Ascites - wikipedia Ascites Ascites Synonyms Peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum, abdominal dropsy The abdomen of a person with cirrhosis which has resulted in massive ascites and prominent superficial veins Pronunciation / əˈsaɪtiːz /, ə - SY - teez, / əˈsʌɪtiːz / Specialty Gastroenterology Symptoms Increased abdominal size, increased weight, abdominal discomfort, shortness of breath Complications Spontaneous bacterial peritonitis, hepatorenal syndrome, low blood sodium Causes Liver cirrhosis, cancer, heart failure, tuberculosis, pancreatitis, blockage of the hepatic vein Diagnostic method Physical exam, ultrasound, CT scan Treatment Low salt diet, medications, draining the fluid Medication Spironolactone, furosemide Frequency > 50 % of people ( with cirrhosis ) Ascites is the abnormal buildup of fluid in the abdomen. Technically, it is more than 25 mL of fluid in the peritoneal cavity. Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and shortness of breath. Complications can include spontaneous bacterial peritonitis. In the developed world, the most common cause is liver cirrhosis. Other causes include cancer, heart failure, tuberculosis, pancreatitis, and blockage of the hepatic vein. In cirrhosis, the underlying mechanism involves high blood pressure in the portal system and dysfunction of blood vessels. Diagnosis is typically based on a examination together with ultrasound or a CT scan. Testing the fluid can help in determining the underlying cause. Treatment often involves a low salt diet, medication such as diuretics, and draining the fluid. A transjugular intrahepatic portosystemic shunt ( TIPS ) may be placed but is associated with complications. Effects to treat the underlying cause, such as by a liver transplant may be considered. Of those with cirrhosis, more than half develop ascites in the ten years following diagnosis. Of those in this group who develop ascites, half will die within three years. The term is from the Greek askítes meaning `` baglike ''. Contents 1 Signs and symptoms 2 Causes 3 Diagnosis 3.1 Classification 4 Pathophysiology 5 Treatment 5.1 Diet 5.2 Diuretics 5.3 Paracentesis 5.4 Surgery 5.5 Low SAAG 6 Complications 6.1 Spontaneous bacterial peritonitis 6.2 Hepatorenal syndrome 6.3 Thrombosis 7 Society and culture 8 References 9 External links Signs and symptoms Mild ascites is hard to notice, but severe ascites leads to abdominal distension. Patients with ascites generally will complain of progressive abdominal heaviness and pressure as well as shortness of breath due to mechanical impingement on the diaphragm. Ascites is detected on physical examination of the abdomen by visible bulging of the flanks in the reclining patient ( `` flank bulging '' ), `` shifting dullness '' ( difference in percussion note in the flanks that shifts when the patient is turned on the side ) or in massive ascites with a `` fluid thrill '' or `` fluid wave '' ( tapping or pushing on one side will generate a wave - like effect through the fluid that can be felt in the opposite side of the abdomen ). Other signs of ascites may be present due to its underlying cause. For instance, in portal hypertension ( perhaps due to cirrhosis or fibrosis of the liver ) patients may also complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy. Those with ascites due to cancer ( peritoneal carcinomatosis ) may complain of chronic fatigue or weight loss. Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance. Causes Causes of high serum - ascites albumin gradient ( SAAG or transudate ) are : Cirrhosis -- 81 % ( alcoholic in 65 %, viral in 10 %, cryptogenic in 6 % ) Heart failure -- 3 % Hepatic venous occlusion : Budd -- Chiari syndrome or veno - occlusive disease Constrictive pericarditis Kwashiorkor ( childhood protein - energy malnutrition ) Causes of low SAAG ( `` exudate '' ) are : Cancer ( metastasis and primary peritoneal carcinomatosis ) -- 10 % Infection : Tuberculosis -- 2 % or spontaneous bacterial peritonitis Pancreatitis -- 1 % Serositis Nephrotic syndrome Hereditary angioedema Other rare causes : Meigs syndrome Vasculitis Hypothyroidism Renal dialysis Peritoneum mesothelioma Abdominal tuberculosis Mastocytosis Diagnosis Ascites in a