Ascites

The most common cause of ascites is liver cirrhosis/scarring. Liver cirrhosis/scarring can be secondary to alcohol, fatty liver disease, hepatitis B and C. Cirrhosis causes an imbalance of pressure between the circulation (high-pressure system) and the abdominal cavity (low-pressure space). This pressure gradient along with decreased protein production (due to cirrhosis) results finally in ascites.

Ascites can also be a result of heart disease in the form of congestive heart failure or valvular heart disease. Ascites can also be a result of protein loss via urine from chronic kidney disease. Malignant ascites is a result of cancers.

Usually, the ascites if in large quantities results in cosmetically disfiguring large belly and easily identified on physical examination. However if the ascitic fluid is less than 500 cc, physical examination assisted with an ultrasound examination can be used to diagnose the presence of ascites.

Ascites is a symptom and diagnosing the underlying illness resulting in ascites is the key. Usually, blood work and occasionally liver biopsy is needed to diagnose the underlying liver condition.

Treatment depends on underlying conditions. Controlling the underlying disease treats ascites due to heart or kidney disease. Malignant ascites is treated with chemotherapy or radiation therapy of underlying cancer. Since chronic liver disease is the major cause of ascites, will focus on the treatment of ascites secondary to chronic liver disease.

Treatment of ascites secondary to liver disease has a 4-pronged approach:

1. Restricting dietary intake of salt to less than 2 gm/day and restricting dietary fluid intake to less than 2 liters/day.
2. Diuretic medications including spironolactone and furosemide. Usually, medication doses are adjusted based on kidney function and electrolytes as noted on blood tests.
3. Therapeutic paracentesis is a procedure wherein the ascitic fluid is drained periodically via a skin incision. People not responding to only diet and medications, benefit from large volume paracentesis done periodically.
4. Surgery in the form of transjugular intrahepatic portosystemic shunts (TIPS) is reserved for patients not responding to the above treatments. TIPS procedure is performed in radiology by an interventional radiologist wherein a shunt is placed in the portovenous (liver veins) and systemic veins (veins returning blood from the liver to heart), thereby decreasing the portal pressures (within the liver). Since the blood is being bypassed from the liver, this procedure may result in worsening of hepatic encephalopathy (term used to describe the mental confusion resulting from advanced liver disease).

Finally, liver transplantation for advanced cirrhotic liver disease can be considered at liver transplant institutes.