Ascites is an accumulation of fluid in the abdominal cavity, the space between the peritoneum (abdominal wall) and the abdominal organs.
The peritoneum produces a fluid that acts like a lubricant and allows the abdominal organs to slide against each other. Sometimes too much fluid accumulates between the inner and outer layers of the peritoneum. This phenomenon is called ascites.
Ascites caused by cancer is called malignant ascites and affects 10% of ascites patients.
Malignant ascites most often occurs in people with cancer of the breast, colon, gastrointestinal tract, ovary, pancreas and uterus.
1. Biliary ascites is the accumulation of fluid with bile pigments and bile.
2. Chylöser ascites is the accumulation of milky lymphatic fluid caused by traumatic injuries, inflammation and tumor diseases of the large lymphatic vessels.
3. Hemorrhagic ascites exists when blood accumulates inside the abdominal cavity.
Ascites fluid can be of the following nature:
1. Transudate, which is formed by increased pressure in the portal vein in cirrhosis. In this case, there is little protein in the liquid.
2. Exudate, which is caused by phenomena of inflammation that change the permeability of the cell membrane, as a result of which part of the fluid contained in the blood leaks.
In an exudate, the amount of proteins it contains, such as albumin, is similar to that in the blood. The difference is less than 1 mg/dl.
Causes of ascites
Malignant ascites is present in about 10% of cases.
Common causes include:
- Malignant tumors of the gastrointestinal tract (carcinoma of the stomach, colon, pancreas; primary hepatocellular carcinoma and metastatic liver cancer).
- Cancer of the ovary: Meigs syndrome is a rare complication of ovarian cancer and forms ascites and (often unilateral) pleural effusion disproportionate to tumor size.
- Hodgkin’s lymphoma and non-Hodgkin’s lymphoma.
- Metastatic carcinoma of the inner abdominal cavity (peritoneal carcinosis).
- Heart failure.
- Nephrotic syndrome (rare).
- Other rare causes, including hypothyroidism.
- Iatrogenic hyperstimulation syndrome as a result of in vitro fertilization.
Symptoms of ascites
There is a difference between patients who develop ascites due to cirrhosis and liver disease and those who get it due to inflammation of the peritoneum caused by cancer.
Liver disease tends to be relatively painless, while cancer patients can experience great pain.
Incidentally, the symptoms are similar in both.
There is abdominal swelling due to the fluid collected in it. This can lead to obstruction of the diaphragm (muscle plate that separates the abdominal cavity from the chest cavity), which supports breathing; the result is shortness of breath.
While a taut and fluid-filled abdomen is easy to spot, at the beginning the fluid of the ascite may be small and difficult to notice.
If the amount of fluid increases, the patient complains of the fullness and severity of the abdomen.
Ascites is the most common sign in patients with cirrhosis of the liver. If it occurs, a lower life expectancy is usually to be expected.
In about 75% of patients with ascites, the cause is cirrhosis and about 50% of patients with cirrhosis develop ascites over a controlled period of 10 years.
Fluid retention (mainly ascites, but also peripheral edema and pleural effusion) is the most common complication of liver disease in the final phase.
The quality of life of patients with ascites and cirrhosis is significantly deteriorated and associated with an unfavorable prognosis. The survival rate after one year is 85% and after 5 years it is 56%.
Attention, a patient with a very long course of stable cirrhosis, who then develops ascites, should be examined for a possible hepatocellular carcinoma.
Complications and consequences
With cirrhosis of the liver, there is not only an accumulation of fluid in the abdominal cavity, swelling of the legs, the formation of bruising, breast enlargement and confusion due to encephalopathy (disease of the brain).
If the ascites develops due to heart failure, it can lead to shortness of breath and swelling of the legs (edema).
The shortness of breath worsens with each load and when lying down (orthopnea).
Patients with ascites due to heart failure wake up during the night with paroxysmal nocturnal shortness of breath.
