Ascites
Encyclopedia
Ascites is a gastroenterological
term for an accumulation of fluid in the peritoneal cavity
.
The medical
condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis
and severe liver disease, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood test
s, an ultrasound scan
of the abdomen, and direct removal of the fluid by needle or paracentesis
(which may also be therapeutic). Treatment may be with medication (diuretic
s), paracentesis, or other treatments directed at the cause.
. Patients with ascites generally will complain of progressive abdominal heaviness and pressure as well as shortness of breath due to mechanical impingement on the diaphragm.
Ascites is detected on physical examination
of the abdomen by visible bulging of the flanks
in the reclining patient ("flank bulging"), "shifting dullness
" (difference in percussion note in the flanks that shifts when the patient is turned on the side) or in massive ascites with a "fluid thrill" or "fluid wave
" (tapping or pushing on one side will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen).
Other signs of ascites may be present due to its underlying etiology. For instance, in portal hypertension
(perhaps due to cirrhosis or fibrosis of the liver) patients may also complain of leg swelling, bruising, gynecomastia
, hematemesis
, or mental changes due to encephalopathy
. Those with ascites due to cancer
(peritoneal carcinomatosis) may complain of chronic fatigue or weight loss. Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance.
(CBC), basic metabolic profile, liver enzymes, and coagulation
should be performed. Most experts recommend a diagnostic paracentesis
be performed if the ascites is new or if the patient with ascites is being admitted to the hospital. The fluid is then reviewed for its gross appearance, protein level, albumin
, and cell counts (red and white). Additional tests will be performed if indicated such as Gram stain and cytopathology
.
The Serum-ascites albumin gradient
(SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites. A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive etiology.
Ultrasound
investigation is often performed prior to attempts to remove fluid from the abdomen. This may reveal the size and shape of the abdominal organs, and Doppler studies may show the direction of flow in the portal vein, as well as detecting Budd-Chiari syndrome
and portal vein thrombosis
. Additionally, the sonographer can make an estimation of the amount of ascitic fluid, and difficult-to-drain ascites may be drained under ultrasound guidance. Abdominal CT scan is a more accurate alternate to reveal abdominal organ structure and morphology.
Causes of low SAAG ("exudate") are:
Other Rare causes:
or an exudate
. Amounts of up to 25 liters are possible.
Roughly, transudates are a result of increased pressure in the portal vein
(>8 mmHg, usually around 20 mmHg), e.g. due to cirrhosis, while exudates are actively secreted fluid due to inflammation
or malignancy. As a result, exudates are high in protein, high in lactate dehydrogenase
, have a low pH
(<7.30), a low glucose
level, and more white blood cell
s. Transudates have low protein (<30g/L), low LDH, high pH, normal glucose, and fewer than 1 white cell per 1000 mm³. Clinically, the most useful measure is the difference between ascitic and serum albumin
concentrations. A difference of less than 1 g/dl (10 g/L) implies an exudate.
Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed.
Regardless of the cause, sequestration of fluid within the abdomen leads to additional fluid retention
by the kidneys due to stimulatory effect on blood pressure hormones, notably aldosterone
. The sympathetic nervous system
is also activated, and renin
production is increased due to decreased perfusion of the kidney. Extreme disruption of the renal blood flow can lead to hepatorenal syndrome
. Other complications of ascites include spontaneous bacterial peritonitis
(SBP), due to decreased antibacterial factors in the ascitic fluid such as complement
.
and no more than 0.5 kg/day for patients with ascites alone. In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis.
(production of urine) since the patient now has more fluid than salt concentration. Salt restriction is effective in about 15% of patients.
is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be sought. Spironolactone
(or other distal-tubule diuretics such as triamterene or amiloride
) is the drug of choice since they block the aldosterone receptor in the collecting tubule. This choice has been confirmed in a randomized controlled trial
. Diuretics for ascites should be dosed once per day. Generally, the starting dose is oral spironolactone 100 mg/day (max 400 mg/day).
40% of patients will respond to spironolactone. For nonresponders, a loop diuretic
may also be added and generally, furosemide
is added at a dose of 40 mg/day (max 160 mg/day), or alternatively (bumetanide
or torasemide
). The ratio of 100:40 reduces risks of potassium imbalance. Serum potassium
level and renal function should be monitored closely while on these medications.
