Ascites

Introduction

Ascites is the accumulation of excess fluid within the peritoneal cavity.

Causes of ascites

Ascites is caused by the following disease conditions:

  1. Portal hypertension secondary to liver cirrhosis
  2. Renal failure
  3. Nephrotic syndrome
  4. Cardiac failure
  5. Abdominal tuberculosis.
  6. Intra-abdominal or pelvic malignancies

Symptoms of ascites

The symptoms of ascites are:

  1. Abdominal enlargement
  2. Abdominal discomfort or pain
  3. Difficulty breathing

Signs of ascites

  1. Distended abdomen.
  2. Shifting dullness
  3. Fluid thrill
  4. Abdominal tenderness
  5. Signs relating to the underlying causes

Investigations

  • Full blood count
  • BUE & Creatinine
  • LFTS
  • INR
  • Urinalysis
  • Abdomino-pelvic ultrasound
  • Chest X-ray
  • Diagnostic paracentesis
    • Appearance and colour
    • Gram stain
    • Cell count and differential
    • Biochemistry e.g. Albumin
    • Microscopy, culture (with bedside inoculation of aerobic & an aerobic blood culture bottles)
    • Acid fast bacilli
    • Cytology

Treatment for ascites

Treatment objectives

  1. To relieve symptoms.
  2. To identify and manage underlying cause

Non-pharmacological treatment

  1. Bed rest
  2. Salt restriction <2 g/day
  3. Fluid restriction to ≤1.5 L/day
  4. Avoid NSAID-use
  5. Alcohol abstinence
  6. Therapeutic paracentesis (sterile abdominal tap) if ascites is tense and/or there is respiratory embarrassment

Note

Removal of up to 5 litres of ascitic fluid without concomitant colloid infusion is a safe short-term option and unlikely to have haemodynamic consequences.

Pharmacological treatment

A. Control of ascitic fluid accumulation

1st Line Treatment
Evidence Rating: [A]
Spironolactone, oral,
Adults

  • 50-200 mg daily

Children

  • 0.3-3 mg/kg daily

And

Furosemide, oral,
Adults

  • 20-80 mg daily

Children

  • 1-2 mg/kg daily

B. Massive ascites in liver cirrhosis with respiratory embarrassment requiring more than 5 litres of fluid drainage

1st Line Treatment
Evidence Rating: [A]
Salt-poor human albumin solution, IV, 6-8 g per litre of ascitic fluid drained

Referral Criteria

Patients with the following conditions must be referred to a specialist.
Poor response to diuretic therapy or diuretic-refractory ascites, complicated cirrhotic ascites with suspected spontaneous bacterial peritonitis, hepato-renal syndrome, and hepatic encephalopathy.
Also refer when an underlying cause cannot be identified.