Ascites is a condition characterized by an abnormal buildup of fluid in the abdomen. It is most commonly caused by liver disease, but can also occur due to cancer, heart failure, kidney disease, infection, pancreatitis, and other conditions. The development of ascites is a serious complication and can negatively impact quality of life. Patients often wonder about life expectancy once ascites sets in.
What is ascites?
Ascites refers specifically to fluid accumulation in the abdominal cavity. This fluid buildup leads to abdominal swelling and distention. The abdomen may become very large and rounded. Mild ascites may not cause noticeable symptoms. Large amounts of ascites can cause abdominal discomfort, shortness of breath, nausea, vomiting, and loss of appetite.
Ascites occurs when there is a disruption in the normal fluid balance in the body. Fluid leaks from the blood vessels into the abdominal cavity. This overwhelms the ability of the lymphatic system to drain the fluid. As fluid accumulates, it compresses the organs and causes symptoms.
Causes of ascites
The most common cause of ascites is cirrhosis of the liver. About 80-85% of ascites cases are due to cirrhosis. Cirrhosis involves scarring of liver tissue, which disrupts normal blood flow through the liver. This increases pressure in the portal vein system bringing blood from the intestines and spleen to the liver.
Other causes of ascites include:
– Heart failure – About 3-5% of ascites is due to congestive heart failure. When the heart pumps inefficiently, blood can back up into the liver and cause ascites.
– Cancer – Cancerous tumors can obstruct blood flow through the liver, portal vein, or inferior vena cava. Ovarian, breast, colon, stomach, and lung cancers sometimes cause malignant ascites.
– Infection – Infections such as tuberculosis can cause inflammation and scarring of the peritoneum (abdominal lining). This is called peritonitis and can result in infected ascites.
– Nephrotic syndrome – Kidney disorders that cause severe proteinuria can lead to low albumin levels in the blood and ascites.
– Pancreatitis – Inflammation of the pancreas disrupts digestion and causes leakage of fluid into the abdomen.
– Intravenous fluid overload – Receiving large amounts of IV fluids over a short period of time can overload the system and lead to ascites.
Life expectancy with ascites
Life expectancy after the development of ascites depends on the underlying cause and how well it can be treated. For example, ascites resulting from congestive heart failure may improve with medications and lifestyle modifications to improve cardiac function. Ascites from liver cirrhosis has a poorer prognosis and lower life expectancy.
According to studies, average life expectancy after being diagnosed with ascites ranges between 6 months and 2 years:
– In patients with ascites due to liver cirrhosis, 50% survived for at least 1 year after diagnosis and 20% survived 3 years after diagnosis.
– In patients with ascites due to heart failure, median survival was 6 months.
– In patients with malignant ascites due to cancer, median survival was 2-4 months.
However, it is important to note that survival times have increased in recent years thanks to improvements in treatments. Factors that can increase or decrease life expectancy with ascites include:
Factors increasing life expectancy
– Young age and otherwise good health
– Mild ascites that is easily controlled with diuretics
– Reversible underlying cause like heart failure or infection
– Good response to treatments for underlying liver disease
– Low sodium diet and good fluid control
– No complications like infections or kidney failure
– Liver transplant if ascites is due to cirrhosis
Factors decreasing life expectancy
– Older age and frailty
– Massive or recurrent ascites requiring paracentesis
– End-stage liver disease not amenable to transplant
– Poor response to diuretics and sodium restriction
– Hepatorenal syndrome or kidney failure
– Spontaneous bacterial peritonitis or other infections
– Uncontrolled encephalopathy, malnutrition, wasting
– Lack of access to quality medical care
Stages of ascites
Ascites is often categorized into the following stages based on severity:
Grade 1 (Mild) – Only detectable by ultrasound exam. No abdominal distention.
Grade 2 (Moderate) – Abdominal distention evident on physical exam. Symmetrical fluid wave on palpation.
Grade 3 (Large) – Marked abdominal distention. Fluid wave and bulging flanks visible. May cause shortness of breath.
Life expectancy decreases with increasing grade of ascites. Mild Grade 1 ascites generally indicates earlier disease and better prognosis compared to massive Grade 3 ascites associated with late-stage disease.
How is ascites diagnosed?
Ascites is diagnosed through a combination of physical examination, imaging tests, and analysis of the abdominal fluid.
Physical exam – The abdomen is inspected for distention and asymmetry. Palpation may reveal a fluid wave or shifting dullness. Bulging flanks may be visible.