Monitoring diuresis: Diuresis can be monitored by weighing the patient daily. The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema
and no more than 0.5 kg/day for patients with ascites alone.
If daily weights cannot be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs. A random urine sodium-to-potassium ratio of > 1 is 90% sensitivity in predicting negative balance (> 78-mmol/day sodium excretion).
Diuretic resistance: Diuretic resistance can be predicted by giving 80 mg intravenous furosemide after 3 days without diuretics and on an 80 mEq sodium/day diet. The urinary sodium excretion over 8 hours < 50 mEq/8 hours predicts resistance.
If a patient exhibits a resistance to or poor response to diuretic therapy, or aquapheresis
may be needed to achieve adequate control of fluid retention and congestion. The use of such mechanical methods of fluid removal can produce meaningful clinical benefits in patients with diuretic resistance and may restore responsiveness to conventional doses of diuretics.
< 130 mmol per liter develops.
may be needed in addition to medical treatments listed above. As this may deplete serum albumin
levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed.
. In the United States, the MELD score
(online calculator) is used to prioritize patients for transplantation.
, peritoneovenous shunt
, and the transjugular intrahepatic portosystemic shunt
(TIPS). However, none of these shunts has been shown to extend life expectancy, and are considered to be bridges to liver transplantation
.
A meta-analysis
of randomized controlled trials by the international Cochrane Collaboration
concluded that "TIPS was more effective at removing ascites as compared with paracentesis...however, TIPS patients develop hepatic encephalopathy significantly more often"
and splenic vein thrombosis: clotting of blood affects the hepatic portal vein or varices associated with splenic vein. This can lead to portal hypertension and reduction in blood flow. When a liver cirrhosis
patient is suffering from thrombosis, it is not possible to perform a liver transplant, unless the thrombosis is very minor. In case of minor thrombosis, there are some chances of survival using cadaveric liver transplant.
-breakers among the Proto-Indo-Europeans
. This proposal builds on the Hittite military oath
as well as various Vedic hymns (RV
7.89, AVS
4.16.7). A similar curse dates to the Kassite
dynasty (12th century BC
), threatening oath-breakers: "May Marduk
, king of heaven and earth, fill his body with dropsy, which has a grip that can never be loosened". Comparable is also Numbers
5:11ff, where a confirmed adulteress is punished with swelling of the abdomen.
Gastroenterology
Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. The name is a combination of three Ancient Greek words gaster , enteron , and logos...
term for an accumulation of fluid in the peritoneal cavity
Peritoneal cavity
The peritoneal cavity is a potential space between the parietal peritoneum and visceral peritoneum, that is, the two membranes that separate the organs in the abdominal cavity from the abdominal wall...
.
The medical
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
and severe liver disease, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood test
Blood test
A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick....
s, an ultrasound scan
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
of the abdomen, and direct removal of the fluid by needle or paracentesis
Paracentesis
Paracentesis is a medical procedure involving needle drainage of fluid from a body cavity, most commonly the peritoneal cavity in the abdomen.A related procedure is thoracocentesis, which is needle drainage of the chest cavity...
(which may also be therapeutic). Treatment may be with medication (diuretic
Diuretic
A diuretic provides a means of forced diuresis which elevates the rate of urination. There are several categories of diuretics. All diuretics increase the excretion of water from bodies, although each class does so in a distinct way.- Medical uses :...
s), paracentesis, or other treatments directed at the cause.
Signs and symptoms
Mild ascites is hard to notice, but severe ascites leads to abdominal distensionAbdominal distension
Abdominal distension is a sensation of elevated abdominal pressure and volume. It is estimated that close to 25% of the US population has some degree of abdominal distension on a regular basis. Some describe it as belching, others claim they feel nausea and yet others say they pass excessive gas...
. Patients with ascites generally will complain of progressive abdominal heaviness and pressure as well as shortness of breath due to mechanical impingement on the diaphragm.
Ascites is detected on physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
of the abdomen by visible bulging of the flanks
Bulging flanks
In medicine, bulging flanks refers to a sign for ascites. If, on inspection , the sides of the abdomen bulge outward in an unusual fashion on a patient, they likely have fluid in the abdomen...
in the reclining patient ("flank bulging"), "shifting dullness
Shifting dullness
In medicine, shifting dullness refers to a sign, elicited on physical examination, for ascites.To perform the test, first the midline is percussed eliciting a resonant note due to gas in the bowel. If there is no area of resonance then the test cannot be performed...
