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Ascites

Definition

Ascites is an abnormal accumulation of fluid in the abdomen.

Description

Rapidly developing (acute) ascites can occur as a complication of trauma, perforated ulcer, appendicitis, or inflammation of the colon or other tube-shaped organ (diverticulitis). This condition can also develop when intestinal fluids, bile, pancreatic juices, or bacteria invade or inflame the smooth, transparent membrane that lines the inside of the abdomen (peritoneum). However, ascites is more often associated with liver disease and other long-lasting (chronic) conditions.

Types of ascites

Cirrhosis, which is responsible for 80% of all instances of ascites in the United States, triggers a series of disease-producing changes that weaken the kidney's ability to excrete sodium in the urine.

Pancreatic ascites develops when a cyst that has thick, fibrous walls (pseudocyst) bursts and permits pancreatic juices to enter the abdominal cavity.

Chylous ascites has a milky appearance caused by lymph that has leaked into the abdominal cavity. Although chylous ascites is sometimes caused by trauma, abdominal surgery, tuberculosis, or another peritoneal infection, it is usually a symptom of lymphoma or some other cancer.

Cancer causes 10% of all instances of ascites in the United States. It is most commonly a consequence of disease that originates in the peritoneum (peritoneal carcinomatosis) or of cancer that spreads (metastasizes) from another part of the body.

Endocrine and renal ascites are rare disorders. Endocrine ascites, sometimes a symptom of an endocrine system disorder, also affects women who are taking fertility drugs. Renal ascites develops when blood levels of albumin dip below normal. Albumin is the major protein

in blood plasma. It functions to keep fluid inside the blood vessels.

— Maureen Haggerty


 
 
Dictionary: as·ci·tes  (ə-sī'tēz) pronunciation
n., pl. ascites.

An abnormal accumulation of serous fluid in the abdominal cavity.

[Middle English aschites, from Late Latin ascītēs, from Greek askītēs, from askos, belly, wineskin.]

ascitic as·cit'ic (-sĭt'ĭk) adj.
 
Oncology Encyclopedia: Ascites

Description

Ascites is defined as an excessive amount of fluid built up within the peritoneal cavity. Both the abdominal organs and the abdomen itself are lined with membranes called the peritoneum. Between these two linings is a space referred to as the peritoneal cavity. In pathological conditions that result in edema, or excessive fluid accumulation in bodily tissues, fluid can build up in the peritoneal cavity.

Smaller abdominal fluid amounts usually do not produce symptoms. However, larger accumulations can cause:

  • rapid weight gain
  • abdominal discomfort and distention
  • shortness of breath and actual dyspnea, or difficulty breathing
  • swollen ankles

Severe cases of ascites can result in the retention of literally gallons (each gallon equals nearly four liters) of liquid in the peritoneal cavity. If fluid retention is sufficiently severe, the abdomen becomes swollen and even painful. Breathing can be affected as the fluid-filled peritoneal cavity presses upon the diaphragm, a very necessary component of respiration. The diaphragm is made up of a dome-shaped sheet of muscles that separates the thoracic, or chest, cavity from the abdomen. When the muscle fibers of the diaphragm contract, the space in the chest cavity is enlarged, and air enters the lungs to fill the enlarged space. When pressure on the diaphragm from fluid build-up occurs, it lessens the ability of these diaphragm muscular fibers to expand and contract, and results in impaired breathing.

