Ascites is the accumulation of fluid in the abdomen, specifically the peritoneal cavity. Ascites can be caused by many factors and presents as mild to extreme abdominal swelling. This condition is also known as hydro-peritoneum and in earlier times, abdominal dropsy.
Since ascites ranges from mild to severe, the symptoms vary. Mild ascites is difficult to detect because the swelling is not predominant in the abdomen.
Patients with severe ascites will have abdominal distention –swelling so severe the patient (male or female) looks pregnant. Individuals with severe ascites will also have the following symptoms: abdominal heaviness and pressure, shortness of breath due to pressure on the abdomen.
Other symptoms depend on the cause of ascites. Portal ascites occurs in patients with specific liver diseases. Symptoms that appear with these conditions are bruising, leg swelling, mental impairment due to encephalopathy (water on the brain), and gynecomastia hematemesis. Gynecomastia hematemesis is defined as enlarged breasts on a man. Ascites can also be dues to cancer, which is known as peritoneal carcinomatosis. Patients with this type of ascites may also experience severe, chronic fatigue and weight loss. Ascites that coincides with heart failure will also present symptoms of wheezing, inability to exercise and shortness of breath.
Ascites is classified into three grades. Grade 1 is only visible via ultrasound or other imaging. Grade 2 is noticeable as swelling that can shift with physical exam and is located on either side of the belly button below the last rib. Grade 3 is obvious, visible swelling of the abdomen in which the fluid can literally wave across the abdomen.
A routine CBC or complete blood count, a liver enzymes test, coagulation tests, basic metabolic profile and a diagnostic paracentesis are performed to diagnose the cause of ascites. Diagnostic paracentesis involves the withdrawal of 50 to 100 mL of abdominal fluid and evaluating its appearance and content. Cell counts will be performed for white and blood cells as well as checking for the appearance of albumin and protein levels. A Gram stain and cytology of this fluid will also be performed to detect cancer.
Albumin levels are tested and evaluated against the serum-ascites albumin gradient (SAAG). A high gradient is defined as a level greater than 1.1 g/dL and determines the cause is portal hypertension. A low gradient, less than 1.1 g/dL defines the ascites as non-portal hypertensive.
Ultrasound will be used to determine the shape and size of abdominal organs before withdrawing fluid. Doppler studies will be able to indicate the direction of flow in the portal vein, detect Budd-Chiari syndrome and/or portal vein thrombosis (clot). The ultra sound can also determine the amount of ascetic fluid and guide the drainage procedure, if it appears to be complicated.
A high SAAG gradient is also known as transudate and can be caused by cirrhosis, heart failure, Budd-Chiari syndrome and constrictive pericarditis. Cirrhosis accounts for 81% of ascites cases in which the cause is high SAAG. Heart failure accounts for 3% of cases. Budd-Chiari Syndrome is defined as a closure (in a variety of degrees) of the vena cava or the hepatic vein. Constrictive pericarditis is when a thick non-compliant fibrous shell forms around the heart impacting the heart’s ability to pump.
A low SAAG gradient of the fluid withdrawn from ascites can be caused by cancer, tuberculosis, pancreatitis, serositis, or nephritic syndrome. Cancer accounts for 10% of cases of low grade SAAG ascites. Low SAAG is also referred to as exudate.
Treatment for ascites is conducted simultaneously while treating the underlying condition or etiology. The goal of treatment is to prevent progression of the condition, relieve symptoms, and avoid or eliminate complications. Most patients with mild ascites can be treated on an outpatient basis.
In transudate ascites, also known as cirrhotic ascites, treatment involves reduction or restriction of salt which facilitates increased production of urine. Production of urine is also referred to as diuresis. Salt restriction is the baseline treatment and medication that counteracts aldosterone behavior should be prescribed as well. Aldosterone is a steroid which controls the balance of salt and water in the body. Distal-tubule diuretics can also be used to block aldosterone receptors. Potassium levels and renal function need to be monitored closely during this treatment.
Severe ascites may require therapeutic paracentesis, a procedure in which fluid is taken from the abdomen in addition to the above treatments. Albumin may be given intravenously as this procedure may decrease the blood serum levels of albumin.
A small number of advanced cirrhosis patients have recurring ascites. Ascites that continues to return and is unresponsive to treatment is considered a case in which liver transplant is needed. In this case a shunt may be used to drain fluid. Three types of shunts used are the protacaval shunt, transjugular intrahepatic portosystem shunt and the peritoneovenous shunt. These shunts have not proven to extend the lives of patients waiting for liver transplants, only ease discomfort until a liver becomes available.
Exudate ascites is ascites with a low SAAG level. This class of ascites does not respond to diuretic therapy or salt restriction. Usually, repeated paracentesis and treating the condition that is causing the ascites are the primary treatment for this class of ascites.
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