Ascites

Ascites often occurs in conjunction with other medical conditions or as a result of an underlying disease. The likelihood of developing ascites increases with the presence of the following conditions:

• Non-alcoholic fatty liver disease
• Alcohol use disorder
• Hepatitis B
• Hepatitis C
• Autoimmune hepatitis
• Congestive heart failure
• Kidney failure
• Infections
• Cancer affecting abdominal organs
• Genetic liver disorders such as Wilson’s disease

Diagnosing ascites typically involves multiple tests, and your doctor may recommend specific procedures. Initially, a physical examination will be conducted to check for abdominal swelling, and blood tests may be ordered to measure protein levels in your blood. Additional imaging and diagnostic tests that may be used include:

Ultrasound

An abdominal ultrasound is a non-invasive test that uses sound waves to produce images of the organs within the abdomen. To ensure clear images, you may be asked to fast for 8 to 12 hours before the test to prevent undigested food from interfering with the sound waves. In the case of a liver or pancreas ultrasound, a fat-free meal the evening prior may be recommended. During the ultrasound, a handheld probe is moved across your abdomen, creating a digital image on a screen for the doctor to view. The procedure is painless and provides real-time images of abdominal organs and blood flow. Ultrasound can detect as little as 100 ml of ascitic fluid.

CT Scan

A CT scan, or computed tomography, is an advanced X-ray technique that provides cross-sectional images of the body. The scan revolves around the body and sends images to a computer for medical professionals to review. An abdominal CT scan allows doctors to examine the organs and blood vessels within the abdominal cavity. It provides detailed images that help in accurate diagnosis. You may be asked to fast for two to four hours prior to the scan, and in some cases, you may be instructed to drink water or contrast material for better visualization of the stomach and intestines.

MRI Scan

Magnetic resonance imaging (MRI) uses magnets and radio waves to create detailed images of the body’s internal structures. This non-invasive technique produces cross-sectional images of the abdomen, allowing doctors to identify any abnormalities within the tissues and organs. MRI does not use radiation and is considered a safer option compared to CT scans. During the procedure, you will lie on your back while the technician communicates with you through a microphone. The machine may produce loud noises, and it is important to remain still during the scan to avoid affecting the results.

Laparoscopy

Laparoscopy is a minimally invasive surgical procedure that allows doctors to examine the abdominal organs. A small incision is made, and a laparoscope—an instrument with a high-intensity light and camera—is inserted to provide real-time images of the inside of the abdomen. The procedure may also involve taking tissue samples if necessary. Laparoscopy is typically used when other diagnostic methods like CT or MRI scans are insufficient.

Fluid Sample (Diagnostic Paracentesis)

Your doctor may collect a sample of fluid from your abdomen using a needle. This fluid is then sent to the lab for analysis to identify any signs of infection or cancer, which can help determine the cause of ascites. Local anesthesia is given before the procedure to minimize discomfort. The fluid is tested for its appearance, protein level, albumin, and cell counts (both red and white). Additional tests, such as microbiological culture, Gram staining (for bacteria), and cytopathology (for cell and fluid examination), may also be performed.

The Serum Ascites Albumin Gradient (SAAG) is often more reliable than older methods for determining the cause of ascites. A high gradient (>1.1 g/dL) typically indicates ascites caused by portal hypertension, while a low gradient (<1.1 g/dL) suggests a non-portal hypertensive cause.

Classification of Ascites

Ascites can be categorized into three grades based on severity:

• Grade 1: Mild, only visible via ultrasound or CT scan.
• Grade 2: Noticeable with flank bulging and shifting dullness.
• Grade 3: Easily visible and confirmed with the fluid wave or thrill test.