Imaging – An ultrasound is often the first imaging test ordered when ascites is suspected. It can show fluid around the liver, spleen, and intestines. CT and MRI scans provide more detailed images.
Paracentesis – Inserting a needle into the abdomen to withdraw fluid for analysis is key. Lab tests on the fluid can determine if infection is present. Cell counts and cancer markers may be ordered if cancer is suspected.
Additional blood and urine tests are done to evaluate liver, kidney, and heart function. Viral hepatitis serologies may be checked. Imaging of the heart and pancreas may be performed.
Treatments for ascites
The goal of ascites treatment is to control the fluid accumulation and prevent complications. Common treatments include:
– Dietary sodium restriction – 1000-2000mg daily limits fluid retention. Fluid intake may also need to be restricted.
– Diuretics – Prescription diuretics like spironolactone and furosemide promote urination and sodium excretion.
– Paracentesis – Draining large fluid buildup through a needle immediately relieves pressure.
– Transjugular intrahepatic portosystemic shunt (TIPS) – Stent placed inside liver to reduce fluid accumulation.
– Liver transplant – Can cure ascites from cirrhosis.
– Treating underlying cause – This may include chemotherapy for cancer, peritoneovenous shunt for portal hypertension, or medical management of heart failure.
In mild ascites, low sodium diet and diuretics are tried first. Paracentesis is used for large or tense ascites causing severe symptoms. TIPS reduces repeat paracenteses but has risks of encephalopathy and heart failure. Transplant is sometimes feasible if liver function is very poor.
Complications of ascites
Some potential complications of ascites include:
– Spontaneous bacterial peritonitis (SBP) – Bacterial infection of ascites fluid often causes fever, abdominal pain, and worsening ascites. It is treated with antibiotics.
– Hepatorenal syndrome – Progresses to kidney failure due to low blood flow through the kidneys. Dialysis may be needed.
– Hepatic hydrothorax – Fluid from ascites can migrate to the chest cavity causing shortness of breath.
– Electrolyte imbalances – Low sodium levels are common. Increased potassium and low magnesium can also occur.
– Impaired wound healing – Massive ascites causes abdominal wall tension that prevents surgical incisions and wounds from healing properly.
– Hernias – Increased abdominal pressure can cause umbilical and inguinal hernias requiring surgical repair.
– Bowel obstruction – Fluid and adhesions can potentially obstruct intestines.
Prognosis and life expectancy by cause
The prognosis for ascites depends on the underlying cause:
Cirrhosis – Ascites from cirrhosis carries a poor prognosis with 50% mortality at 1 year. However, effective treatments for hepatitis and alcoholism are improving outcomes. Younger patients with early cirrhosis who abstain from alcohol may live for many years.
Heart failure – If heart function improves with medications, ascites may resolve. But most patients have limited life expectancy of less than 2 years. Severity of heart failure predominately impacts survival.
Cancer – Malignant ascites related to abdominal cancers usually indicates advanced disease. Life expectancy is a few months and focus is on palliative treatments. But some patients live longer with drainage and chemotherapy.
Infection – Ascites from infection like tuberculosis will resolve if treated effectively and early. But delay can lead to high mortality.
Nephrotic syndrome – Ascites caused by kidney disorders carries a variable prognosis depending on underlying diagnosis and response to treatments like steroids or immunosuppressants.
Pancreatitis – Underlying pancreatitis must be managed to resolve ascites. Mild and chronic pancreatitis have better outlook than severe acute necrotizing pancreatitis.
Other causes – Ascites resulting from one-time events like abdominal surgery, IV fluid overload, or perforated ulcer can resolve with treatment of the inciting problem.
Conclusion
The development of ascites is a serious milestone indicating progression of advanced underlying disease. While some cases may respond well to treatments, ascites is generally correlated with reduced life expectancy.
Median survival times of 1-2 years are typical once ascites sets in. But this depends heavily on the specific cause and response to therapy. Best outcomes are seen in mild ascites with reversible causes like infection. Worst prognoses occur in end-stage liver failure and late-stage cancers.
Ongoing advances in managing diseases leading to ascites – including hepatitis, alcoholism, heart failure, and portal hypertension – continue to improve prognosis. Access to optimal medical care and treatments like liver transplantation can prolong survival. But ascites remains an ominous sign marking declining health in serious chronic illnesses.