" (difference in percussion note in the flanks that shifts when the patient is turned on the side) or in massive ascites with a "fluid thrill" or "fluid wave
Fluid wave test
In medicine, the fluid wave test or fluid thrill test is a test for ascites. It is performed by having the patient push their hands down on the midline of the abdomen. The examiner then taps one flank, while feeling on the other flank for the tap...
" (tapping or pushing on one side will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen).
Other signs of ascites may be present due to its underlying etiology. For instance, in portal hypertension
Portal hypertension
In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 10 mmHg or greater.-Causes:Causes can be divided into prehepatic, intrahepatic, and posthepatic...
(perhaps due to cirrhosis or fibrosis of the liver) patients may also complain of leg swelling, bruising, gynecomastia
Gynecomastia
Gynecomastia or Gynaecomastia, , is the abnormal development of large mammary glands in males resulting in breast enlargement. The term comes from the Greek γυνή gyné meaning "woman" and μαστός mastós meaning "breast"...
, hematemesis
Hematemesis
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...
, or mental changes due to encephalopathy
Encephalopathy
Encephalopathy means disorder or disease of the brain. In modern usage, encephalopathy does not refer to a single disease, but rather to a syndrome of global brain dysfunction; this syndrome can be caused by many different illnesses.-Terminology:...
. Those with ascites due to cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
(peritoneal carcinomatosis) may complain of chronic fatigue or weight loss. Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance.
Classification
Ascites exists in three grades:- Grade 1: mild, only visible on ultrasound and CT
- Grade 2: detectable with flank bulging and shifting dullness
- Grade 3: directly visible, confirmed with fluid thrill
Diagnosis
Routine complete blood countComplete blood count
A complete blood count , also known as full blood count or full blood exam or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood...
(CBC), basic metabolic profile, liver enzymes, and coagulation
Coagulation
Coagulation is a complex process by which blood forms clots. It is an important part of hemostasis, the cessation of blood loss from a damaged vessel, wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding and begin repair of the damaged vessel...
should be performed. Most experts recommend a diagnostic paracentesis
Paracentesis
Paracentesis is a medical procedure involving needle drainage of fluid from a body cavity, most commonly the peritoneal cavity in the abdomen.A related procedure is thoracocentesis, which is needle drainage of the chest cavity...
be performed if the ascites is new or if the patient with ascites is being admitted to the hospital. The fluid is then reviewed for its gross appearance, protein level, albumin
Human serum albumin
Human serum albumin is the most abundant protein in human blood plasma. It is produced in the liver. Albumin constitutes about half of the blood serum protein...
, and cell counts (red and white). Additional tests will be performed if indicated such as Gram stain and cytopathology
Cytopathology
Cytopathology is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by Rudolf Virchow in 1858. A common application of cytopathology is the Pap smear, used as a screening tool, to detect precancerous cervical lesions and prevent cervical...
.
The Serum-ascites albumin gradient
Serum-ascites albumin gradient
The serum-ascites albumin gap is a calculation used in medicine to help determine the cause of ascites. The SAAG may be a better discriminant than the older method of classifying ascites fluid as a transudate versus exudate....
(SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites. A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive etiology.
Ultrasound
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
investigation is often performed prior to attempts to remove fluid from the abdomen. This may reveal the size and shape of the abdominal organs, and Doppler studies may show the direction of flow in the portal vein, as well as detecting Budd-Chiari syndrome
Budd-Chiari syndrome
In medicine , Budd–Chiari syndrome is the clinical picture caused by occlusion of the hepatic veins. It presents with the classical triad of abdominal pain, ascites and hepatomegaly. Examples of occlusion include thrombosis of hepatic veins. The syndrome can be fulminant, acute, chronic, or...
and portal vein thrombosis
Portal vein thrombosis
Portal vein thrombosis is a form of venous thrombosis affecting the hepatic portal vein, which can lead to portal hypertension and reduction in the blood supply to the liver.-Causes:...
. Additionally, the sonographer can make an estimation of the amount of ascitic fluid, and difficult-to-drain ascites may be drained under ultrasound guidance. Abdominal CT scan is a more accurate alternate to reveal abdominal organ structure and morphology.
