Introduction
Ascites is the accumulation of excess fluid within the peritoneal cavity.
Causes of ascites
Ascites is caused by the following disease conditions:
- Portal hypertension secondary to liver cirrhosis
- Renal failure
- Nephrotic syndrome
- Cardiac failure
- Abdominal tuberculosis.
- Intra-abdominal or pelvic malignancies
Symptoms of ascites
The symptoms of ascites are:
- Abdominal enlargement
- Abdominal discomfort or pain
- Difficulty breathing
Signs of ascites
- Distended abdomen.
- Shifting dullness
- Fluid thrill
- Abdominal tenderness
- Signs relating to the underlying causes
Investigations
- Full blood count
- BUE & Creatinine
- LFTS
- INR
- Urinalysis
- Abdomino-pelvic ultrasound
- Chest X-ray
- Diagnostic paracentesis
- Appearance and colour
- Gram stain
- Cell count and differential
- Biochemistry e.g. Albumin
- Microscopy, culture (with bedside inoculation of aerobic & an aerobic blood culture bottles)
- Acid fast bacilli
- Cytology
Treatment for ascites
Treatment objectives
- To relieve symptoms.
- To identify and manage underlying cause
Non-pharmacological treatment
- Bed rest
- Salt restriction <2 g/day
- Fluid restriction to ≤1.5 L/day
- Avoid NSAID-use
- Alcohol abstinence
- Therapeutic paracentesis (sterile abdominal tap) if ascites is tense and/or there is respiratory embarrassment
Note
Removal of up to 5 litres of ascitic fluid without concomitant colloid infusion is a safe short-term option and unlikely to have haemodynamic consequences.
Pharmacological treatment
A. Control of ascitic fluid accumulation
1st Line Treatment
Evidence Rating: [A]
Spironolactone, oral,
Adults
- 50-200 mg daily
Children
- 0.3-3 mg/kg daily
And
Furosemide, oral,
Adults
- 20-80 mg daily
Children
- 1-2 mg/kg daily
B. Massive ascites in liver cirrhosis with respiratory embarrassment requiring more than 5 litres of fluid drainage
1st Line Treatment
Evidence Rating: [A]
Salt-poor human albumin solution, IV, 6-8 g per litre of ascitic fluid drained
Referral Criteria
Patients with the following conditions must be referred to a specialist.
Poor response to diuretic therapy or diuretic-refractory ascites, complicated cirrhotic ascites with suspected spontaneous bacterial peritonitis, hepato-renal syndrome, and hepatic encephalopathy.
Also refer when an underlying cause cannot be identified.