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Ascites

What is ascites?

Ascites is the buildup of an abnormal amount of fluid inside the abdomen (belly). This is a common problem in patients with cirrhosis (scarring) of the liver. Approximately 80% of patients with cirrhosis of the liver develop ascites.

What are the symptoms of ascites?

Most people who develop ascites develop a large belly and experience a rapid gain in weight. Some people also develop swelling of the ankles and shortness of breath.

What causes ascites?

Ascites is the end result of a series of events. Cirrhosis of the liver is the most common cause of ascites. When cirrhosis occurs, blood flow through the liver is blocked. This blockage causes an increase in the pressure in the main vein (the portal vein) that delivers blood from the digestive organs to the liver. This condition is called portal hypertension. Ascites occurs when portal hypertension develops. The kidneys cannot rid the body of enough sodium (salt) through urine. Not being able to rid the body of salt causes fluids to build up in the abdomen (ascites).

What are the risk factors for development of ascites?

Common risk factors for the development of ascites include hepatitis B, hepatitis C, alcohol abuse and the other diseases that lead to fluid buildup (congestive heart failure, kidney failure), and cancers of organs in the abdomen.

How is ascites diagnosed?

Ascites is diagnosed based on physical exam, medical history, blood tests, ultrasound or CT scan, and paracentesis. Paracentesis is a procedure in which a needle is inserted through the abdominal wall (after local anesthesia) and fluid is removed. This fluid is examined for signs of infection, cancer, or other medical problems.

What are the complications of ascites?

  • Abdominal pain, discomfort and difficulty breathing. These problems may occur when too much fluid builds up in the abdominal cavity. This may limit a patient’s ability to eat, walk and perform daily activities.
  • Infection. The fluids that build up in the gut as a result of ascites could become infected with bacteria. When this happens, the condition is called spontaneous bacterial peritonitis. It usually causes fever and abdominal pain. The diagnosis is generally made by taking a sample from the abdominal cavity as described above (ie, by performing a paracentesis). Spontaneous bacterial peritonitis is a serious condition that requires treatment with IV antibiotics. After recovery from this infection, long-term treatment with oral antibiotics is needed to keep the infection from recurring.
  • Fluid in the lungs. This condition is called hepatic hydrothorax. Abdominal fluid fills the lung (mostly on the right side). This results in shortness of breath, cough, hypoxemia (lack of oxygen in the blood) and/or chest discomfort.
  • Kidney failure. Worsening of cirrhosis of the liver can lead to kidney failure. This condition is called hepatorenal syndrome. It is rare, but is a serious condition and may lead to death within about 3 months.
  • Heart failure, respiratory failure and hepatic encephalopathy (worsening of brain function) can occur as complications of liver surgery.

What are the best treatments for ascites?

  • Limit the amount of salt in your diet. The most important step to treating ascites is to drastically reduce your salt intake. Recommended limits are 2,000 mg or less a day. Seeing a nutritional specialist (dietitian) is helpful especially because the salt content in foods is difficult to determine. Salt substitutes – that do not contain potassium -- can be used.
  • Take diuretics ("water pills") as prescribed. Often, patients will require diuretics ("water pills") to treat ascites. Common diuretics are spironolactone (Aldactone) and/or furosemide (Lasix). These water pills can cause problems with your electrolytes (sodium, potassium) and kidney function (creatinine). Taking water pills is not a substitute for reducing your salt intake. Both are needed to treat ascites.
Other, increasingly more aggressive treatments include:
  • Paracentesis as a treatment. Sometimes fluids continue to build up in the abdomen despite use of diuretics and a restricted salt diet. In these cases, patients may need paracentesis to remove this large amount of excess fluid.
  • Surgery. Surgical placement of a shunt (tube) between the main vein (portal vein) and smaller veins is sometimes used as a treatment. By increasing blood flow, all organs of the body are better able to perform their function. For example, in patients with ascites, improved kidney function helps rid the body of excess sodium (salt) and prevent the buildup of fluids.
  • Liver transplant. This approach is reserved for patients with very severe cirrhosis whose livers are failing.

What can I do to control my ascites?

  • Weight yourself daily. Call your doctor if you gain more than 10 lbs (or more than 2 lbs per day on 3 consecutive days).
  • Limit the amount of alcohol you drink. Better yet, do not drink any alcoholic beverages at all. Reducing the amount of alcohol you drink reduces the risk of developing ascites.
  • Limit use of nonsteroidal anti-inflammatory drugs (NSAIDs). Ibuprofen (Advil, Motrin), aspirin, indomethacin, sulindac are examples of NSAIDs. These drugs affect the kidneys, causing water and salt to be retained by the body.
  • Follow guidelines for a low-salt diet. Recommended limits are 2,000 mg or less a day.
References

European Association for the Study of Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010;53:397-417.

Runyon BA. American Association for the Study of Liver Diseases Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: An update. Hepatology 2009;49:2087-107.

Sandhu BS, Sanyal AJ. Management of Ascites in Cirrhosis. Clin Liver Dis 2005;9:715-32.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 6/16/2011…#14792