Causes
Causes of high SAAG ("transudate") are:- CirrhosisCirrhosisCirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
- 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%) - Heart failure - 3%
- Hepatic Venous occlusion: Budd-Chiari syndromeBudd-Chiari syndromeIn medicine , Budd–Chiari syndrome is the clinical picture caused by occlusion of the hepatic veins. It presents with the classical triad of abdominal pain, ascites and hepatomegaly. Examples of occlusion include thrombosis of hepatic veins. The syndrome can be fulminant, acute, chronic, or...
or veno-occlusive disease - Constrictive pericarditisConstrictive pericarditisIn many cases, constrictive pericarditis is a late sequela, in other words a condition that is the consequence of a previous disease, of an inflammatory condition of the pericardium...
- KwashiorkorKwashiorkorKwashiorkor is an acute form of childhood protein-energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. The presence of edema caused by poor nutrition defines kwashiorkor...
Causes of low SAAG ("exudate") are:
- CancerCancerCancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
(primary peritoneal carcinomatosis and metastasis) - 10% - Infection: TuberculosisTuberculosisTuberculosis, MTB, or TB is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs but can also affect other parts of the body...
- 2% or Spontaneous bacterial peritonitisSpontaneous bacterial peritonitisSpontaneous bacterial peritonitis is the development of peritonitis despite the absence of an obvious source for the infection. It occurs almost exclusively in people with portal hypertension , usually as a result of cirrhosis of the liver... - PancreatitisPancreatitisPancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the small intestine. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years...
- 1% - SerositisSerositisSerositis refers to inflammation of the serous tissues of the body, the tissues lining the lungs , heart , and the inner lining of the abdomen and organs within...
- Nephrotic syndromeNephrotic syndromeNephrotic syndrome is a nonspecific disorder in which the kidneys are damaged, causing them to leak large amounts of protein from the blood into the urine....
or Protein losing enteropathy - Hereditary angioedemaAngioedemaAngioedema or Quincke's edema is the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues. It is very similar to urticaria, but urticaria, commonly known as hives, occurs in the upper dermis...
Other Rare causes:
- Meigs syndromeMeigs syndromeIn medicine, Meigs syndrome, also Meigs' syndrome, is the triad of ascites, pleural effusion and benign ovarian tumor . It resolves after the resection of the tumor...
- VasculitisVasculitisVasculitis refers to a heterogeneous group of disorders that are characterized by inflammatory destruction of blood vessels. Both arteries and veins are affected. Lymphangitis is sometimes considered a type of vasculitis...
- HypothyroidismHypothyroidismHypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone.Iodine deficiency is the most common cause of hypothyroidism worldwide but it can be caused by other causes such as several conditions of the thyroid gland or, less commonly, the pituitary gland or...
- Renal Dialysis
- Peritoneum Mesothelioma
Pathophysiology
Ascitic fluid can accumulate as a transudateTransudate
Transudate is extravascular fluid with low protein content and a low specific gravity .This is in contrast to transudate where the extracellular fluid is an ultrafiltrate of blood plasma and thus larger molecules such as proteins and cell debris are absent....
or an exudate
Exudate
An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. It can apply to plants as well as animals. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as sap or blood...
. Amounts of up to 25 liters are possible.
Roughly, transudates are a result of increased pressure in the portal vein
Hepatic portal vein
The hepatic portal vein is not a true vein, because it does not conduct blood directly to the heart. It is a vessel in the abdominal cavity that drains blood from the gastrointestinal tract and spleen to capillary beds in the liver...
(>8 mmHg, usually around 20 mmHg), e.g. due to cirrhosis, while exudates are actively secreted fluid due to inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
or malignancy. As a result, exudates are high in protein, high in lactate dehydrogenase
Lactate dehydrogenase
Lactate dehydrogenase is an enzyme present in a wide variety of organisms, including plants and animals.Lactate dehydrogenases exist in four distinct enzyme classes. Two of them are cytochrome c-dependent enzymes, each acting on either D-lactate or L-lactate...
, have a low pH
PH
In chemistry, pH is a measure of the acidity or basicity of an aqueous solution. Pure water is said to be neutral, with a pH close to 7.0 at . Solutions with a pH less than 7 are said to be acidic and solutions with a pH greater than 7 are basic or alkaline...