Ascites, in itself, is not a disease, but rather a symptom of several other pathological conditions. These include:

  • Cirrhosis of the liver, which is responsible for 80% of all instances of ascites in the United States.
  • Pancreatic ascites develops when a cyst that has thick, fibrous walls (pseudocyst) bursts and permits pancreatic juices to enter the abdominal cavity.
  • Chylous ascites, which has a milky appearance caused by lymph that has leaked into the abdominal cavity. Although chylous ascites is sometimes caused by trauma, abdominal surgery, tuberculosis, or another peritoneal infection, it is usually a symptom of lymphoma or some other cancer.
  • Cancer causes 10% of all occurrences of ascites in the United States. It is most commonly a consequence of disease that originates in the peritoneum (peritoneal carcinomatosis) or of cancer that spreads (metastasizes) from another part of the body. Tumors especially prone to malignant ascites formation include ovarian cancer and metastatic gastrointestinal tumors.
  • Endocrine and renal ascites are rare disorders. Endocrine ascites, sometimes a symptom of an endocrine system disorder, also affects women who are taking fertility drugs. Renal ascites develops when blood levels of albumin dip below normal. Albumin is the major protein in blood plasma. It functions to keep fluid inside the blood vessels.

Causes

The two most important factors in the production of ascites due to chronic liver disease are low levels of albumin in the blood and an increase in the pressure within the branches of the portal vein that run through liver (portal hypertension). Low levels of albumin in the blood cause a change in the pressure necessary to prevent fluid exchange (osmotic pressure). This change in pressure allows fluid to seep out of the blood vessels. The scarring that occurs in cirrhosis causes portal hypertension. Blood that cannot flow through the liver because of the increased pressure leaks into the abdomen and causes ascites.

Other conditions that contribute to ascites development include:

Persons who have systemic lupus erythematosus but do not have liver disease or portal hypertension occasionally develop ascites. Depressed thyroid activity sometimes causes pronounced ascites, but inflammation of the pancreas (pancreatitis) rarely causes significant accumulations of fluid.

Treatments

Reclining minimizes the amount of salt the kidneys absorb, so treatment generally starts with bed rest and a low-salt diet. Urine-producing drugs (diuretics) may be prescribed if initial treatment is ineffective. The weight and urinary output of patients using diuretics is normally carefully monitored, often on a daily basis. This scrutiny involves watching for signs of:

  • Hypovolemia (massive loss of blood or fluid) that can often result in drastic drops in blood pressure.
  • Azotemia (abnormally high blood levels of nitrogen-bearing materials).
  • Potassium imbalance that can result in cardiac arrhythmia.
  • High sodium concentration. Sodium should be restricted from the diet as much as possible.

Because of the discomfort and respiratory difficulty moderate-to-severe accumulations of fluid can produce, fluid removal, or paracentesis, is often the treatment of choice. Paracentesis involves the extraction of fluid from the abdominal cavity via a needle that is usually inserted into the peritoneum under local anesthesia. This is a relatively safe and painless method of relieving fluid build-up. It is considered safer than diuretic therapy, resulting in fewer complications and requiring shorter hospital stays.

Large-volume paracentesis is also the preferred treatment for massive ascites. Diuretics are sometimes used to prevent new fluid accumulations, and the procedure may need to be repeated periodically.

In cases of ascites that do not respond appropriately to the treatments described above, a peritoneovenous shunt may be inserted. This device is equipped with a one-way valve that allows fluid from the peritoneal cavity to pass into the venous blood circulatory system. From there the fluid is eliminated by the kidneys. In cases of malignant ascites, there is a concern that the use of such a shunt could enhance the spread of the cancer. This relatively small risk must be balanced against the positive effect the shunt can have on the individual's quality of life as well as against his or her expected survival period.

Alternative and Complementary Therapies

Dietary alterations, focused on reducing salt intake, are an important facet of treatment. Potassium-rich foods like low-fat yogurt, mackerel, cantaloupe, and baked potatoes help balance excess sodium intake and help ensure proper heart function. Such complementary therapies should always be considered an adjunct to, not a substitute for, the conventional treatments described above.

Resources

Periodicals

Bieligk, S.C., B.F. Calvo, and D.G. Coit. "Peritoneovenous Shunting for Nongynecologic Malignant Ascites." Cancer 91, no. 7 (April 2001): 1247–9.