Patients suffering from cancer, in addition to the expansion of the abdomen, complain of pain, weight loss and exhaustion.
Those who suffer from spontaneous bacterial peritonitis (inflammation of the peritoneum) develop fever and abdominal pain
Diagnosis of ascites
To diagnose ascites, the doctor must examine the abdominal area and ask the patient about past symptoms.
The following examinations can help diagnose ascites:
- Blood tests, helpful values are: AST, ALT (transaminases to evaluate liver function), complete blood count to determine if there are changes in the blood, azotemia or creatininemia to evaluate kidney function, blood sugar and electrolytes (concentration of potassium, sodium and chlorine).
- ultrasound; With the help of this examination procedure, the amount of fluid in the abdomen can be determined, a thrombus in the portal vein can be detected and also a Budd-Chiari syndrome can be detected.
- Paracentesis (taking the fluid from the abdomen with a syringe and analyzing it) after finding the fluid to investigate the cause (for example, an infection, cancer or other condition). The most important values of ascites fluid are the proteins (to rule out cirrhosis) and the number of white blood cells to determine whether the patient has an infection.
Treatment of ascites
Accompaniment of the patient
The therapy of ascites depends on the cause. In most patients, cirrhosis, which leads to portal hypertension, is the main cause.
If portal hypertension is the cause of ascites, therapy is usually carried out with diuretics (for example, Lasix) and a salt-free diet.
In contrast, ascites caused by peritoneal inflammation or cancer does not respond to the administration of diuretics or other remedies such as a salt-free diet.
Treatment can be attempted without hospitalization. However, hospitalization may be necessary in three situations:
1. to clarify the cause of liver disease;
2. to educate the patient on how to prepare a diet with limited salt content;
3. for careful monitoring of laboratory values of creatinine, urea nitrogen and electrolytes in blood and urine.
In hospitals, the control of body weight and fluid balance, i.e. supply and export of fluids, are important. Fluid restriction is only required if the sodium concentration in the blood is below 120 mmol/l.
It is important to achieve the balance of sodium, which can be approximated by imports (food intake, sodium medicines and infusion solutions) and export via urine.
A negative balance of sodium is a sign of budding weight loss.
The goal to aim for a patient without peripheral edema is a negative balance of sodium with a weight loss of 0.5 kg per day.
Medication for ascites
Most patients with cirrhosis of the liver and ascites respond to diuretics and dietary restriction of sodium.
The combination of spironolactone and furosemide is most effective for a rapid decrease in ascite.
The starting dose is 100 mg spironolactone and 40 mg furosemide, taken together in the morning.
If there is no decrease in body weight or increase in urinary output after two or three days, the dose of both drugs must be increased.
The amounts can be increased up to 400 mg spironolactone and 160 mg furosemide per day.
Only 10% of patients do not respond to this therapy (diuretics and sodium restriction in the diet).
Patients who respond to this therapy of ascites do not need anything else as long as it remains effective.
Diuretic-resistant ascites The treatment options for drug-resistant ascites
- Therapeutic paracentesis Paracentesis
up to 1 liter of fluid can bring relief from shortness of breath caused by the tension associated with high-grade ascites.
The release of higher volumes and the complete paracentesis (largest volume known to date 22.5 l) is discussed.
Some authors suggest that intravenous substitution of 10 g of albumin per liter of drained ascites fluid prevents a reduction in plasma volume and certain irregularities in electrolytes and creatinine.
- Intrahepatic portosystemic transjugular shunt. This is a medical procedure that creates an artificial channel to connect the portal vein to the hepatic vein.
patients with cirrhosis of the liver who develop ascites have a mortality rate of 50% in 3 years; those with refractory ascites have a 1-year survival rate of less than 50%.
For most cirrhosis patients, therapeutic paracentesis and changing their diet without liver transplantation means an improvement in their quality of life, but survival is not improved in the long run.
Malignant ascites indicates the spread of the disease and an infaust prognosis.