to the flanks

Diagnosis

Several diagnostic methods are used to confirm and evaluate ascites:

Physical Examination

The physician examines the abdomen by palpation and percussion. A characteristic finding is shifting dullness – a dull percussion note in the flanks that changes with the position of the patient.

Ultrasound (Sonography)

Abdominal ultrasound is the primary imaging method for detecting and estimating the volume of ascites. It can identify as little as 100 ml of fluid and is non-invasive and widely available.

Ascitic Tap (Paracentesis)

A sample of the fluid is withdrawn using a needle and analyzed in the laboratory. Key parameters include protein content, cell count, bacteria, and tumor cells. The SAAG (Serum-Ascites Albumin Gradient) helps distinguish between portal hypertension-related ascites and other causes: a SAAG of 1.1 g/dL or higher suggests portal hypertension.

Additional Investigations

Depending on the suspected cause, further blood tests, computed tomography (CT), magnetic resonance imaging (MRI), or liver biopsy may be required.

Treatment

Treatment is tailored to the underlying cause and the severity of the ascites:

General Measures

Sodium restriction: Limiting salt intake to less than 5 g per day helps reduce fluid retention.
Weight monitoring: Daily weight checks allow tracking of fluid balance.

Medications

Diuretics are the cornerstone of medical treatment for ascites caused by liver disease. Spironolactone and furosemide are typically used in combination to promote renal sodium and water excretion.

Therapeutic Paracentesis

When large volumes of fluid (more than 5 liters) have accumulated, direct drainage through a needle inserted into the abdominal wall provides rapid symptom relief. Intravenous albumin is administered simultaneously to maintain circulatory stability and prevent complications.

TIPS (Transjugular Intrahepatic Portosystemic Shunt)

For recurrent or refractory ascites related to portal hypertension, a TIPS procedure can effectively lower portal pressure. A channel is created between the portal vein and a hepatic vein using a catheter-guided approach, reducing the pressure that drives fluid accumulation.

Treatment of the Underlying Disease

In malignant ascites, oncological therapy is the primary approach. In heart failure-related ascites, optimizing cardiac treatment is essential. Successful management of the underlying condition can significantly reduce or resolve ascites.

Prognosis

The outlook for patients with ascites largely depends on the underlying cause. Ascites related to liver cirrhosis carries a serious prognosis: without liver transplantation, approximately 50% of patients die within 2 years of its onset. Malignant ascites is generally associated with a poorer prognosis. Early diagnosis and consistent treatment can substantially improve quality of life.

References

European Association for the Study of the Liver (EASL): EASL Clinical Practice Guidelines on the management of ascites in cirrhosis. Journal of Hepatology, 2022.
Runyon BA: Management of adult patients with ascites due to cirrhosis. Hepatology, 2013.
Kasper DL et al.: Harrison's Principles of Internal Medicine, 21st edition. McGraw-Hill Education, 2022.

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