🔅Ascites is a condition in which fluid collects in spaces within your abdomen. It often occurs as a result of cirrhosis, a liver disease that causes scarring and fibrosis of the liver.

– Ascites can cause various symptoms and complications, such as: abdominal pain, bloating, shortness of breath, infection, kidney failure, and bleeding. Ascites can also indicate the severity and progression of liver disease, and affect the survival and quality of life of people with cirrhosis.

CAUSES OF ASCITES

– The causes of ascites can be classified into two categories: portal hypertension and non-portal hypertension.

– Portal hypertension is high blood pressure in the portal vein, which carries blood from the digestive organs to the liver. When the liver is damaged by cirrhosis, the blood flow through it is obstructed, leading to increased pressure in the portal vein. This causes fluid to leak out of the blood vessels into the abdominal cavity. Portal hypertension is responsible for about 80% of ascites cases. The most common causes of portal hypertension are chronic viral hepatitis (B or C), alcohol abuse, autoimmune hepatitis, and genetic liver diseases.

– Non-portal hypertension causes of ascites are less common and include heart failure, kidney failure, cancer, infection, pancreatitis, and low protein levels in the blood. These conditions can affect the production or absorption of fluid in the abdomen, or cause inflammation or obstruction of the lymphatic system.

DIAGNOSIS OF ASCITES

– The diagnosis of ascites is based on a combination of physical examination, medical history, laboratory tests, and imaging studies.

• Physical examination may reveal a swollen and tense abdomen, a protruding belly button, swelling in the legs and ankles, and signs of liver disease such as jaundice or spider veins.

• Medical history may include questions about alcohol consumption, viral hepatitis exposure, family history of liver disease, and previous episodes of ascites.

• Laboratory tests may include blood tests to check liver function, kidney function, electrolytes, blood count, and clotting factors.

• A sample of fluid from the abdomen may also be taken using a needle (paracentesis) and analyzed for signs of infection, cancer, or other diseases.

• Imaging studies may include ultrasound, CT scan, or MRI to visualize the liver and the amount of fluid in the abdomen.

TREATMENT OPTIONS FOR ASCITES

– The treatment of ascites depends on the underlying cause and the severity of symptoms. The main goals of treatment are to reduce fluid accumulation, prevent complications, and improve quality of life. The general principles of treatment are:

🔅 Dietary Modification

– Reducing salt intake to less than 2 grams per day can help prevent fluid retention and lower blood pressure. Fluid intake may also need to be restricted in some cases.

🔅 Diuretics

– These are medications that increase urine output and help remove excess fluid from the body. The most commonly used diuretics for ascites are spironolactone and furosemide. They should be used with caution and under medical supervision, as they can cause side effects such as low blood pressure, low potassium levels, kidney damage, and encephalopathy (brain dysfunction).

🔅 Paracentesis

– This is a procedure that involves draining large amounts of fluid from the abdomen using a needle and a catheter. It can provide immediate relief of symptoms such as abdominal pain and shortness of breath. However, it can also cause complications such as infection, bleeding, electrolyte imbalance, and kidney failure. Therefore, it should be reserved for severe or refractory cases of ascites that do not respond to diuretics.

🔅 Transjugular intrahepatic portosystemic shunt (TIPS)

– This is a procedure that creates a new pathway for blood flow between the portal vein and the hepatic vein (a vein that drains blood from the liver). It reduces portal hypertension and decreases fluid leakage into the abdomen. However, it also increases the risk of encephalopathy, infection, bleeding, and liver failure. Therefore, it should be considered only for selected patients who have recurrent or refractory ascites that cannot be managed by other methods.

🔅 Liver transplantation

– This is a surgical procedure that replaces a diseased liver with a healthy one from a donor. It is the only definitive cure for cirrhosis and its complications such as ascites. However, it is limited by the availability of donors, the risk of rejection or infection, and the need for lifelong immunosuppression.

PREVENTION OF ASCITES

– The prevention of ascites is mainly based on preventing or treating the underlying causes of cirrhosis or other conditions that can lead to ascites. Some preventive measures include:

• Stop drinking alcohol: Alcohol is one of the most common causes of cirrhosis and ascites. Abstaining from alcohol can prevent further liver damage and improve liver function.

• Maintain a healthy weight: Obesity can cause fatty liver disease (NAFLD), which can progress to cirrhosis and ascites if left untreated. Losing weight can reduce fat accumulation in the liver and improve liver function.

• Exercise regularly: Physical activity can improve blood circulation, lower blood pressure, reduce inflammation, and prevent obesity.

• Stop smoking: Smoking can increase the risk of liver cancer, which can cause ascites. Quitting smoking can lower the risk of cancer and improve overall health.

• Limit salt intake: Salt can cause fluid retention and increase blood pressure. Reducing salt intake can help prevent or reduce ascites.

• Practice safe sex: Sexually transmitted infections such as hepatitis B and C can cause chronic liver disease and cirrhosis. Using condoms and getting vaccinated can prevent these infections and protect the liver.

• Do not use recreational drugs: Injecting drugs such as heroin can expose the user to hepatitis B and C, as well as other infections that can damage the liver. Avoiding drug use can prevent these infections and protect the liver.

THE PROGNOSIS OF ASCITES

– The prognosis of ascites depends on the underlying cause, the severity of symptoms, the response to treatment, and the development of complications.

– Ascites is a sign that the liver is not working as it should. The survival rate five years after an ascites diagnosis is around 30% to 40%. Your healthcare provider may refer you to a liver specialist to discuss a possible liver transplant.

– Some of the complications that can worsen the prognosis of ascites are:

🔅 Spontaneous bacterial peritonitis (SBP)

– This is a bacterial infection of the ascitic fluid that can cause fever, abdominal pain, and shock. It can be treated with antibiotics, but it has a high mortality rate if not diagnosed and treated promptly.

🔅 Hepatorenal syndrome (HRS)

– This is a type of kidney failure that occurs in people with advanced liver disease and ascites. It is caused by reduced blood flow to the kidneys due to portal hypertension and low blood pressure. It can be treated with medications or dialysis, but it has a poor prognosis if not reversed quickly.

🔅 Hyponatremia

– This is a low level of sodium in the blood that can occur in people with ascites due to dilution by excess fluid or excessive use of diuretics. It can cause confusion, seizures, coma, and death if not corrected.

🔅 Pleural effusion

– This is a buildup of fluid in the chest cavity that can occur when ascitic fluid moves from the abdomen to the chest through small openings in the diaphragm (the muscle that separates the chest from the abdomen). It can cause shortness of breath, cough, chest pain, and infection. It can be treated with diuretics or drainage.

🔅 Gastrointestinal bleeding

– This is bleeding from the digestive tract that can occur when portal hypertension causes enlarged veins (varices) in the esophagus or stomach to rupture. It can cause vomiting blood, black stools, anemia, shock, and death if not treated urgently.