While it’s not always possible to completely prevent ascites, the risk of developing it can be reduced by addressing the underlying causes. Here are some ways to lower your risk:

• Maintain a healthy lifestyle with a balanced diet that is low in fats and salt.
• Keep a healthy body weight and engage in regular physical activity to help prevent ascites.
• Limit alcohol intake, as alcohol abuse is a major cause of ascites.
• Avoid consuming undercooked fish or meat to reduce the risk of infections, especially if you have cirrhosis.
• Follow your doctor’s advice for managing any existing conditions that may increase your risk of ascites.
• If you have underlying conditions that put you at higher risk, consult your doctor before starting any new medications.

Specialists to Visit

If you experience symptoms like abdominal swelling, rapid weight gain, difficulty breathing when lying down, loss of appetite, abdominal pain, bloating, nausea, vomiting, heartburn, swelling in the feet or ankles, or shortness of breath, it may indicate ascites. You should consult the following specialists for diagnosis and treatment:

• General physician
• Hepatologist
• Gastroenterologist

A hepatologist specializes in diagnosing, treating, and managing liver, gallbladder, bile duct, and pancreas-related conditions. A gastroenterologist focuses on digestive system disorders. If you notice any of these symptoms, seek advice from a qualified healthcare professional for proper evaluation and care.

There are several treatment options available for managing ascites, including:

Lifestyle Modifications

• Common lifestyle changes that can help manage ascites include avoiding alcohol and limiting sodium intake. The recommended sodium intake is usually no more than 1500 mg per day, or as advised by your doctor. You may also need to limit certain types of fluids in your diet.

Diuretic Medications (Water Pills)

• Diuretics, or water pills, are used to help the body eliminate excess fluid. The most commonly prescribed diuretics for ascites are furosemide and spironolactone. These medications assist the kidneys in removing extra sodium and water, which helps reduce pressure around the liver.

Spironolactone use may be limited by issues such as hyponatremia (low sodium), hyperkalemia (high potassium), and painful gynecomastia (breast tenderness). If gynecomastia becomes problematic, amiloride can be used as an alternative. Typically, furosemide is used in combination with spironolactone in a 40:100 ratio, with maximum daily doses of 160 mg for furosemide and 400 mg for spironolactone. Your doctor will monitor your blood chemistry and recommend reducing your salt and alcohol intake while on these medications.

Pharmacologic Therapy

• For refractory ascites, additional pharmacologic treatment may be used. This includes medications like midodrine or clonidine, which are alpha-adrenergic agonists that help constrict blood vessels, counteracting the expansion of vessels in the abdominal area. These medications are added to diuretic therapy when necessary.

Therapeutic Paracentesis

• In cases where ascites is severe or recurrent and does not respond to diuretics, a procedure known as therapeutic paracentesis may be performed. This involves using a thin needle to remove the excess fluid from the abdominal cavity. After the procedure, you will be advised to follow a low-salt and low-fluid diet to prevent the fluid from re-accumulating. If a large volume of fluid is removed, intravenous albumin may be given to replace the lost protein.

Ultrafiltration

• If diuretic therapy is ineffective or poorly tolerated, ultrafiltration (also known as aquapheresis) may be required. This mechanical process helps control fluid retention and congestion, and can be beneficial for patients with diuretic resistance. It may restore the body’s ability to respond to standard diuretic doses.

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• For severe ascites that does not respond to diuretics, a permanent shunt may be placed inside the body through a procedure called TIPS. This stent (a wire mesh tube) creates a channel to bypass the liver, reducing the need for regular fluid drainage. This approach is typically used when other treatments have failed.

Liver Transplantation

• In cases of severe liver disease where ascites does not improve, a liver transplant may be necessary. If ascites is caused by liver or kidney failure, surgical intervention may be required. For ascites resulting from bacterial or viral infections, your doctor will focus on treating the infection to relieve symptoms.

Ascites that does not respond to medical treatments is often considered an indication for a liver transplant. In the United States, the MELD score is used to prioritize patients for transplantation. The MELD score is a reliable predictor of survival in individuals with cirrhosis, alcoholic hepatitis, and acute liver failure.