person with abdominal cancer as seen on ultrasound Liver cirrhosis with ascites Routine complete blood count ( CBC ), basic metabolic profile, liver enzymes, and coagulation should be performed. Most experts recommend a diagnostic paracentesis be performed if the ascites is new or if the patient with ascites is being admitted to the hospital. The fluid is then reviewed for its gross appearance, protein level, albumin, and cell counts ( red and white ). Additional tests will be performed if indicated such as microbiological culture, Gram stain and cytopathology. The serum - ascites albumin gradient ( SAAG ) is probably a better discriminant than older measures ( transudate versus exudate ) for the causes of ascites. A high gradient ( > 1.1 g / dL ) indicates the ascites is due to portal hypertension. A low gradient ( < 1.1 g / dL ) indicates ascites of non-portal hypertensive as a cause. Ultrasound investigation is often performed prior to attempts to remove fluid from the abdomen. This may reveal the size and shape of the abdominal organs, and Doppler studies may show the direction of flow in the portal vein, as well as detecting Budd - Chiari syndrome ( thrombosis of the hepatic vein ) and portal vein thrombosis. Additionally, the sonographer can make an estimation of the amount of ascitic fluid, and difficult - to - drain ascites may be drained under ultrasound guidance. An abdominal CT scan is a more accurate alternate to reveal abdominal organ structure and morphology. Classification Ascites exists in three grades : Grade 1 : mild, only visible on ultrasound and CT Grade 2 : detectable with flank bulging and shifting dullness Grade 3 : directly visible, confirmed with the fluid wave / thrill test Pathophysiology Ascitic fluid can accumulate as a transudate or an exudate. Amounts of up to 35 liters are possible. Roughly, transudates are a result of increased pressure in the hepatic portal vein ( > 8 mmHg, usually around 20 mmHg ), e.g. due to cirrhosis, while exudates are actively secreted fluid due to inflammation or malignancy. As a result, exudates are high in protein and lactate dehydrogenase and have a low pH ( < 7.30 ), a low glucose level, and more white blood cells. Transudates have low protein ( < 30 g / L ), low LDH, high pH, normal glucose, and fewer than 1 white cell per 1000 mm3. Clinically, the most useful measure is the difference between ascitic and serum albumin concentrations. A difference of less than 1 g / dl ( 10 g / L ) implies an exudate. Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed. Regardless of the cause, sequestration of fluid within the abdomen leads to additional fluid retention by the kidneys due to stimulatory effect on blood pressure hormones, notably aldosterone. The sympathetic nervous system is also activated, and renin production is increased due to decreased perfusion of the kidney. Extreme disruption of the renal blood flow can lead to hepatorenal syndrome. Other complications of ascites include spontaneous bacterial peritonitis ( SBP ), due to decreased antibacterial factors in the ascitic fluid such as complement. Treatment Diagram showing ascites being drained Ascites is generally treated while an underlying cause is sought, in order to prevent complications, relieve symptoms, and prevent further progression. In patients with mild ascites, therapy is usually as an outpatient. The goal is weight loss of no more than 1.0 kg / day for patients with both ascites and peripheral edema and no more than 0.5 kg / day for patients with ascites alone. In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis. Treatments in high SAAG ( `` transudate '' ) are : Diet Salt restriction is the initial treatment, which allows diuresis ( production of urine ) since the patient now has more fluid than salt concentration. Salt restriction is effective in about 15 % of patients. Water restriction is needed if serum sodium levels drop below 130 mmol L. Diuretics Since salt restriction is the basic concept in treatment, and aldosterone is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be sought. Spironolactone ( or other distal - tubule diuretics such as triamterene or amiloride ) is the drug of choice since they block the aldosterone receptor in the collecting tubule. This choice has been confirmed in a randomized controlled trial. Diuretics for ascites should be dosed once per day. Generally, the starting dose is oral spironolactone 100 mg / day ( max 400 mg / day ). 