What Are Ascites?
Ascites is a condition when fluid fills the abdominal cavity (the part of the body that is between the thorax or chest and pelvis). Ascites often occurs when the heart stops working properly. Fluid will fill the cavity between the abdomen and organs called the abdominal or peritoneal cavity.
Abdominal cavity is below the chest cavity. This organ is separated by a diaphragm. Ascitic fluid can have many sources such as liver disease, cancer, congestive heart failure, or kidney failure.
Causes of Ascites
The cause of ascites is advanced liver disease or cirrhosis. Although the exact mechanism of the development of ascites is still not fully understood, many theories link portal hypertension (increased pressure on blood flow to the liver) as a major contributor to the cause of ascites.
This basic principle is similar to the formation of edema in other parts of the body due to imbalance of pressure inside and outside the circulation (high pressure system inside), in this case the abdominal cavity is a cavity with low pressure. An increase in protal blood pressure and a decrease in albumin (a protein present in the blood) are responsible for the gradient pressure and cause abdominal ascites.
Another factor that contributes to ascites is the retention of salt and water. The volume of circulating blood can be considered low by sensors in the kidney so that the formation of ascites can drain some fluid volume from the blood.
This kidney signal is to reabsorb more salt and water to compensate for the loss of body fluid volume. Some other causes of ascites are related to increased pressure gradients from congestive heart failure and advanced kidney failure due to general fluid retention in the body.
In rare cases, increased pressure in the portal system can be caused by internal or external obstruction of the portal blood vessels, resulting in portal hypertension without cirrhosis.
This example can occur in a mass condition (malignancy or tumor) that compresses the portal vessels from inside the abdominal cavity or the presence of blood clots in portal blood vessels that block normal flow and increase pressure in a room (for example, Budd-Chiari syndrome).
Ascites can also manifest as a result of cancer, called malignant ascites. This type of ascites is usually a manifestation of advanced-stage cancer of the organs in the abdominal cavity, such as, colon cancer, pancreatic cancer, gastric cancer, breast cancer, lymphoma, lung cancer, or ovarian cancer.
Pancreatic ascites can be seen in people with chronic pancreatitis or inflammation of the pancreas. The most common cause of chronic pancreatitis is prolonged alcohol abuse. Pancreatic ascites can also be caused by acute pancreatitis and trauma to the pancreas.
Ascites is traditionally divided into 2 types: transudate and exudate. This classification is based on the amount of protein found in the liquid. A more advanced system calculates the amount of albumin in ascitic fluid compared to albumin present in serum (blood flow). This is called Serum Asites Gradient Albumin.
Risk Factors for Ascites
The most common cause of ascites is cirrhosis of the liver. Many other risk factors that cause ascites and cirrhosis are similar. Most risk factors are hepatitis B, hepatitis C, and long-term alcohol abuse. Other potential risk factors associated with this condition such as congestive heart failure and kidney disease.
There are no symptoms associated with ascites especially if the case is mild (usually the fluid in the abdominal cavity is less than about 100-400 milligrams in adults). As more fluid accumulates, an increase in abdominal girth and abdominal size is commonly seen. Abdominal pain, discomfort, and bloating are also often seen when ascites becomes larger.
Shortness of breath can also occur due to enlarged ascites, this is because of increased pressure on the diaphragm and migration of fluid across the diaphragm causing pleural effusion (fluid around the lungs).
Treatment of ascites is largely dependent on the underlying cause. For example, peritoneal carcinomatosis or malignant ascites can be treated with surgical resection of cancer and chemotherapy, while ascites management associated with heart failure is directed at treating heart failure with medical management and dietary restrictions. Because cirrhosis of the liver is the main cause of ascites, it will be the main focus of this section.
Managing ascites in cirrhosis patients usually involves limiting sodium food intake and prescription diuretics (water pills). Limiting sodium (salt) intake to less than 2 grams per day is a very practical, successful, and widely recommended step for patients with ascites.
In most cases, this approach needs to be combined with the use of diuretics because salt restriction alone is generally not an effective way to treat ascites. Consultation with a nutritionist regarding daily salt restriction can be very helpful for patients with ascites.
- Ascites medicine
Diuretic drugs will increase the excretion of salt and water from the kidneys. The recommended diuretic in the setting of liver ascites is a combination of spironolactone (aldactone) and furosemide (Lasix). A single dose of 100 milligrams of spironolactone and 40 milligrams of furosemide is usually recommended as the initial dose.
This can be increased gradually to get an appropriate response with a maximum dose of 400 milligrams of spironolactone and 160 milligrams of furosemide, as long as the patient can tolerate an increase in the dose of the diuretic drug without side effects. Consumption of these drugs together in the morning is usually recommended to prevent frequent urination at night.
- Parasynthesis therapy
For patients who do not respond well or cannot tolerate the above treatment regimen, paracentesis therapy (a needle is placed into the stomach area, under sterile conditions, to suck up fluid in the peritoneal cavity) can be done to remove large amounts of fluid. Several liters (4 to 5 liters) of liquid can be taken safely by the procedure. For patients with malignant ascites, this procedure may also be more effective than the use of diuretics.
- Ascites surgery
In cases that are recurrent and not cured, a surgical procedure may be needed to control ascites. Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure performed through the internal jugular vein (main vein of the neck) under local anesthesia by an interventional radiologist.
A shunt is placed between the portal venous system and the systemic venous system (veins that return blood back to the heart), thereby reducing portal pressure. This procedure is provided for patients who have a minimal response to aggressive medical care.
This procedure has been proven to reduce ascites and reduce the use of diuretics in most cases. However, this is associated with significant complications such as hepatic encephalopathy and even death.
Traditional shunt placement (peritoneoven shunts and systemic systemic shunts) has been abandoned due to high rates of complications.
- Liver transplant
Finally, liver transplantation for advanced cirrhosis can be considered a treatment for ascites due to liver failure. A liver transplant involves a very complicated, prolonged process that requires close attention.
Complications of Ascites
Some ascites complications are related to breathing difficulties due to suppression of the diaphragm and due to pleural effusion. Infection is another serious complication. In patients with ascites associated with portal hypertension, bacteria from the intestine are able to spontaneously invade ascitic fluid and cause infection. This is called spontaneous bacterial peritonitis. Antibodies are rare in ascites, so the immune response in ascites is very small and limited.