Organizations

National Cancer Institute, National Institute of Health. 31

Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 4-CANCER. .

—Joan Schonbeck, R.N.

 
Food and Nutrition: ascites

Abnormal accumulation of fluid in the peritoneal cavity, occurring as a complication of cirrhosis of the liver, congestive heart failure, cancer, and infectious diseases. Depending on the underlying cause, treatment may sometimes consist of a high-energy, high-protein, low-sodium diet, together with diuretic drugs and fluid restriction.

 
Dental Dictionary: ascites
(əsī′tēz)
n

An abnormal accumulation of serous fluid, containing large amounts of protein and electrolytes, in the peritoneal cavity. Ascites is a complication of cirrhosis, congestive heart failure, nephrosis, malignant neoplastic disease, and various fungal and parasitic diseases.

 
Veterinary Dictionary: ascites

1. abnormal accumulation of serous (edematous) fluid within the peritoneal cavity. Characterized by distention of the abdomen, a fluid thrill on percussion, a typical ground glass appearance on radiography and a positive result on paracentesis.
2. a disease of poultry with pulmonary arterial vasoconstriction associated with poor ventilation and oxygen levels, predisposed by high altitude and respiratory disease. There may be a genetic predisposition.

  • bilious a. — see bile peritonitis.
  • cardiogenic a. — that caused by cardiac insufficiency.
  • chylous a. — see chylous ascites.
  • fetal a. — affected fetuses are usually dropsical and cause dystocia, even the aborting ones; usually accompanies another defect, e.g. achondroplasia.
 
Wikipedia: ascites
Ascites
Classification & external resources
ICD-10 R18.
ICD-9 789.5
DiseasesDB 943
eMedicine ped/2927  med/173

In medicine (gastroenterology), ascites (also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy) is an accumulation of fluid in the peritoneal cavity. Although most commonly due to cirrhosis and severe liver disease, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis (which may also be therapeutic). Treatment may be with medication (diuretics), paracentesis or other treatments directed at the cause.

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 etiology. 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.

Classification

Ascites exists in three grades:[1]

  • Grade 1: mild, only visible on ultrasound
  • Grade 2: detectable with flank bulging and shifting dullness
  • Grade 3: directly visible, confirmed with fluid thrill

Diagnosis

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 Gram stain and cytology.[2]

The Serum-ascities albumin gradient (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites.[3] 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 etiology.

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 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. Abdominal CT scan is a more accurate alternate to reveal abdominal organ structure and morphology.

Causes

Causes of high SAAG ("transudate") are:[2]

Causes of low SAAG ("exudate") are:

Pathophysiology

Ascitic fluid can accumulate as a transudate or an exudate. Amounts of up to 25 liters are fully possible.

Roughly, transudates are a result of increased pressure in the portal vein (>8 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, high in lactate dehydrogenase, have a low pH (<7.30), a low glucose level, and more white blood cells. Transudates have low protein (<30g/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.[2]

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 the feared hepatorenal syndrome. Other complications of ascites include spontaneous bacterial peritonitis (SBP), due to decreased antibacterial factors in the ascitic fluid such as complement.

Treatment

Ascites is generally treated simultaneously while an underlying etiology is sought in order to prevent complications, to relieve symptoms and to 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.[4] In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis.[5][6]

High SAAG

Salt restriction

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.[7]

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.[8] Diuretics for ascites should be dosed once per day.[9] Generally, the starting dose is oral spironolactone 100 mg/day (max 400 mg/day). 40% of patients will respond to spironolactone.[7] 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.[9] Serum potassium level and renal function should be monitored closely while on these medications.[10] 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.[4] If daily weights cannot be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs.[9] A random urine sodium-to-potassium ratio of > 1 is 90% sensitivity in predicting negative balance (> 78-mmol/day sodium excretion).[11] Diuretic resistance: Diuretic resistance can be predicted by giving 80 mg intravenous furosemide after 3 days without diuretics and on a 80 mEq sodium/day diet. The urinary sodium excretion over 8 hours < 50 mEq/8 hours predicts resistance.[12]

Water restriction

Water restriction is needed if hyponatremia < 130 mmol per liter develops.[10]

Paracentesis

Main article: Paracentesis

In those with severe (tense) ascites, therapeutic paracentesis may be needed in addition to medical treatments listed above.[5][6] As this may deplete serum albumin levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed.

