Ascites

What Is It, Causes, Appearance, Treatment, and More

Author: Ashley Mauldin, MSN, APRN, FNP-BC

Editors: Antonella Melani, MD, Ahaana Singh, Lisa Miklush, PhD, RN, CNS

Illustrator: Jillian Dunbar


What is ascites?

Ascites refers to the buildup of excess fluid in the abdominal cavity. Based on the severity of fluid accumulation, ascites can be categorized as mild, moderate, and large. 

There are two different types of ascites: uncomplicated and refractory ascites. Uncomplicated ascites is the most common type and responds well to treatment; refractory ascites, on the other hand, is less common and very difficult to treat, leading to a high mortality rate. Often, refractory ascites can be associated with kidney failure.

What causes ascites?

The most common cause of ascites is cirrhosis, which is a late stage of liver disease characterized by permanent scarring and fibrosis of the liver, often as a consequence of chronic alcoholism or hepatitis. Normally, the liver receives blood from the spleen and gastrointestinal organs via the portal vein. When fibrosis becomes extensive, it is harder for blood to flow through the liver. As a consequence, the blood coming from the portal vein may start to back up, leading to portal hypertension, which refers to increased blood pressure in the portal vein. As a result, fluid may start to leak out of the portal vein and into the abdomen, leading to ascites. 

Other risk factors of ascites include liver cancer, heart failure, pancreatitis, hypoalbuminemia, and peritoneal tuberculosis

To determine the underlying cause of ascites, initially a liver ultrasound will be done, and then a diagnostic paracentesis can be performed if needed. A paracentesis is a procedure where a large needle is inserted into the peritoneal cavity to aspirate the ascitic fluid. The ascitic fluid can then be sent off and analyzed.

Is ascites life-threatening?

Ascites can lead to the development of life-threatening complications, such as spontaneous bacterial peritonitis, which is a bacterial infection of the ascitic fluid. If not caught and treated promptly, bacteria can enter the bloodstream and lead to sepsis. In turn, sepsis can trigger a systemic inflammatory response and circulatory dysfunction. The end-stage result is organ damage and failure, such as kidney failure, or the worsening of liver failure. 

Other complications that ascites can include hepatorenal syndrome, malnutrition, pleural effusion, and gastrointestinal bleeding.

What does ascites look like?

The presentation of ascites can vary depending on its severity. Those with mild ascites may have an abdomen that appears normal, whereas those with more severe ascites may have a very large distended abdomen. As the fluid accumulates in the abdominal cavity. The belly button can also protrude from the body with severe ascites.

What does ascites feel like?

Ascites can put pressure within the abdomen, causing it to feel very large and tight. As the abdomen grows larger, the increased pressure on nearby organs may cause abdominal discomfort, lack of appetite, and shortness of breath.

How do you treat ascites?

To treat ascites, the choice of treatment depends on its severity and the underlying cause. In mild cases, salt intake should be reduced to 2000mg per day or less. In addition, diuretic medications (water pills) are often prescribed. The individual is also encouraged to avoid nonsteroidal anti-inflammatory medications (NSAIDs) and alcohol consumption. 

In addition, more severe ascites can be treated through paracentesis, which involves aspiration of large amounts of fluid from the abdominal cavity. Due to the potential recurrence, some individuals may require the paracentesis to be repeated multiple times.

Cases of refractory ascites that persist despite treatment may benefit from the placement of a transjugular intrahepatic portosystemic shunt (TIPS), which is a procedure that creates a new path for blood to flow from the portal vein to the liver, so as to alleviate portal hypertension. Ultimately, a final treatment option for ascites is a liver transplant.

Can ascites be reversed?

With treatment, ascites can be temporarily reversed. But over time, more invasive treatments will be needed to temporarily reverse ascites. Eventually, most people with ascites will need a liver transplant.

What are the most important facts to know about ascites?

Ascites is an abnormal accumulation of fluid in the abdominal cavity, which can lead to a very large distended abdomen. As the abdomen grows larger, the increased pressure may cause abdominal discomfort, lack of appetite, and shortness of breath. Moreover, ascites can lead to serious complications, such as spontaneous bacterial peritonitis, hepatorenal syndrome, malnutrition, pleural effusion, and gastrointestinal bleeding. Most often, ascites affects people with cirrhosis and portal hypertension. Ascites is treated by decreasing dietary sodium and taking diuretic medications. In addition, more severe cases may need a paracentesis, placement of a transjugular intrahepatic portosystemic shunt, and ultimately a liver transplant.

Related links

Cirrhosis
High Yield: Cirrhosis
Clinical Reasoning: Cirrhosis
Sex cord-gonadal stromal tumor
Hepatocellular carcinoma

Resources for research and reference

Ascites. (2018). MedlinePlus. Retrieved September 3, 2020, from https://medlineplus.gov/ency/article/000286.htm

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Chalasani, N. and Vuppalanchi, R. (2013). Ascites: A Common Problem in People with Cirrhosis. American College of Gastroenterology. Retrieved August 20, 2020, from https://gi.org/topics/ascites/

Garbuzenko, D. V. & Arefyev, N. O. (2019). Current approaches to the management of patients with cirrhotic ascites. World Journal of Gastroenterology, 25(28): 3738–3752. DOI: 10.3748/wjg.v25.i28.3738

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Marciano, S., Díaz, J. M., Dirchwolf, M., & Gadano, A. (2019). Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies. Hepatic Medicine: Evidence and Research, 11: 13–22. DOI: 10.2147/HMER.S164250

Moore, K. P. & Aithal, G. P. (2006). Guidelines on the management of ascites in cirrhosis. Gut, 2016(55): v1–v12 Retrieved September 03, 2020 from DOI: 10.1136/gut.2006.099580

Zhao, R., Lu, J., Shi, Y., Zhao, H., Xu, K., & Sheng, J. (2017). Current management of refractory ascites in patients with cirrhosis. The Journal of International Medical Research, 46(3): 1138–1145. DOI: 10.1177/0300060517735231