What is ascites?
Ascites is the buildup of fluid in the abdomen. It occurs when fluid leaks from the blood vessels into the abdominal cavity. This causes the abdomen to become distended or swollen. Ascites is a sign of advanced liver disease and is most commonly caused by cirrhosis of the liver. Some other causes include cancer, heart failure, infection, pancreatitis, and blockage of the hepatic vein (Budd-Chiari syndrome).
What causes ascites in cirrhosis?
In cirrhosis, scar tissue replaces normal, healthy tissue in the liver. This blocks and damages blood vessels in the liver. As a result, pressure increases in the portal vein system bringing blood from the intestines and spleen to the liver. The high pressure causes fluid to leak out of the blood vessels into the abdominal cavity.
In addition, the liver cannot make albumin and other proteins that keep fluid in the blood vessels. Low albumin levels also contribute to ascites formation.
Other factors that can worsen ascites include constipation, kidney problems, malnutrition, and a high-salt diet.
Is ascites always fatal?
No, ascites is not always fatal. With treatment, many people with ascites live for months or even years. However, ascites is a serious complication that requires medical care. Without treatment, ascites can be life-threatening.
Here is an overview of the prognosis for ascites:
– Mild ascites may not significantly affect life expectancy. With a low-salt diet and diuretics, mild ascites can be managed long-term.
– Moderate ascites reduces life expectancy to about 2 years. But with consistent treatment, patients can live longer.
– Severe ascites has a poorer prognosis. Without a liver transplant, life expectancy is less than 6 months.
– Refractory ascites no longer responds to medical therapy. Survival is usually less than 6 months without a transplant.
So while ascites can significantly decrease life expectancy, it does not automatically mean someone only has months to live. Ongoing treatment and liver transplantation in select patients can lengthen survival.
What are the symptoms of ascites?
The main symptom of ascites is increased abdominal girth and swelling. Common symptoms include:
– Abdominal swelling or distention
– Tight, stretched abdomen
– Dimpling or bulging flanks
– Sense of abdominal fullness or bloating
– Abdominal discomfort or pain
– Shortness of breath
– Decreased appetite
– Nausea
– Vomiting
– Heartburn
– Feeling full after eating little
– Difficulty moving around
As the fluid builds up, it pushes up on the diaphragm making it difficult to breathe deeply. It can also push on the stomach contributing to nausea and vomiting.
What tests diagnose ascites?
If ascites is suspected, tests to confirm the diagnosis include:
– Physical exam – The doctor will look for a distended, swollen abdomen and fluid wave test. This involves placing a hand on one side of the abdomen and tapping the other side to feel a wave-like motion through the fluid.
– Imaging – An abdominal ultrasound or CT scan will show fluid surrounding the abdominal organs.
– Paracentesis – Inserting a thin needle into the abdomen to remove some fluid confirms ascites. The fluid is sent for lab testing.
These tests help determine the amount of fluid present, what type it is, and what is causing it. This guides treatment.
What is the treatment for ascites?
Treating ascites involves both relieving symptoms in the short-term and controlling what is causing fluid buildup. Common treatments include:
– Low-salt diet – Restricting sodium and fluids helps decrease fluid retention.
– Diuretics (“water pills”) – Prescription medications help the body eliminate excess fluid through urine.
– Paracentesis – Draining large amounts of fluid from the abdomen provides quick relief of symptoms.
– Medications – Blood pressure medications can help decrease pressure in the portal veins.
– Liver transplant – This may be an option for some patients with advanced liver failure.
– Treating underlying cause – Stopping alcohol use, managing heart failure, controlling infections can prevent additional fluid accumulation.
What is the long-term outlook for ascites?
The long-term outlook depends on the severity of someone’s liver disease and how well the ascites responds to treatment.
Some key points about long-term outlook:
– Mild ascites with early cirrhosis – Can often be controlled with lifestyle changes and diuretics. Patients can live for years.
– Recurrent ascites – May require repeat paracentesis and hospitalizations. Life expectancy is 2 years without transplant.
– Refractory ascites – Does not respond well to treatment and recurs rapidly. Life expectancy is less than 6 months without transplant.
– Post-transplant ascites – Ascites caused by portal hypertension often resolves after successful liver transplant.
– Non-cirrhotic ascites – Treating the underlying condition can allow patients to live years with managed ascites.
– End-stage liver disease – Ascites is a poor prognostic sign. Palliative care can help manage symptoms for remaining months.
So while ascites can decrease life expectancy, survival times vary greatly depending on response to treatment and a patient’s overall liver function.
What are the complications of ascites?
Some potential complications of ascites include:
Spontaneous Bacterial Peritonitis (SBP)
– Bacteria from the intestines can infect the ascitic fluid leading to peritonitis, an inflamed lining of the abdomen.