Liver transplantation

Main article: liver transplantation

Ascites that is refractory to medical therapy is considered an indication for liver transplantation. In the United States, the MELD score (online calculator)[13] is used to prioritize patients for transplantation.

Shunting

In a minority of the patient 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" [14]

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

Cultural significance

It has been suggested that ascites was seen as a punishment especially for oath-breakers among the Proto-Indo-Europeans.[15] 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), threatening oath-breakers: "May Marduk, king of heaven and earth, fill his body with dropsy, which has a grip that can never be loosened".[citation needed] Comparable is also Numeri 5:11ff, where a confirmed adulteress is punished with swelling of the abdomen.

References

  1. ^ Moore KP, 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. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 2003;38:258-66. PMID 12830009.
  2. ^ a b c Warrell DA, Cox TN, Firth JD, Benz ED. Oxford textbook of medicine. Oxford: Oxford University Press, 2003. ISBN 0-19-262922-0.
  3. ^ Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992;117:215-20. PMID 1616215.
  4. ^ a b Shear L, Ching S, Gabuzda GJ (1970). "Compartmentalization of ascites and edema in patients with hepatic cirrhosis". N. Engl. J. Med. 282 (25): 1391-6. PMID 4910836. 
  5. ^ a b Ginés P, Arroyo V, Quintero E, et al (1987). "Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study". Gastroenterology 93 (2): 234-41. PMID 3297907. 
  6. ^ a b Salerno F, Badalamenti S, Incerti P, et al (1987). "Repeated paracentesis and i.v. albumin infusion to treat 'tense' ascites in cirrhotic patients. A safe alternative therapy". J. Hepatol. 5 (1): 102-8. PMID 3655306. 
  7. ^ a b Gatta A, Angeli P, Caregaro L, Menon F, Sacerdoti D, Merkel C (1991). "A pathophysiological interpretation of unresponsiveness to spironolactone in a stepped-care approach to the diuretic treatment of ascites in nonazotemic cirrhotic patients". Hepatology 14 (2): 231-6. PMID 1860680. 
  8. ^ Fogel MR, Sawhney VK, Neal EA, Miller RG, Knauer CM, Gregory PB (1981). "Diuresis in the ascitic patient: a randomized controlled trial of three regimens". J. Clin. Gastroenterol. 3 Suppl 1: 73-80. PMID 7035545. 
  9. ^ a b c Runyon BA (1994). "Care of patients with ascites". N. Engl. J. Med. 330 (5): 337-42. PMID 8277955. 
  10. ^ a b Ginès P, Cárdenas A, Arroyo V, Rodés J (2004). "Management of cirrhosis and ascites". N. Engl. J. Med. 350 (16): 1646-54. DOI:10.1056/NEJMra035021. PMID 15084697. 
  11. ^ Runyon BA, Heck M. Utility of 24-hour urine sodium collection and urine Na/K ratios in the management of patients with cirrhosis and ascites [abstract]. Hepatology. 1996;24:571A.
  12. ^ Spahr L, Villeneuve JP, Tran HK, Pomier-Layrargues G (2001). "Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites". Hepatology 33 (1): 28-31. DOI:10.1053/jhep.2001.20646. PMID 11124817. 
  13. ^ Cosby RL, Yee B, Schrier RW (1989). "New classification with prognostic value in cirrhotic patients". Mineral and electrolyte metabolism 15 (5): 261-6. PMID 2682175. 