(<7.30), a low glucose
Glucose
Glucose is a simple sugar and an important carbohydrate in biology. Cells use it as the primary source of energy and a metabolic intermediate...
level, and more white blood cell
White blood cell
White blood cells, or leukocytes , are cells of the immune system involved in defending the body against both infectious disease and foreign materials. Five different and diverse types of leukocytes exist, but they are all produced and derived from a multipotent cell in the bone marrow known as a...
s. Transudates have low protein (<30g/L), low LDH, high pH, normal glucose, and fewer than 1 white cell per 1000 mm³. Clinically, the most useful measure is the difference between ascitic and serum albumin
Serum albumin
Serum albumin, often referred to simply as albumin is a protein that in humans is encoded by the ALB gene.Serum albumin is the most abundant plasma protein in mammals. Albumin is essential for maintaining the osmotic pressure needed for proper distribution of body fluids between intravascular...
concentrations. A difference of less than 1 g/dl (10 g/L) implies an exudate.
Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed.
Regardless of the cause, sequestration of fluid within the abdomen leads to additional fluid retention
Water retention (medicine)
The term water retention signifies an abnormal accumulation of fluid in the circulatory system or within the tissues or cavities of the body.Water is found both inside and outside the body’s cells...
by the kidneys due to stimulatory effect on blood pressure hormones, notably aldosterone
Aldosterone
Aldosterone is a hormone that increases the reabsorption of sodium ions and water and the release of potassium in the collecting ducts and distal convoluted tubule of the kidneys' functional unit, the nephron. This increases blood volume and, therefore, increases blood pressure. Drugs that...
. The sympathetic nervous system
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...
is also activated, and renin
Renin
Renin , also known as an angiotensinogenase, is an enzyme that participates in the body's renin-angiotensin system -- also known as the Renin-Angiotensin-Aldosterone Axis -- that mediates extracellular volume , and arterial vasoconstriction...
production is increased due to decreased perfusion of the kidney. Extreme disruption of the renal blood flow can lead to hepatorenal syndrome
Hepatorenal syndrome
Hepatorenal syndrome is a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure...
. Other complications of ascites include spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis is the development of peritonitis despite the absence of an obvious source for the infection. It occurs almost exclusively in people with portal hypertension , usually as a result of cirrhosis of the liver...
(SBP), due to decreased antibacterial factors in the ascitic fluid such as complement
Complement system
The complement system helps or “complements” the ability of antibodies and phagocytic cells to clear pathogens from an organism. It is part of the immune system called the innate immune system that is not adaptable and does not change over the course of an individual's lifetime...
.
Treatment
Ascites is generally treated while an underlying etiology is sought, in order to prevent complications, relieve symptoms, and prevent further progression. In patients with mild ascites, therapy is usually as an outpatient. The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edemaPeripheral edema
Peripheral edema is the swelling of tissues, usually in the lower limbs, due to the accumulation of fluids.The condition is commonly associated with aging, but can be caused by many other conditions, including congestive heart failure, trauma, alcoholism, altitude sickness, pregnancy,...
and no more than 0.5 kg/day for patients with ascites alone. In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis.
Salt restriction
Salt restriction is the initial treatment, which allows diuresisDiuresis
Diuresis may refer to:* Urine production, as an aspect of fluid balance* Excessive urine production - see polyuria* Immersion diuresis...
(production of urine) since the patient now has more fluid than salt concentration. Salt restriction is effective in about 15% of patients.
Diuretics
Since salt restriction is the basic concept in treatment, and aldosteroneAldosterone
Aldosterone is a hormone that increases the reabsorption of sodium ions and water and the release of potassium in the collecting ducts and distal convoluted tubule of the kidneys' functional unit, the nephron. This increases blood volume and, therefore, increases blood pressure. Drugs that...
is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be sought. Spironolactone
Spironolactone
Spironolactone , commonly referred to as simply spiro, is a diuretic and is used as an antiandrogen.It is a synthetic 17-lactone drug that is a renal competitive aldosterone antagonist in a class of pharmaceuticals called...
(or other distal-tubule diuretics such as triamterene or amiloride
Amiloride
Amiloride is a potassium-sparing diuretic, first approved for use in 1967 , used in the management of hypertension and congestive heart failure. Amiloride was also tested as treatment of cystic fibrosis, but it was revealed inefficient in vivo due to it's short time of action, therefore...
