Ascites: A Common Problem in People with Cirrhosis
Accumulation of fluid in the abdominal cavity is called ascites. Ascites is common in people with cirrhosis and it usually develops when the liver is starting to fail. In general, the development of ascites indicates advanced liver disease and patients should be referred for consideration of liver transplantation.
Cirrhosis of the liver is the most common cause of ascites but other conditions such as heart failure, kidney failure, infection or cancer can also cause ascites. Ascites is caused by a combination of elevated pressure in the veins running through the liver (portal hypertension) and a decrease in liver function caused by scarring of the liver, i.e., cirrhosis.
Most patients who develop ascites notice abdominal distension and rapid weight gain. Some people also develop swelling of ankles and shortness of breath from accumulation of fluid around the lungs. Additional symptoms or complication may occur and are listed below.
Abdominal pain, discomfort and difficulty breathing: These may occur when too much fluid accumulates in the abdominal cavity. This may limit the ability to eat, ambulate and perform activities of daily living.
Infection: This is called spontaneous bacterial peritonitis (SBP) and it usually causes abdominal pain, tenderness, fever or nausea. If this is not promptly diagnosed or treated, a patient may develop kidney failure, severe infection in the blood stream or mental confusion. The diagnosis is generally made by taking a sample of the fluid from the abdominal cavity. This infection can be treated with intravenous antibiotics, and after recovery, patients will require long term treatment with antibiotics to prevent SBP from recurring.
Ascites related hernias: Elevated intra-abdominal pressure can lead to the development of umbilical (around the bellybutton) and inguinal (groin) hernias that can cause abdominal discomfort. Surgical repair is generally avoided unless there is severe pain suggesting the intestines or tissue may be pinched or twisted along with a persistent bulge from the hernia. Surgeons who have experience in treating patients with cirrhosis should perform these operations.
Fluid accumulation in the chest: This is called hepatic hydrothorax and the abdominal fluid fills into the lung cavities (mostly on your right side) in addition to the abdominal cavity. This condition may result in shortness of breath with exertion or sometimes at rest also.
In general, the development of ascites indicates evidence of advanced liver disease and patients should be referred for consideration of liver transplantation.
Depending on how much fluid is present in the abdomen, ascites may be diagnosed by the doctor on physical examination but is usually confirmed by tests such as ultrasound or CT scan of the abdomen. In the majority of patients, the doctor will recommend that a small needle be inserted through the abdominal wall (after local anesthesia) to remove fluid to be examined in the laboratory. This test is called a paracentesis. The fluid removed will be examined for signs of infection or cancer and to determine the cause for the fluid accumulation.
The development of ascites generally suggests that the liver is not working well. The survival rate 5 years after ascites develops is only 30-40% and it is important that the patient and doctor discuss a referral to a liver specialist and a liver transplant center.
The most important step to treat ascites is to strictly reduce the salt intake. Salt intake is limited to to 4-5 grams per day (2,000 mg of sodium) or less. As it can be difficult to determine the salt content of various foods, it is generally recommended that a patient with ascites see a nutritionist (dietician) for advice about various foods to avoid. Patients may use salt substitute but it is essential to choose one without potassium because the potassium levels can increase with certain medications to treat ascites. It is important to discuss with the doctor or the dietician which salt substitute may be safer to use.
Most often, patients will require water pills (diuretics) to treat ascites. Commonly used water pills are spironolactone (Aldactone) and/or furosemide (Lasix) and their dosages are appropriately adjusted. These water pills can cause problems with blood electrolytes (levels of sodium and potassium) and as such close monitoring by blood tests may be required. It is important to realize that taking water pills is not a substitute for reducing your salt intake, as water pills will work only when they are taken together with restricted salt intake.
Checking body weight daily on a scale and contacting the physician whenever there is a gain of more than 10 pounds (or greater than 2 pounds per day for 3 consecutive days) is a good strategy for better management in patients with ascites.
When fluid accumulation cannot be treated optimally with water pills and salt restricted diet, patients may require a large amount of fluid be removed (paracentesis) for relief of symptoms. Other procedures such as having a radiologist place a shunt within the liver (called TIPS) to prevent significant fluid accumulation from ascites are available for patients who have difficult to treat ascites. As mentioned earlier, patients with ascites have a serious health risk and are often evaluated for liver transplantation. More than half of these patients may not survive 2-3 years without liver transplantation.
Author(s) and Publication Date(s)
Naga P. Chalasani, MD, FACG, and Raj K. Vuppalanchi, MD, Indiana University School of Medicine, Indianapolis, IN – Published January 2006. Updated July 2013.