Ascites: Causes, Symptoms & Treatment

Ascites, or abdominal dropsy, is an accumulation of fluid in the abdominal cavity and is usually a symptom of an advanced underlying disease, most of which have an inauspicious (unfavorable) prognosis. In the vast majority of cases, ascites correlates with cirrhosis of the liver.

What are ascites?

Ascites (also abdominal dropsy) is the term used to describe a pathologic accumulation of fluid in the free peritoneal cavity (abdominal cavity), which usually manifests as a symptom of a progressive underlying disease, usually with a poor prognosis. In most cases, ascites is manifested by an enlarged abdominal circumference or bulging abdomen with a distended umbilical region, often preceded by flatulence (flatulence). In some cases, an umbilical hernia may develop as a result of ascites. Ascites can be differentiated by appearance into serous (clear to yellowish), chyle (milky), hemorrhagic (bloody), and purulent (bacterial) ascites.

Causes

The most common cause of ascites is advanced liver failure such as cirrhosis (80 percent). Liver cirrhosis can be due to drug and/or alcohol abuse, chronic hepatitis, autoimmune hepatitis, nonalcoholic steatohepatitis (fatty liver hepatitis), and, in rarer cases, hemochromatosis (iron storage disease) or Wilson disease (copper storage disease). Significantly, the liver becomes increasingly scarred as cirrhosis progresses. This obstructs blood flow, resulting in blood stasis in the abdomen. The blood is forced out of the vessels by the pressure and leaks into the free abdominal cavity. This process is further catalyzed by decreased synthesis of blood proteins, particularly albumin, by the increasingly insufficient liver. Furthermore, malignant (malignant) tumors as well as inflammatory changes of the peritoneal cavity (peritonitis) or pancreas (pancreatitis) can cause ascites. Rechtherz and renal insufficiency are also considered favoring factors.

Symptoms, complaints, and signs

Ascites can manifest itself through a number of symptoms, complaints, and signs. Initially, there is swelling of the abdomen, which is usually painless and increases as the condition progresses. There may also be an umbilical hernia, which is manifested by pain in the area of the belly button and the navel bulging conspicuously forward. Many sufferers gain weight and in some cases (for example, if there is concomitant peripheral edema) also suffer from water retention in the area of the arms and legs. Gastrointestinal complaints may also occur. Typical symptoms include flatulence and diarrhea, but also nausea and vomiting. Ascites can be recognized by the fact that the symptoms mentioned persist over a longer period of time and increase in intensity in the course of this. In addition, ascites often occurs in connection with inflammation of the peritoneum, cancer and other diseases. Those affected usually suffer from a general feeling of illness. In the course, the loss of weight can lead to a deficiency supply of the body. Typical deficiency symptoms are dizziness, concentration disorders and a general decrease in physical and mental performance. Ascites can be clearly diagnosed on the basis of these symptoms.

Diagnosis and course

Ascites can be detected by palpation (palpation) and percussion (palpation) of the abdomen starting at an accumulated fluid of approximately 1 liter. In addition, the diagnosis is confirmed by abdominal sonography, which can detect fluid volumes as small as 50 to 200 ml. If the cause is unclear, ascites puncture with subsequent analysis of the punctured fluid and/or computed tomography is usually used. If the punctured fluid is milky or bloody, a laparoscopy should be performed to determine whether trauma or tumors are the underlying cause. Purulent ascites, on the other hand, indicates an inflammatory disease of the abdominal cavity (peritonitis). In addition, liver values (especially albumin) are checked if liver insufficiency is suspected. If left untreated, severe ascites can lead to inguinal or umbilical hernia, disturbed sodiumpotassium balance, renal insufficiency, and tachycardia. In general, the prognosis depends on the specific underlying disease.If ascites occurs in association with liver cirrhosis, this is a prognostically inauspicious sign, since approximately half of those affected die within 5 years of diagnosis. In contrast, ascites secondary to acute pancreatitis usually resolves with healing of the underlying disease.

Complications

Ascites is associated with several complications. Almost always, abdominal ascites causes herniations in the wall of the intestine. The tears can become infected and lead to serious infections in the abdomen and intestines. The increased intra-abdominal pressure also increases the risk of hydrothorax and further damage to the gastrointestinal tract. Furthermore, ascites can cause sequelae such as dyspnea, a diaphragmatic herniation, or an upside-down stomach. A bacterial viral infection can cause further complications such as acute kidney failure, in addition to often severe pain, fever symptoms and feelings of pressure. In cirrhosis of the liver, ascites increases the risk of variceal bleeding. A particularly dangerous complication is spontaneous bacterial peritonitis, an emigration of intestinal bacteria to other parts of the body. The disorder often occurs without significant symptoms such as fever or abdominal pain, but leads to death in up to 50 percent of all patients. Complications can arise during the treatment of ascites if the intestinal wall is injured during surgery. If local anesthetic is administered, allergic reactions may occur. Diagnostic ascites puncture may cause infection and more severe bleeding. Rarely, injury to organs in the abdomen occurs.

When should you see a doctor?

