Ascites

What is ascites?

Ascites (ay-SITE-eez) is when too much fluid builds up in your abdomen (belly). This condition most often happens in people who have cirrhosis (scarring) of the liver. It can make movement difficult and be very uncomfortable.

A sheet of tissue called the peritoneum covers your abdominal organs, including your stomach, intestines, liver and kidneys. The peritoneum has two layers. Ascites happens when fluid builds up between the two layers. The fluid can make it look like you have a watermelon or basketball in your belly.

Symptoms of ascites

The main symptoms of ascites are a large belly and rapid weight gain (two or three pounds per day for three days). You may also have swelling in your ankles (edema).

Other symptoms include:

• Shortness of breath
• Difficulty sitting and/or difficulty with movement
• Digestive issues, like bloating, abdominal pain, indigestion and constipation
• Back pain
• Fatigue

Ascites causes

Cirrhosis is the most common cause of ascites, but it’s not the only cause. Other conditions that can cause it include:

• Congestive heart failure
• Kidney failure
• Cancer of the organs in the abdomen and pelvis
• Tuberculosis

An even less common cause is nephrotic syndrome.

How does cirrhosis cause ascites?

Cirrhosis damages your liver and affects how blood flows through it. This damage can increase pressure in your portal vein, which carries blood to your liver. When this happens, it’s called portal hypertension. This sends an incorrect signal to your kidneys to hold onto sodium and water. When this goes on long enough, salt and water spill out into your abdominal cavity.

Risk factors for ascites

Having a condition that causes cirrhosis puts you at the greatest risk of developing ascites. These conditions include:

• Metabolic dysfunction-associated steatohepatitis (MASH)
• Alcohol use disorder
• Hepatitis B
• Hepatitis C
• Autoimmune hepatitis
• Genetic liver diseases like hemochromatosis, Wilson disease and alpha-1 antitrypsin deficiency

Complications of ascites

Ascites can lead to:

• Chronic abdominal discomfort. The fluid buildup may lead to pain, discomfort and difficulty breathing. These symptoms can interfere with your ability to eat, walk and do daily activities.
• Infection. Peritonitis is when the fluid in your abdomen becomes infected. You may develop a fever and stomach pain. You’ll need IV antibiotics and long-term antibiotic treatment to keep the infection from coming back.
• Hepatic hydrothorax (fluid around the lungs). Abdominal fluid can leak into your chest and lungs, causing shortness of breath, cough and hypoxemia (lack of oxygen in your blood). You may need thoracentesis to remove the fluid.
• Ascites-related hernias. The increase in abdominal pressure can lead to hernias. Your healthcare provider will discuss your treatment options.
• Kidney failure. If cirrhosis worsens, it can lead to kidney failure.

How doctors diagnose ascites

Your healthcare provider performs a physical exam and checks your belly for signs of fluid buildup. They’ll ask you about your symptoms and medical history. They may also order blood tests to check your liver and kidney function.

Tests for ascites

After the exam, your provider will recommend other tests to confirm a diagnosis:

• Ultrasound or CT scan. These imaging scans show your abdominal area in more detail. They can show areas of fluid as well as the size of your liver.
• Paracentesis. You’ll get a local anesthetic before this procedure so you don’t feel pain. Your provider inserts a needle into your abdomen to remove fluid. They examine the fluid for signs of cancer, infection and other conditions.

Your healthcare provider will check to make sure the ascites aren’t due to heart or kidney problems or cancer.

What is the treatment for ascites?

Treatment for ascites involves reducing fluid buildup in your belly. Healthcare providers typically try these treatment methods first:

• Limiting sodium. Healthcare providers may recommend limiting sodium intake to less than 2,000 milligrams a day. A dietitian can help create a healthy eating plan for you. They can also teach you how to read food labels so you can avoid high-sodium foods.
• Taking diuretics. Diuretics (or water pills) help your kidneys get rid of extra fluid and sodium.
• Treat the underlying condition. For example, if cancer is causing ascites, chemotherapy can help shrink the tumor and stop the fluid from building up.

Sometimes, diuretics and lowering sodium intake aren’t enough to improve ascites. You may need other treatments, including:

• Paracentesis. Your provider inserts a needle into your abdomen to remove the fluid. This procedure can remove a large amount of excess fluid and be done as often as necessary.
• Transjugular intrahepatic portosystemic shunt (TIPS). TIPS involves your provider creating a new pathway (shunt) for blood to travel so it avoids your liver. This can prevent fluid from leaking into your abdomen. TIPS may be appropriate if your ascites aren’t responding to other therapies.
• Liver transplant. A liver transplant may be necessary in severe cases of cirrhosis.

The treatment your provider recommends is based on factors like the severity of ascites, your medical history and the overall health of your liver.

When should I see my healthcare provider?

Contact your provider if you have cirrhosis of the liver and notice the following symptoms:

• Rapid weight gain
• Increase in the size of your belly
• Shortness of breath

Go to the emergency room right away if you have:

• Fever
• Intense stomach pain

What should I ask my healthcare provider?

If you have ascites, ask your healthcare provider:

• What treatments are available?
• Should I consider a liver transplant?
• What foods should I avoid?
• What medications are available?
• Will the ascites return?

How can I prevent ascites?

The best way to prevent ascites is to take care of your liver. Some things you can do are:

• Avoid beverages containing alcohol.
• Avoid foods that are high in salt.
• Get some physical activity every day.
• Maintain a weight that’s healthy for you.
• Reduce your risk of hepatitis B and C (which increase your risk for cirrhosis).

What’s the outlook for people with ascites?

Ascites is a sign that your liver isn’t working as it should. It can impact your quality of life and cause uncomfortable symptoms. Medications, low-sodium foods and procedures like paracentesis can help improve your symptoms and reduce your risk of complications. Your healthcare team will monitor you to make sure treatment is working.

If you have ascites, these steps can help you manage the condition:

• Check your weight. Weigh yourself daily. Call your healthcare provider if you gain more than two pounds per day for three consecutive days.
• Limit alcohol. It’s best to avoid beverages that contain alcohol to reduce your ascites risk.
• Limit NSAID use. Nonsteroidal anti-inflammatory drugs, like ibuprofen (Motrin^® and Advil^®) and aspirin cause your body to retain excess water and salt.
• Eat a low-salt diet. Try to consume no more than 2,000 milligrams of sodium per day.