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Ascites

Overview

Ascites are an abnormal accumulation of fluid in your abdominal cavity. The organs in your abdominal cavity are covered by a serous sheath called the “Peritoneum,” which has two layers. Its function is to protect, lubricate, support, and connect the abdominal organs. The space inside those two layers is called the peritoneal cavity. Due to some disease processes, fluid can build up in this space. More than 25 milliliters of fluid is abnormal. However, it can be up to one liter and makes it difficult for a person to move and perform daily activities comfortably.
Ascites can develop due to multiple causes; the most common is portal hypertension due to cirrhosis. It is managed by treating the underlying cause and the dietary restriction of salts. If left untreated can lead to an infection of the peritoneum called Spontaneous Bacterial Peritonitis.

Causes

Ascites are caused when the blood vessels have a lot of pressure built inside them, causing them to leak or when there is not enough protein to hold the fluid inside the vessels or/and when they are leaking due to membrane instability caused by inflammation. The most common culprit of ascites is liver cirrhosis, which can be due to alcohol or viral or fatty liver disease. Some other causes of ascites are;

  • Heart failure
  • Kwashiorkor (disease due to Protein deficiency)
  • Nephrotic syndrome (a disease of leaking proteins through the kidney)
  • Cancer (primary or metastases)
  • Abdominal tuberculosis
  • Hypothyroidism
  • Vasculitis
  • Hepatic venous occlusion; veno-occlusive disease or Budd–Chiari syndrome
  • Pancreatitis
  • Constrictive pericarditis

Types

Ascites can be divided into two types based on fluid composition.
Transudative ascites: when the protein in the ascitic fluid is less than 3 grams per 100 ml, it is called transudative. It usually results from increased hydrostatic pressure or/and decreased proteins in the blood to retain water inside blood vessels, for example, cardiac failure, portal hypertension, nephrotic syndrome.
Exudative ascites: When the ascetic fluid protein is more than 3 grams per 100 ml, it is called exudative. It usually results from inflammation—for example, cancer, tuberculosis, etc.

Signs And Symptoms

Ascites develop gradually. At the beginning with lesser fluid, the symptoms would be minimal, but as the quantity of fluid increases, you may feel the following signs and symptoms;

  • Enlargement of belly or Swelling in the abdomen(abdominal distension)
  • Shortness of breath ( due to belly impingement on the chest)
  • Swelling of the legs
  • Problems of digestion
  • Bloating
  • Fatigue
  • Back pain

Epidemiology

Ascites are a result of other diseases. The most common of which is cirrhosis of the liver. Cirrhosis can be due to a result of chronic alcohol or viral liver disease. Alcoholic liver disease is more common in the west; however, chronic viral hepatitis C and B cases are increasing in the United States. Once the diagnosis is made, it takes up to 10 years to develop ascites. Among Patients who develop an episode of cirrhotic ascites, about 50%  will die within three years.

Risk Factors

Following are the risk factors that may increase the chances of having ascites;

  • Excessive alcohol consumption.
  • Being overweight or obese.
  • Iv drug abusers who share infected needles and syringes
  • Unprotected sex with multiple sexual partners
  • Infection with viral hepatitis C and B
  • Kidney disease
  • Malnutrition resulting in protein deficiency
  • Heart disease
  • Infection with tuberculosis
  • cancer

Diagnosis

Your doctor will take a detailed history to establish a diagnosis, asking questions about your condition, risk factors, etc. A thorough physical examination can point towards signs like the fluid thrill and shifting dullness specific to ascites. In the fluid thrill test, one side of the abdomen is tapped with a finger; a wave is produced due to the fluid movement, which is felt by the other hand on the opposite side of the abdomen. In the shifting dullness test, the abdomen is percussed, and a dull sound is produced where the fluid is present, which changes when the person is turned on the side. You may be advised of some investigations to find out the root cause of ascites.
Blood tests: Routine complete blood count (CBC), liver enzymes, coagulation profile, electrolytes, thyroid profile, lipid profile, viral markers, etc
Imaging: Ultrasound abdomen is performed to find out the fluid and other organs in the abdomen.
Diagnostic paracentesis: The ascitic fluid is taken out through a needle, which is then sent to a laboratory to check for proteins, inflammatory cells, cancer cells, culture, and gram stain, etc.

Treatment

Treatment is directed towards treating the cause of ascites and preventing the build-up of fluid in the abdomen.
Salt restriction: you may be asked to limit your intake of salts because salt retains water in the body. When there is less salt, there would be increased urine production to excrete the water from the body.
Medications: Diuretic medicines that excrete excess water by producing more urine are used, for example, spironolactone, Furosemide. Potassium levels are needed to be followed with this treatment.
Therapeutic paracentesis: In this procedure, fluid can be removed from the abdomen using a needle and a bag. Albumin is needed to be given to the patient during the treatment.
Shunts: The fluid is shunted using tubes to other body cavities or blood vessels to enable it to leave the body. A connection is made between blood vessels of the liver to prevent developing portal hypertension. However, this is not a permanent procedure, and liver transplantation would be needed. Examples are the transjugular intrahepatic portosystemic shunt (TIPS), portacaval shunt, and peritoneovenous shunt.

Prognosis

Ascites must be treated to prevent complications like Spontaneous bacterial peritonitis, hernias, kidney failure, or fluid building in the lungs. Spontaneous bacterial peritonitis is the infection of the peritoneum and fluid causing fever and stomach pain, treated with IV antibiotics.
About 50%  of patients with ascites will die within 3 years. If ascites are refractory to treatment, less than 50% of patients will survive till one year.

Lifestyle Modifications

To cope up with the condition, you must;

  • Have a regular check on weight gain as it may build up more fluid.
  • Follow a strict diet plan with salt restriction
  • Take your prescribed medicines regularly.
  • Avoid drinking alcohol
  • Consuming a healthy diet rich in vitamins, minerals, omega 3 fatty acids, anti-oxidants and avoiding fatty and fried food
  • Be cautious with using medicines that can harm your kidneys, like NSAIDs.