) is the drug of choice since they block the aldosterone receptor in the collecting tubule. This choice has been confirmed in a randomized controlled trial
Randomized controlled trial
A randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
. Diuretics for ascites should be dosed once per day. Generally, the starting dose is oral spironolactone 100 mg/day (max 400 mg/day).
40% of patients will respond to spironolactone. For nonresponders, a loop diuretic
Loop diuretic
Loop diuretics are diuretics that act on the ascending loop of Henle in the kidney. They are primarily used in medicine to treat hypertension and edema often due to congestive heart failure or renal insufficiency...
may also be added and generally, furosemide
Furosemide
Furosemide or frusemide is a loop diuretic used in the treatment of congestive heart failure and edema. It is most commonly marketed by Sanofi-Aventis under the brand name Lasix...
is added at a dose of 40 mg/day (max 160 mg/day), or alternatively (bumetanide
Bumetanide
Bumetanide is a loop diuretic of the sulfamyl category to treat heart failure. It is often used in people in whom high doses of furosemide are ineffective. It is marketed by Hoffmann-La Roche. The main difference between the two substances is in bioavailability and pharmacodynamic potency...
or torasemide
Torasemide
Torasemide or torsemide is a pyridine-sulfonyl urea type loop diuretic mainly used in the management of edema associated with congestive heart failure. It is also used at low doses for the management of hypertension...
). The ratio of 100:40 reduces risks of potassium imbalance. Serum potassium
Potassium
Potassium is the chemical element with the symbol K and atomic number 19. Elemental potassium is a soft silvery-white alkali metal that oxidizes rapidly in air and is very reactive with water, generating sufficient heat to ignite the hydrogen emitted in the reaction.Potassium and sodium are...
level and renal function should be monitored closely while on these medications.
Monitoring diuresis: Diuresis can be monitored by weighing the patient daily. The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema
Peripheral edema
Peripheral edema is the swelling of tissues, usually in the lower limbs, due to the accumulation of fluids.The condition is commonly associated with aging, but can be caused by many other conditions, including congestive heart failure, trauma, alcoholism, altitude sickness, pregnancy,...
and no more than 0.5 kg/day for patients with ascites alone.
If daily weights cannot be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs. A random urine sodium-to-potassium ratio of > 1 is 90% sensitivity in predicting negative balance (> 78-mmol/day sodium excretion).
Diuretic resistance: Diuretic resistance can be predicted by giving 80 mg intravenous furosemide after 3 days without diuretics and on an 80 mEq sodium/day diet. The urinary sodium excretion over 8 hours < 50 mEq/8 hours predicts resistance.
If a patient exhibits a resistance to or poor response to diuretic therapy, or aquapheresis
Aquapheresis
Aquapheresis is a medical technology designed to remove excess salt and water from the body safely, predictably, and effectively from patients suffering from a condition called fluid overload. It removes the excess salt and water and helps to restore a patient’s fluid balance or...
may be needed to achieve adequate control of fluid retention and congestion. The use of such mechanical methods of fluid removal can produce meaningful clinical benefits in patients with diuretic resistance and may restore responsiveness to conventional doses of diuretics.
Water restriction
Water restriction is needed if hyponatremiaHyponatremia
Hyponatremia is an electrolyte disturbance in which the sodium concentration in the serum is lower than normal. In the vast majority of cases, hyponatremia occurs as a result of excess body water diluting the serum sodium and is not due to sodium deficiency. Sodium is the dominant extracellular...
< 130 mmol per liter develops.
Paracentesis
In those with severe (tense) ascites, therapeutic paracentesisParacentesis
Paracentesis is a medical procedure involving needle drainage of fluid from a body cavity, most commonly the peritoneal cavity in the abdomen.A related procedure is thoracocentesis, which is needle drainage of the chest cavity...
may be needed in addition to medical treatments listed above. As this may deplete serum albumin
Serum albumin
Serum albumin, often referred to simply as albumin is a protein that in humans is encoded by the ALB gene.Serum albumin is the most abundant plasma protein in mammals. Albumin is essential for maintaining the osmotic pressure needed for proper distribution of body fluids between intravascular...
levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed.
Liver transplantation
Ascites that is refractory to medical therapy is considered an indication for liver transplantationLiver transplantation
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic location as the original...