  14. ^ Saab S, Nieto JM, Lewis SK, Runyon BA (2006). "TIPS versus paracentesis for cirrhotic patients with refractory ascites". Cochrane database of systematic reviews (Online) (4): CD004889. DOI:10.1002/14651858.CD004889.pub2. PMID 17054221. 
  15. ^ Oettinger, Norbert. Die Militärischen Eide der Hethiter. Wiesbaden, 1976. ISBN 3-447-01711-2.
Symptoms and signs (R00-R69, 780-789)
Circulatory and
respiratory systems		 Tachycardia - Bradycardia - Palpitation - Heart murmur - Epistaxis - Hemoptysis - Cough - abnormalities of breathing (Dyspnea, Orthopnoea, Stridor, Wheeze, Cheyne-Stokes respiration, Hyperventilation, Mouth breathing, Hiccup, Bradypnea, Hypoventilation) - Chest pain - Asphyxia - Pleurisy - Respiratory arrest - Sputum - Bruit/Carotid bruit - Rales
Digestive system and abdomen Abdominal pain - Acute abdomen - Nausea - Vomiting - Heartburn - Dysphagia - Flatulence - Burping - Fecal incontinence - Encopresis - Hepatomegaly - Splenomegaly - Hepatosplenomegaly - Jaundice - Ascites - Fecal occult blood - Halitosis
Skin and subcutaneous tissue disturbances of skin sensation (Hypoesthesia, Paresthesia, Hyperesthesia) - Rash - Cyanosis - Pallor - Flushing - Petechia - Desquamation - Induration - Diaphoresis
Nervous and
musculoskeletal systems		 abnormal involuntary movements (Tremor, Spasm, Fasciculation, Athetosis) - Gait abnormality - lack of coordination (Ataxia, Dysmetria, Dysdiadochokinesia, Hypotonia) - Tetany - Meningism - Hyperreflexia
Urinary system Dysuria - Vesical tenesmus - Urinary incontinence - Urinary retention - Oliguria - Polyuria - Nocturia
Cognition, perception,
emotional state and behaviour		 Anxiety - Somnolence - Coma - Amnesia (Anterograde amnesia, Retrograde amnesia) - Dizziness/Vertigo - smell and taste (Anosmia, Ageusia, Parosmia, Parageusia)
Speech and voice speech disturbances (Dysphasia, Aphasia, Dysarthria) - symbolic dysfunctions (Dyslexia, Alexia, Agnosia, Apraxia, Acalculia, Agraphia) - voice disturbances (Dysphonia, Aphonia)
General symptoms and signs Fever (Hyperpyrexia) - Headache - Chronic pain - Malaise - Fatigue - Fainting (Vasovagal syncope) - Febrile seizure - Shock (Cardiogenic shock) - Lymphadenopathy - Edema (Peripheral edema, Anasarca) - Hyperhidrosis (Sleep hyperhidrosis) - Delayed milestone - Failure to thrive - food and fluid intake (Anorexia, Polydipsia, Polyphagia) - Cachexia - Xerostomia - Clubbing

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Dictionary. The American Heritage® Dictionary of the English Language, Fourth Edition Copyright © 2007, 2000 by Houghton Mifflin Company. Updated in 2007. Published by Houghton Mifflin Company. All rights reserved.  Read more
Oncology Encyclopedia. Gale Encyclopedia of Cancer. Copyright © 2006 by The Gale Group, Inc. All rights reserved.  Read more
Food and Nutrition. A Dictionary of Food and Nutrition. Copyright © 1995, 2003, 2005 by A. E. Bender and D. A. Bender. All rights reserved.  Read more
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Veterinary Dictionary. Saunders Comprehensive Veterinary Dictionary 3rd Edition. Copyright © 2007 by D.C. Blood, V.P. Studdert and C.C. Gay, Elsevier. All rights reserved.  Read more
Wikipedia. This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Ascites".  Read more

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