If ascites is suspected, a doctor should be consulted as soon as possible. If there is any unusual weight gain or swelling in the abdomen, a doctor must clarify the cause. The same applies if a general feeling of malaise, a sensation of pressure in the abdominal region or a stabbing pain under the breastbone occurs quite suddenly. If these symptoms persist for more than a few days, it is advisable to seek medical advice. If flatulence or symptoms of constipation persist, a doctor should also be consulted. Blood in the urine or stool as well as vomiting or diarrhea are further warning signs that require medical clarification. Patients suffering from heart disease, tumors of the peritoneum or acute pancreatitis should talk to a doctor. Abdominal dropsy may also be due to chlamydial or gonococcal infection, tuberculosis, or inflammatory vascular disease. Patients with a corresponding medical history should have unusual symptoms clarified immediately, as ascites may have already developed. Rapid treatment may then be vital.

Treatment and therapy

Therapeutic measures for ascites depend on its extent and the underlying disease. In low-grade ascites, drug therapy with diuretics (including spironolactone, xipamide, and furosemide) in combination with minimized fluid intake (1.2 to 1.5 liters daily) aims to reduce or flush out the fluid present in the free peritoneal cavity. The renal values should be checked regularly, since too rapid flushing can lead to renal insufficiency (hepatorenal syndrome). If drug therapy is unsuccessful or if there is pronounced ascites, paracentesis (ascites puncture) may be considered. Since high concentrations of blood proteins are discharged with the fluid, liver function should be checked. If liver function is insufficient, albumin substitution by infusion is indicated to compensate. In addition, as part of a surgical procedure, a TIPS (transjugular intrahepatic portosystemic stent shunt) can be implanted to minimize pressure in the portal vein system or a peritoneovenous shunt can be implanted through which the fluid can be drained via a catheter. In principle, the underlying disease of ascites should always be treated. For example, liver transplantation may be indicated in the presence of liver cirrhosis. Tumors or their metastases in the abdomen are generally addressed with chemotherapy, whereas bloody or milky ascites resulting from trauma may require surgical treatment.

Outlook and prognosis

The prognosis for ascites depends on the underlying disease present.Since this is not a stand-alone disease but a secondary symptom due to previous diseases, the cause of the underlying disease must first be found and treated. If this is successful, the ascites also recedes completely until it has disappeared completely. In the case of serious diseases such as cancer, the prognosis depends on the time of diagnosis and the type of tumor. If it is easily treatable and detected early, there is often a good chance of cure. This changes as soon as the tumor has spread or there is already extensive damage to the tissue. In the case of an underlying chronic disease, the prognosis is also less optimistic. Chronic diseases have a progressive course. Therefore, there is a steady increase in the existing symptoms. Treatment attempts to influence the course of the disease and to delay its progression for as long as possible. In addition, individual symptoms are combated to the extent possible. Nevertheless, there is rarely a chance of cure. In order to minimize the symptoms of ascites, the excess fluid is drained off within a course of treatment. However, since it is newly formed due to the disease, this is not an intervention that can bring about a cure.

Prevention

Ascites can be prevented by consistent therapy of the potential underlying diseases. In addition, ascites is associated in most cases with cirrhosis of the liver, which is caused in particular by alcohol and drug abuse. Protective vaccinations against inflammatory liver disease (hepatitis) also represent a prophylactic measure against ascites.

Follow-up

Follow-up care after ascites depends largely on the causative disease and the course of the disease. If the underlying condition is positive, follow-up must initially be biweekly or monthly. During the follow-up visits, the physician will, among other things, measure the blood values and, if necessary, also perform a physical examination and again take samples from the abdominal cavity. In addition, a medical history will be taken. Depending on the underlying condition, the physician will ask about any accompanying symptoms of ascites and the patient’s general condition and include them in the further planning. If no complications occur during treatment and the ascites subsides as planned, the intervals between follow-up visits can be extended. If ascites occurs without further symptoms, it must be checked whether another, as yet undetected cancer is causative. Subsequently, further investigations are necessary for clarification. In a few patients, water retention is detected again during follow-up. In this case, an indwelling catheter or permanent drainage must be placed. If a permanent drain was placed during therapy, it must be checked and removed if necessary. In addition, any accompanying symptoms must be clarified and cured following the actual therapy.

What you can do yourself

Medical treatment for ascites is based on the extent of the symptoms and the causative disease. A mildly pronounced ascites does not necessarily require extensive therapy. In most cases, it is sufficient to take mild diuretics which, in combination with rest and bed rest, promise rapid relief. Accompanying this, fluid intake must be reduced to ensure flushing out of the infected fluid. After the acute phase, the body’s water balance must be rebalanced by appropriate additional fluid intake. Accompanying this, the diet must be changed. Through a healthy and balanced diet, which is best prepared in collaboration with a nutritionist, the symptoms should quickly recede. If complications should nevertheless arise, the responsible physician must be informed. It is possible that a recurrence has developed or that there is another problem that needs to be clarified and, if necessary, treated. Should a surgical procedure be performed, the patient must take it easy. Physical activities should be avoided after the operation. This is especially true if there is a serious underlying disease such as a tumor condition. In the case of bloody ascites, further medical examinations are necessary after the operation.