. In the United States, the MELD score
Model for End-Stage Liver Disease
The Model for End-Stage Liver Disease, or MELD, is a scoring system for assessing the severity of chronic liver disease. It was initially developed to predict death within three months of surgery in patients who had undergone a transjugular intrahepatic portosystemic shunt procedure, and was...
(online calculator) is used to prioritize patients for transplantation.
Shunting
In a minority of patients with advanced cirrhosis that have recurrent ascites, shunts may be used. Typical shunts used are portacaval shuntPortacaval shunt
A portacaval shunt is a treatment for high blood pressure in the liver. A connection is made between the portal vein, which supplies 75% of the liver's blood, and the inferior vena cava, the vein that drains blood from the lower two-thirds of the body...
, peritoneovenous shunt
Peritoneovenous shunt
A peritoneovenous shunt is a shunt which drains peritoneal fluid from the peritoneum into veins, usually the internal jugular vein or the superior vena cava...
, and the transjugular intrahepatic portosystemic shunt
Transjugular intrahepatic portosystemic shunt
A Transjugular Intrahepatic Portosystemic Shunt is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein...
(TIPS). However, none of these shunts has been shown to extend life expectancy, and are considered to be bridges to liver transplantation
Liver transplantation
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic location as the original...
.
A meta-analysis
Meta-analysis
In statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...
of randomized controlled trials by the international Cochrane Collaboration
Cochrane Collaboration
The Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
concluded that "TIPS was more effective at removing ascites as compared with paracentesis...however, TIPS patients develop hepatic encephalopathy significantly more often"
Low SAAG
Exudative ascites generally does not respond to manipulation of the salt balance or diuretic therapy. Repeated paracentesis and treatment of the underlying cause is the mainstay of treatment.Thrombosis
Complications involve portal vein thrombosisThrombosis
Thrombosis is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets and fibrin to form a blood clot to prevent blood loss...
and splenic vein thrombosis: clotting of blood affects the hepatic portal vein or varices associated with splenic vein. This can lead to portal hypertension and reduction in blood flow. When a liver cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
patient is suffering from thrombosis, it is not possible to perform a liver transplant, unless the thrombosis is very minor. In case of minor thrombosis, there are some chances of survival using cadaveric liver transplant.
Society and culture
It has been suggested that ascites was seen as a punishment especially for oathOath
An oath is either a statement of fact or a promise calling upon something or someone that the oath maker considers sacred, usually God, as a witness to the binding nature of the promise or the truth of the statement of fact. To swear is to take an oath, to make a solemn vow...
-breakers among the Proto-Indo-Europeans
Proto-Indo-Europeans
The Proto-Indo-Europeans were the speakers of the Proto-Indo-European language , a reconstructed prehistoric language of Eurasia.Knowledge of them comes chiefly from the linguistic reconstruction, along with material evidence from archaeology and archaeogenetics...
. This proposal builds on the Hittite military oath
Hittite military oath
The Hittite military oath is a Hittite text on two cuneiform tablets.The first tablet is only preserved in fragments , the second tablet survives in three copies, and can be restituted almost completely. The oldest copy is fragmentary, but two younger copies are well preserved...
as well as various Vedic hymns (RV
Rigveda
The Rigveda is an ancient Indian sacred collection of Vedic Sanskrit hymns...
7.89, AVS
Atharvaveda
The Atharvaveda is a sacred text of Hinduism and one of the four Vedas, often called the "fourth Veda"....
4.16.7). A similar curse dates to the Kassite
Kassites
The Kassites were an ancient Near Eastern people who gained control of Babylonia after the fall of the Old Babylonian Empire after ca. 1531 BC to ca. 1155 BC...
dynasty (12th century BC
12th century BC
-Overview:The 12th century BC is the period from 1200 to 1101 BC. Although many human societies were literate in this period, most individual persons mentioned in this article ought to be considered legendary rather than historical...
), threatening oath-breakers: "May Marduk
Marduk
Marduk was the Babylonian name of a late-generation god from ancient Mesopotamia and patron deity of the city of Babylon, who, when Babylon became the political center of the Euphrates valley in the time of Hammurabi , started to...
, king of heaven and earth, fill his body with dropsy, which has a grip that can never be loosened". Comparable is also Numbers
Book of Numbers
The Book of Numbers is the fourth book of the Hebrew Bible, and the fourth of five books of the Jewish Torah/Pentateuch....
5:11ff, where a confirmed adulteress is punished with swelling of the abdomen.