ASCITES

Ascites

Definition

Ascites is the enormous accumulation of fluid (pale yellow and clear fluid) in the abdominal peritoneal cavity. Fluid fills between the abdomen and the organs. This cavity is the lining between the abdominal wall and the stomach. This cavity is located below the chest cavity and it is separated by the diaphragm, the ascitic fluid is produced due to variety of disease such as cancer, liver disease, kidney failure and heart failure.

Ascites

History

Ascites were recognised in ancient times. In 20 B.C Celsus first described the technique of paracentesis for aspirating the fluid from the peritoneal cavity by using a bronze tube with flanged collar to drain fluid.

In 1827, Ludwig van Beethoven gave large volume paracenteses to one of the famous patients. whose physician wrote about his deathbed with the following description:

“‘The tremendous volume of the water accumulated called for immediate relief; and I found myself compelled to advocate the abdominal puncture in order to preclude the danger of sudden bursting.’ Beethoven had almost immediate relief, and when he saw the stream of water, cried out that the operation made him think of Moses, who struck the rock with his staff and made the water gush forth. ”  Two days later Beethoven died. At autopsy his liver was described as “shrunken to half its normal volume…it was beset with knots the size of a bean…the spleen was double its proper size and dark coloured and firm.” (Adams)

Epidemiology

Mortality/Morbidity

Wandering patients with a scene of cirrhotic ascites have a 3-year death rate of 50%. The advancement of hard-headed ascites conveys a poor visualization, with a 1-year survival rate of less than 50%.

Sex

Healthy men have almost no intraperitoneal liquid; however ladies may regularly have as much as 20 mL, contingent upon the period of their menstrual cycle.

Types

Ascites is divided into two types. It is classified based on the amount of protein present in the fluid. The most useful system has been developed based on the albumin fluid present in the ascites when compared to serum albumin (albumin measured in the blood). This is called the Serum Ascites Albumin Gradient or SAAG.

Ascites related to portal hypertension (cirrhosis, congestive heart failure, Budd-Chiari) is generally higer than 1.1.

Ascites caused by other reasons (malignant, pancreatitis) is lesser than 1.1.

Risk factors

Some of the common risk factors that cause the ascites are as follows:

• Hepatitis B
• Hepatitis C and
• Long standing alcohol abuse
• IV drug use
• Adverse reactions due to medications

Other underlying conditions such as

• Congestive heart failure
• Malignancy and
• Kidney disease

Causes

The main cause of ascites is liver problems such as follows:

Acute liver failure: Acute liver failure results in ascites due to the adverse injury in liver cells or due to some medications that cause adverse reactions in the liver. For example, acetaminophen overdose causes liver failure.

Cirrhosis: It is a form of liver disease in which the liver is damaged by replacing it with scar tissue. As the more liver tissue is lost the gradual liver failure occurs. The most common cause of cirrhosis such as alcoholic hepatitis, viral hepatitis and fatty liver diseases.

Budd-Chiari syndrome: this is due to the blockage in the vein that drains the liver. This causes abdominal pain and hepatosplenomegaly (enlargement of liver and spleen).

Cancer: Ascites can also manifest as a result of cancers called malignant ascites.

Other causes of failure:

Nephrotic syndrome: It is the damage of  kidney due to the protein leakage into the urine and causes decrease in oncotic pressure and may results in ascites.

Heart failure: It is the inability of the heart muscle to pump the fluid in in the blood vessels. This result in problems such as fluid fills up in the lungs and causes other organs to fail. This fluid leaks into the peritoneal cavity and forms ascites.

Disorders of the pancreas: Pancreas disorders also cause ascites. Pancreas disorders such as acute pancreatitis (inflammation of pancreas), chronic pancreatitis and pancreatic cancer. Acute pancreatitis causes fluid accumulation due to the inflammatory response. Chronic pancreatitis is due to malnutrition that causes decrease in total body protein, loss of oncotic pressure and ascites. Pancreatic cancer causes direct fluid loss.

Irritation of the peritoneal fluid: Due to the irritation of peritoneum, inflammation occurs thus it causes fluid leakage. Irritation is due to the infection or a malignancy.

Hypothyroidism: Ascites found uncommonly in hypothyroidism. Low thyroid function can be treated after prolonged time. When the thyroid level in the body becomes normal, ascites will also resolves.

