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Ascites

Basics

  • Pathologic fluid accumulation in peritoneal cavity; common in cirrhosis.
  • Graded as:
  • Grade 1: mild, US detectable only, responsive
  • Grade 2: moderate, symmetric abdominal distension, recurrent
  • Grade 3: large/gross, marked distension, refractory ascites (RA)
  • Normal peritoneal fluid: none in men; up to 20 mL in women (menstrual phase).

Epidemiology

  • Children: nephrotic syndrome, malignancy common causes.
  • Adults: cirrhosis (81%), cancer (10%), heart failure (3%), TB (2%), other (6%).
  • 50-60% cirrhotics develop ascites within 10 years.
  • Mortality ~44% at 5 years after ascites onset.

Etiology and Pathophysiology

  • Distinguish portal hypertension vs nonportal hypertension causes by SAAG:
  • SAAG ≥1.1 g/dL: portal hypertension (cirrhosis, heart failure, Budd-Chiari, portal vein thrombosis).
  • SAAG <1.1 g/dL: nonportal causes (carcinomatosis, TB, nephrotic syndrome, pancreatitis, infections).
  • Portal hypertension leads to increased visceral capillary pressure → fluid shifts → systemic hypovolemia → activation of RAAS.
  • Risk factors: hepatitis B/C, alcohol, CHF, kidney disease, malignancy, TB.

Diagnosis

History

  • Risk factors: alcohol, TB exposure, malignancy, cardiac disease, metabolic syndrome.
  • Symptoms: progressive abdominal distension, pain, fever (suggests SBP), dyspnea.

Physical Exam

  • Abdominal distension, flank shifting dullness (sensitivity 83%, specificity 56%).
  • Signs of chronic liver disease: palmar erythema, spider angiomata, jaundice, asterixis.
  • Signs of heart failure: peripheral edema, elevated JVP.
  • Cachexia, Virchow node for malignancy.

Differential Diagnosis

  • Obesity, large ovarian tumors, bowel obstruction, massive splenomegaly.

Diagnostic Tests

  • Ultrasound (detects small fluid volumes).
  • Diagnostic paracentesis: analyze cell count, protein, Gram stain, culture.
  • PMN leukocytes ≥250/mm³ diagnostic for spontaneous bacterial peritonitis (SBP).
  • Calculate SAAG (serum albumin - ascitic fluid albumin).
  • CT/MRI for intra-abdominal pathology if indicated.
  • Portal Doppler ultrasound for thrombosis/cirrhosis.
  • Labs: CBC, CMP, PT/INR, cultures.
  • Laparoscopy if non-diagnostic workup.

Treatment

General Measures

  • Sodium restriction ≤2 g/day if portal hypertension.
  • Water restriction only if hyponatremia (<120-125 mEq/L).
  • Avoid alcohol; optimize nutrition.
  • Baclofen may reduce alcohol craving in alcoholic cirrhosis.

Medications

  • First-line: spironolactone (100-400 mg/day) + furosemide (40-160 mg/day), maintaining 100:40 ratio.
  • Monitor renal function and electrolytes closely.
  • Avoid NSAIDs, ACE inhibitors, ARBs, and nonselective beta-blockers in refractory ascites.
  • Second-line: midodrine (7.5 mg TID) for refractory or hypotensive patients.
  • Alternative diuretics: amiloride, triamterene, torsemide, bumetanide.
  • Avoid vaptans in chronic liver disease.

Procedures

  • Therapeutic paracentesis for tense/refractory ascites.
  • Albumin infusion after removal of >5 L ascitic fluid (5.5-8.0 g/L per liter removed).
  • TIPS for refractory ascites.
  • Peritoneovenous shunts and automated low flow pumps in selected cases.
  • Indwelling catheters for malignant ascites (palliative).
  • Avoid PEG tubes in ascitic patients (high mortality risk).

Follow-Up and Monitoring

  • Regular monitoring of renal function, electrolytes.
  • Evaluate for hepatocellular carcinoma every 6 months with ultrasound.
  • Calculate Child-Pugh and MELD scores regularly.

Patient Education

  • Emphasize sodium restriction and adherence to medications.
  • Encourage mobility and frequent monitoring of symptoms.
  • Advise prompt medical attention if worsening symptoms or fever.

Prognosis

  • Depends on underlying cause.
  • Ascites signals advanced disease; 44% mortality at 5 years in cirrhosis.
  • Refractory ascites carries high mortality (50% at 6 months).

Complications

  • Spontaneous bacterial peritonitis (SBP).
  • Hepatorenal syndrome (Type 1 rapid AKI; Type 2 slow progression).
  • Cellulitis in edematous patients.
  • Pneumonia, infection.

ICD10 Codes

  • R18.8 Other ascites
  • R18.0 Malignant ascites
  • K70.31 Alcoholic cirrhosis with ascites

Clinical Pearls

  • Cirrhosis is the most common cause of ascites.
  • New-onset or hospitalized ascites warrants diagnostic paracentesis.
  • Sodium restriction and diuretics remain mainstay treatment.
  • Avoid NSAIDs, ACE inhibitors, ARBs, and beta-blockers in ascitic patients.
  • Poor compliance with sodium restriction is most common cause of diuretic-resistant ascites.