Ascites refers to collection of fluid within the abdominal cavity and is most commonly seen in patients with cirrhosis of the liver, a condition in which the liver becomes irreversibly damaged and scarred and replaced with fibrous tissue

CAUSES OF ASCITES
• Liver damage due to various causes
• Cirrhosis liver
• History of alcohol excess
• Hepatitis B or C infection of liver

Miscellaneous causes
• Tuberculosis
• Hypothyroidism
• Kidney or heart failure (causing fluid retention)
• Cancer of ovary, pancreas, liver or endometrium
• Chronic inflammation of pancreas (pancreatitis)

GRADES OF ASCITES
• Grade 1 – Mild ascites that can be identified only by ultrasound examination (less than 500 ml)
• Grade 2 – Moderate ascites with symmetrical abdominal swelling
• Grade 3 – Large ascites causing marked abdominal swelling

CLINICAL FEATURES OF ASCITES
For ascites to be readily visible during clinical examination, at least 1500 ml (1.5 liters) of fluid should have collected within the abdominal cavity. Signs and symptoms of ascites include
• Distended abdomen
• Sudden weight gain
• Abdominal bloating and feeling of fullness
• Loss of appetite
• Breathlessness on lying down
• Heartburn
• Nausea and vomiting (due to fluid pressing on stomach)
• Urinary urgency
• Constipation

DIAGNOSIS
History and Physical examination
History of alcohol abuse, known carrier of hepatitis B or C infection, history of heart or kidney disease

If ascites is marked, it may be readily evident on physical examination. For moderate degree of ascites, the flanks appear full when the patient is lying down and on standing the fluid collects in the lower part of the abdomen

Clues to diagnosis on clinical examination
Signs of liver disease – jaundice, breast enlargement in men (gynecomastia), palmar erythema (reddish palms), spider nevi on abdomen, wasting of muscles
Enlarged left supraclavicular lymph node (Virchow’s node) – may suggest cancer of the upper abdomen
Firm nodule in the umbilicus (Sister’s Joseph nodule) – suggestive of peritoneal deposit of carcinoma originating from liver, stomach or pancreatic cancer

Fluid thrill
A large ascites can be confirmed by a ‘fluid thrill’. This test requires two persons. The first person places the side of the palm of his hand firmly on the centre of the belly, with the fingers pointing towards the groin. The second person places the palm of one hand on one flank and then gently flicks the other flank using thumb and index finger. If a large amount of fluid is present, a “fluid thrill” can be felt by the palm resting on the opposite flank

Blood tests
Blood tests to assess liver and kidney function. If liver function tests are deranged further investigations to pinpoint the cause may be done such as testing for hepatitis B and C.
Thyroid function tests to rule out depressed thyroid function (hypothyroidism)

Imaging tests
Smaller ascites (less than 500 ml) may be diagnosed on ultrasound imaging of the abdomen which may also demonstrate underlying pathology of the liver, kidneys or an abdominal malignancy
Chest x-ray may be done to confirm buildup of fluid in the lungs, cancer that has spread to the lungs, or heart failure.
CT scan or MRI of abdomen may be done in suspected carcinoma to diagnose and stage the disease
Echocardiogram of heart to assess heart function

Abdominal paracentesis
A sample of fluid from the abdomen is removed with a syringe and sent off for laboratory for analysis. Analysis may reveal cancer cells or evidence of infection

COMPLICATIONS OF ASCITES
• Abdominal pain and discomfort
• Breathing difficulties due to ascites and fluid collection in lungs
• Infection of the ascites fluid with subsequent peritonitis
• Liver failure due to cirrhosis
• Kidney failure due to deteriorating liver function (hepatorenal syndrome)

TREATMENT OF ASCITES
1. Reduce salt intake in diet (as salt promotes fluid retention)
2. Restrict fluid intake as per doctor’s advice
3. Avoid /limit salt substitutes containing potassium (since some medicines used to treat ascites can cause a rise in blood potassium levels)
4. Stop alcohol intake
5. Diuretics to promote excretion of salt and water from the body
6. Paracentesis- For recurrent or severe ascites, the excess fluid is drained by means of a needle to provide symptomatic relief. In some cases over 5 liters of fluid have been removed. This procedure is associated with risk of infection and the patient is usually prescribed antibiotics
7. Chemotherapy for treatment of cancer
8. Surgery
A tube called shunt is placed within the liver to reroute blood flow and thereby reduce high portal pressure (portal hypertension) and decreasing ascites formation
Liver transplant may be recommended in end stage liver disease that does not respond to other treatments

PREVENTION OF ASCITES
• Avoid alcohol
• Maintain healthy weight and exercise regularly
• Limit salt intake in diet
• Manage underlying conditions such as kidney, liver and heart disease
• Practise safe sex to avoid getting hepatitis B/C infection
• Persons at high risk eg health care personnel should get vaccinated against hepatitis B
• Avoid substance abuse or recreational drug use
• Do not take medications without a doctor’s supervision. For drugs with potential side effects in the liver, periodic monitoring of liver function is advised

PROGNOSIS
Prognosis and outlook of ascites depends on the underlying condition. Although symptoms can be managed and reduced, treatment of the underlying cause determines the outcome.
For persons with cirrhosis as well as a form of ascites that is resistant to diuretics, there is no satisfactory treatment
Paracentesis (draining of fluid) and shunt procedures without a liver transplant may improve a person’s quality of life but may not increase life expectancy in patients with liver failure