Manifestation of Ascites

Usually, very little amount of fluid in the abdomen does not show any symptoms, but when a moderate and massive amount of fluid retention can experience few signs and symptoms.

• Vomiting and nausea
• Abrupt weight gain
• Abdominal pain
• Sudden increase in waist size
• Abdominal swelling (distention)

• Feeling discomfort while sitting and sleeping
• Abdominal feels stretched
• The navel is protruded out or flat
• Shortness of breath due to pressure applied to the lungs by swollen abdomen
• Loss of appetite
• Swelling of legs, hands, and ankles due to accumulation of excess fluid

• Heartburn, vomiting, and indigestion
• Bloating
• Fatigue

Complications Of Ascites

• Infection of peritoneum called spontaneous bacterial peritonitis (SBP)
• Untreated SBP leads to fatalities
• Protein malnutrition
• Hepatic encephalopathy
• Kidney failure (Hepatorenal syndrome)
• Mental confusion
• Fever above 100.5°F (38.05°C)

Diagnosis and Testing of Ascites

If the above symptoms and signs persist for a long time seek medical attention immediately. Your doctor performs the following exams and tests.

• A complete blood count (CBC) is helpful to find the infections, anemia, and liver functions. Various other blood tests that are useful for analyzing the ascites are LFTs, Clotting screen, and TFTs.
• Electrolyte tests: It is carried out by routine blood tests called U&Es, it stands for Urine & Electrolytes.
• Paracentesis or Ascites tap: To find the causes and conditions of ascites, your doctor may use a thin needle to aspirate a sample of ascites fluid from the abdomen for testing. It is a less invasive procedure.
• Urinalysis: The Renal function of the kidney is checked through routine urine test in case of kidney failure.

Imaging studies

• Ultrasound: It is used to access the ascites fluid and liver function in the abdominal region. Ultrasound can also be used to cirrhosis and malignancy because of ascites.
• Magnetic resonance imaging (MRI): If ultrasound fails to get the proper information on ascites, MRI is used to confirm and find the damage of organs in the abdomen. Also, it is used to differentiate ascites from fat in the abdomen.
• CT- Scan: CT is also used to diagnose the disease conditions of spleen, liver and umbilical veins.

Liver biopsy

• A small tissue is collected from the liver to detect cirrhosis, which is a cause of ascites development. A biopsy is done through the laparoscopic procedure.

Management of ascites

The condition of ascites is treatable with proper treatment options and care.

Diuretics (Water pills)

• Diuretics are most commonly used for treating ascites. It is helpful to flush the extra fluid from the abdomen by reducing the amount of salt.
• The most common diuretics are Furosemide (Lasix) and Spironolactone (Aldactone).
• While administering diuretics your diet should be low water and low salt otherwise the fluid will return back into the body.

Therapeutic paracentesis

Therapeutic paracentesis is a procedure to drain the fluid from the abdomen. A needle or a tiny tube is placed in the peritoneal space and fluid is withdrawn under a sterile condition. This tube drains about 4 to 5 liters of abdominal fluids very safely. For severe cases of malignant ascites, this procedure can be more effective than diuretics.

Antibiotics

• Antibiotics are used to reduce the chances of getting infections in the peritoneum of abdominal organs.
• Most cases of SBP during ascites are due to gut bacteria’s such as coli, Klebsiella, even though Streptococcal and staphylococcus also cause infections.
• Cefotaxime (2 gram) is given intravenously for every eight hours.

Surgery

For more severe cases of ascites, surgical interventions can help to control.

• A permanent tube called Transjugular intrahepatic portosystemic shunts (TIPS) is placed between the portal venous system and the systemic venous system by that portal pressure can be reduced.

• In the advanced stages of cirrhosis, liver transplantation may be considered as a cure for ascites in case of liver failure.
• Liver transplant is a complex process, which requires a very close attention and monitoring of ascites patients by transplant specialist.

How to prevent Ascites

• Quit alcohol, this can prevent being affected from liver cirrhosis.
• Low salt diet (less than 1500mg/day of sodium).
• Get vaccinated to escape from hepatitis.
• Patients with cirrhosis should limit the use of Nonsteroidal anti-inflammatory drugs (ibuprofen). This may reduce the blood flow to kidney, thus reducing the excretion of water and salt from the body.
• Avoid drugs that given intravenously. Since hepatitis can spread through used needles.