– Signs include fever, chills, abdominal pain, nausea, fatigue, diarrhea.
– Treated with antibiotics in the hospital, but can be fatal if not treated.
Hepatorenal Syndrome
– Advanced cirrhosis and ascites can lead to progressive kidney failure.
– Caused by extremely low blood flow to the kidneys.
– Treatment requires medications to improve kidney blood flow. Dialysis may be needed.
Hernias
– Pressure from ascites can push out weak areas of abdominal wall causing hernias.
– Umbilical and inguinal hernias are most common.
– Can become incarcerated or strangulated requiring urgent surgery.
Spontaneous Rupture
– Rarely, ascitic fluid can leak through a tear or hole in the abdominal lining.
– Causes severe abdominal pain and tenderness.
– Requires hospitalization and invasive surgery if severe.
Managing ascites is critical to avoid these types of dangerous complications. Seeking medical care for worsening ascites, pain, fevers or other concerning symptoms is important.
What is the clinical classification of ascites?
Clinically, doctors classify ascites into the following grades to help guide treatment:
Grade 1 – Mild ascites
Only detectable on ultrasound or CT scan. No visible swelling of abdomen.
Grade 2 – Moderate ascites
Visible abdominal distention. Mild discomfort present.
Grade 3 – Severe ascites
Large or tense abdominal distention. Discomfort more pronounced. Shortness of breath common. Skin may be shiny and taut. Moving around difficult.
Classifying the grade of ascites helps determine the best course of treatment and outlook. Mild ascites often just requires lifestyle changes. But severe ascites portends poorer short-term prognosis and need for invasive procedures or transplant.
What is refractory ascites?
Refractory ascites is fluid that no longer responds adequately to standard medical therapies. Key characteristics include:
– Does not improve with low-salt diet and high-dose diuretics
– Recurs rapidly after paracentesis, even with medication use
– Frequently requires repeat paracentesis
Refractory ascites signals deteriorating liver function and poor prognosis. Survival is often 6 months or less without liver transplant.
Causes include advanced cirrhosis, portal vein thrombosis, Budd-Chiari syndrome, massive liver tumor burden, and cardiac dysfunction. Treatment options are limited for refractory fluid. Medications, frequent paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplant may help.
What causes transient ascites?
Many non-cirrhotic conditions can cause ascites that resolves after treating the underlying disorder. Some causes of transient ascites include:
– Infection – Peritonitis, appendicitis, pancreatitis
– Cancer – Ovarian, pancreatic, breast, colon, stomach
– Nephrotic syndrome – Kidney disorder causing protein loss
– Myxedema – Severe hypothyroidism
– Ovarian hyperstimulation syndrome
– Medications – Corticosteroids, NSAIDs, bisphosphonates
– GI perforation – Stomach/bowel wall tears
– Heart failure – Scarring of heart muscle
– Post-surgery – Gallbladder, ovarian surgery
Once the infection clears, cancer shrinks, or heart failure is controlled, transient ascites usually resolves. Therefore, identifying and treating the root cause is key.
How do doctors diagnose the cause of ascites?
Determining the cause of ascites involves:
– Medical history – Asking about risk factors like alcohol use, medications, family history of liver disease.
– Physical exam – Looking for signs of liver disease like enlarged spleen, dilated veins, jaundice.
– Blood tests – Low albumin and liver enzyme abnormalities suggest liver disease. High amylase points to pancreatitis.
– Imaging – CT or ultrasound to identify tumors, infections, organ problems.
– Paracentesis – Removing fluid for analysis provides key insights.
– Cytology – Checking for cancer cells under a microscope.
– Albumin level – Levels lower than serum indicate portal hypertension.
– Cell counts – High white blood cell count indicates infection or inflammation.
Once test results are in, doctors can narrow down the most likely cause – cirrhosis, cancer, infection, cardiac issues, or other systemic disorders. This guides the proper treatment approach.
| Type of Ascites | Key Features |
|---|---|
| Cirrhotic | – Related to portal hypertension from liver scarring – Low albumin level in fluid – No cancer cells present – Normal amylase |
| Cancer | – Positive cytology showing cancer cells – Related to peritoneal spread or pressure from tumor |
| Infectious | – Cloudy fluid – High white blood cell count – Positive bacterial culture |
| Pancreatitis | – High amylase level – Necrotic pancreas on imaging |
| Hepatic vein occlusion | – Fluid high in protein content – Swollen liver without cirrhosis |
Summary
In summary, while ascites is a concerning complication requiring prompt evaluation and treatment, it does not automatically signal imminent death from liver failure. Mild ascites can often be managed for years. Even severe ascites may respond well to therapies like paracentesis and diuretics. Life expectancy depends greatly on the individual’s overall liver function and the underlying cause of fluid retention. Ongoing care and being attentive to worsening symptoms and complications are key to optimizing outcomes.