40 % of patients will respond to spironolactone. For nonresponders, a loop diuretic may also be added and generally, furosemide is added at a dose of 40 mg / day ( max 160 mg / day ), or alternatively ( bumetanide or torasemide ). The ratio of 100 : 40 reduces risks of potassium imbalance. Serum potassium level and renal function should be monitored closely while on these medications. Monitoring diuresis : Diuresis can be monitored by weighing the patient daily. The goal is weight loss of no more than 1.0 kg / day for patients with both ascites and peripheral edema and no more than 0.5 kg / day for patients with ascites alone. If daily weights can not be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs. A random urine sodium - to - potassium ratio of > 1 is 90 % sensitivity in predicting negative balance ( > 78 - mmol / day sodium excretion ). Diuretic resistance : Diuretic resistance can be predicted by giving 80 mg intravenous furosemide after 3 days without diuretics and on an 80 mEq sodium / day diet. The urinary sodium excretion over 8 hours < 50 mEq / 8 hours predicts resistance. If a patient exhibits a resistance to or poor response to diuretic therapy, ultrafiltration or aquapheresis may be needed to achieve adequate control of fluid retention and congestion. The use of such mechanical methods of fluid removal can produce meaningful clinical benefits in patients with diuretic resistance and may restore responsiveness to conventional doses of diuretics. Paracentesis Main article : Paracentesis In those with severe ( tense ) ascites, therapeutic paracentesis may be needed in addition to medical treatments listed above. As this may deplete serum albumin levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed. Surgery Ascites that is refractory to medical therapy is considered an indication for liver transplantation. In the United States, the MELD score ( online calculator ) is used to prioritize patients for transplantation. In a minority of people with advanced cirrhosis that have recurrent ascites, shunts may be used. Typical shunts used are portacaval shunt, peritoneovenous shunt, and the transjugular intrahepatic portosystemic shunt ( TIPS ). However, none of these shunts has been shown to extend life expectancy, and are considered to be bridges to liver transplantation. A meta - analysis of randomized controlled trials by the international Cochrane Collaboration concluded that `` TIPS was more effective at removing ascites as compared with paracentesis... however, TIPS patients develop hepatic encephalopathy significantly more often ''. Low SAAG Exudative ascites generally does not respond to manipulation of the salt balance or diuretic therapy. Repeated paracentesis and treatment of the underlying cause is the mainstay of treatment. Complications Spontaneous bacterial peritonitis Main article : Spontaneous bacterial peritonitis Hepatorenal syndrome Main article : Hepatorenal syndrome Thrombosis Complications involve portal vein thrombosis and splenic vein thrombosis : clotting of blood affects the hepatic portal vein or varices associated with splenic vein. This can lead to portal hypertension and reduction in blood flow. When a liver cirrhosis patient is suffering from thrombosis, it is not possible to perform a liver transplant, unless the thrombosis is very minor. In case of minor thrombosis, there are some chances of survival using cadaveric liver transplant. Society and culture It has been suggested that ascites was seen as a punishment especially for oath - breakers among the Proto - Indo - Europeans. This proposal builds on the Hittite military oath as well as various Vedic hymns ( RV 7.89, AVS 4.16. 7 ). A similar curse dates to the Kassite dynasty ( 12th century BC ). Comparable is also Numbers 5 : 11ff, where an accused adulteress is confirmed with swelling of the abdomen. References ^ Jump up to : `` Ascites ''. National Library of Medicine. Retrieved 14 December 2017. ^ Jump up to : `` Ascites - Hepatic and Biliary Disorders ''. Merck Manuals Professional Edition. May 2016. Retrieved 14 December 2017. ^ Jump up to : Pedersen, JS ; Bendtsen, F ; Møller, S ( May 2015 ). `` Management of cirrhotic ascites ''. Therapeutic advances in chronic disease. 