Ascites can lead to several potential complications, such as:

Abdominal Problems

• The buildup of fluid may cause discomfort and pain in the abdomen, making it difficult to breathe. These symptoms can interfere with daily activities like walking or eating.

Infection

• The fluid accumulation can become infected, resulting in spontaneous bacterial peritonitis (SBP). This infection can cause fever and abdominal pain, requiring immediate medical treatment. Long-term antibiotics or IV antibiotics may be prescribed to prevent future infections.

Fluid Accumulation in the Lungs

• In some cases, the fluid in the abdomen may spread to the lungs, particularly on the right side. This can lead to chest pain, shortness of breath, coughing, and low oxygen levels in the blood. Thoracentesis, a procedure to drain fluid from around the lungs, may be necessary.

Ascites-Related Hernia

• The increased abdominal pressure caused by ascites can result in a hernia, where an organ pushes through a weakened area of muscle or tissue. This is particularly common in cases of umbilical or inguinal hernias.

Kidney Failure

• As liver cirrhosis worsens, it may lead to kidney failure. Treatment options will be discussed with your doctor based on your specific condition.

Hepatorenal Syndrome (HRS)

• In severe cases, ascites can lead to hepatorenal syndrome, where kidney function declines due to advanced liver disease. In HRS, kidney dysfunction occurs without any identifiable cause, and the kidneys are not structurally damaged.

If you're managing ascites, there are therapies that can assist in controlling the condition. These include:

Exercise

Maintaining a healthy lifestyle and engaging in light exercises such as walking daily can be beneficial in managing your condition. Consult with your doctor to determine which exercises are best suited for you.

Dietary Adjustments

Follow a low-sodium diet and adhere to the protein guidelines provided by your doctor. The specific dietary recommendations you receive will depend on the severity of your condition and the treatment plan you're following. It is crucial to follow your doctor's advice, as your diet plays a significant role in your overall health.

Yoga

Practicing simple yoga exercises can help reduce stress and anxiety, which may further improve your health.

Managing ascites effectively requires certain lifestyle adjustments. Individuals diagnosed with ascites should consider the following home-care strategies for better management:

• Always take your prescribed medications on schedule to help control your condition.
• Label your medications and set a daily alarm to ensure you take them consistently at the same time each day.
• Adhere to all the guidance provided by your doctor, especially regarding your diet and any lifestyle changes.
• Stick to the treatment plan outlined by your healthcare provider, as following it closely can promote faster recovery.
• Maintain a balanced diet while reducing alcohol intake and avoiding foods that could worsen your condition.

A diagnosis of ascites can be overwhelming and make daily activities challenging. However, modern medicine offers various solutions that can help you maintain a healthy lifestyle and prevent fluid buildup. Along with medical treatments, lifestyle changes can aid in managing the condition. Here are some tips to consider:

Dietary Changes

Your doctor might refer you to a dietitian who can assist in creating a sodium-restricted meal plan. It's important to read food labels and avoid high-sodium foods. Instead, use salt substitutes and opt for fresh, salt-free ingredients. However, be cautious with potassium-based substitutes if you are taking medication for ascites, as they may elevate potassium levels.

Avoid Alcohol

Consuming alcohol, especially in large quantities, can significantly worsen liver health when you have ascites. Alcohol strains the liver as it works to filter toxins, which is crucial since alcohol doesn’t metabolize effectively. Beverages like wine and beer contain phosphorus, which can contribute to heart issues or even fatal outcomes if your liver struggles to manage excess potassium. It's best to consult your doctor about safe drinking practices and frequency, though most individuals with ascites are advised to completely eliminate alcohol.

Lifestyle Modifications

Maintaining a healthy weight is essential. You might be encouraged to monitor your weight daily to track fluid retention. Regular exercise can improve your overall health. Discuss with your doctor which types of physical activity are appropriate for your situation.