6 ( 3 ) : 124 -- 37. doi : 10.1177 / 2040622315580069. PMC 4416972. PMID 25954497. Jump up ^ Staff writer ( 2010 ). `` Ascites ''. Dictionary.com : An Ask.com Service. Oakland, CA : IAC. Retrieved December 14, 2017. ^ Jump up to : Warrell DA, Cox TN, Firth JD, Benz ED. Oxford textbook of medicine. Oxford : Oxford University Press, 2003. ISBN 0 - 19 - 262922 - 0. Jump up ^ Kumar & Clark 's Clinical Medicine e. 8 Chapter 7 : Liver, biliary tract and pancreatic disease Pg. 335 Jump up ^ Branco - Ferreira M, Pedro E, Barbosa MA, Carlos AG ( 1998 ). `` Ascites in hereditary angioedema ''. Allergy. 53 ( 5 ) : 543 -- 5. doi : 10.1111 / j. 1398 - 9995.1998. tb04098. x. PMID 9636820. Jump up ^ Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG ( August 1992 ). `` The serum - ascites albumin gradient is superior to the exudate - transudate concept in the differential diagnosis of ascites ''. Ann. Intern. Med. 117 ( 3 ) : 215 -- 20. doi : 10.7326 / 0003 - 4819 - 117 - 3 - 215. PMID 1616215. Jump up ^ Moore, K.P. ; Wong, F. ; Gines, P. ; Bernardi, M. ; Ochs, A. ; Salerno, F. ; Angeli, P. ; Porayko, M. ; Moreau, R. ; Garcia - Tsao, G. ; Jimenez, W. ; Planas, R. ; Arroyo, V ( 2003 ). `` The Management of Ascites in Cirrhosis : Report on the Consensus Conference of the International Ascites Club ''. 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External links Classification ICD - 10 : R18 ICD - 9 - CM : 789.5 MeSH : D001201 DiseasesDB : 943 External resources MedlinePlus : 000286 eMedicine : ped / 2927 med / 173 Patient UK : Ascites Symptoms and signs : digestive system and abdomen ( R10 -- R19, 787,789 ) Upper Nausea Vomiting Heartburn Aerophagia Dysphagia oropharyngeal esophageal Odynophagia Halitosis Xerostomia Hypersalivation Burping Wet burp Defaecation Flatulence Fecal incontinence Encopresis Blood : Fecal occult blood Rectal tenesmus Constipation Obstructed defecation Diarrhea Rectal discharge Psoas sign Obturator sign Rovsing 's sign Hamburger sign Heel tap sign Aure - Rozanova 's sign Dunphy sign Alder 's sign Lockwood 's sign Rosenstein 's sign Abdomen Abdominal pain Acute abdomen Colic Baby colic Abdominal guarding Rebound tenderness Abdominal distension Bloating Ascites Tympanites Shifting dullness Bulging flanks Fluid wave test Abdominal mass Hepatosplenomegaly Hepatomegaly Splenomegaly Jaundice Mallet - Guy sign Puddle sign Disorders of blood flow Decreases Clots Thrombus Thrombosis Renal vein thrombosis Ischemia Brain ischemia Ischaemic heart disease large intestine : Ischemic colitis small intestine : Mesenteric ischemia Infarction Types Anemic Hemorrhagic Location Heart Brain Spleen Limb Increases Hemorrhage Bruise / Hematoma Petechia Purpura Ecchymosis head Epistaxis Hemoptysis Intracranial hemorrhage Hyphema Subconjunctival hemorrhage torso Hemothorax Hemopericardium Pulmonary hematoma abdomen Gastrointestinal bleeding Haemobilia Hemoperitoneum Hematocele Hematosalpinx joint Hemarthrosis Edema Anasarca Angioedema / Lymphedema Exudate / Transudate Cerebral edema Pulmonary edema Hydrothorax Ascites / hydroperitoneum Hydrosalpinx Other Hyperemia Retrieved from `` https://en.wikipedia.org/w/index.php?title=Ascites&oldid=856766244 '' Categories : Symptoms and signs : Digestive system and abdomen Hidden categories : Infobox medical condition ( new ) All articles with unsourced statements Articles with unsourced statements from December 2013 RTT Talk Contents About Wikipedia Български Bosanski Català Čeština Deutsch Eesti Español Euskara فارسی Français Frysk Galego 한국어 Հայերեն हिन्दी Hrvatski Italiano עברית ಕನ್ನಡ Қазақша Nederlands 日本 語 Norsk Oʻzbekcha / ўзбекча Polski Português Русский Slovenčina Slovenščina Српски / srpski Srpskohrvatski / српскохрватски Suomi Svenska தமிழ் తెలుగు ไทย Українська Tiếng Việt 中文 31 more Edit links This page was last edited on 27 August 2018, at 11 : 47 ( UTC ). 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Question: ascites is one of the late features of
Answer: liver cirrhosis