Ascites or Fluid in the Abdomen

Approved by the Cancer.Net Editorial Board, 06/2021

Ascites is the buildup of fluid in the abdomen. The peritoneum is a membrane that surrounds the organs inside the abdomen that makes ascitic fluid. This fluid is normal in the body, but cancer can cause the peritoneum to produce too much of this fluid. This is called “malignant ascites” and it is often a sign of advanced cancer.

What causes ascites?

Malignant ascites is caused by cancer that has spread to the lining of the organs inside your abdomen. It can also happen when cancer spreads to the liver. You are more likely to develop ascites if you have one of these cancers:

What are symptoms of ascites?

Ascites often causes a lot of discomfort. People with ascites may have the following symptoms:

• Weight gain

• Shortness of breath

• Abdominal swelling

• Feeling full quickly when eating, which is called early satiety

• Sense of fullness or bloating

• Sense of heaviness

• Constipation

• Indigestion, which is a general term for discomfort in your upper abdomen

• Nausea or vomiting

• Changes to the belly button

• Hemorrhoids, which causes painful swelling near your anus

• Ankle swelling

• Fatigue

• Loss of appetite

Tell your health care team if you experience any of the above symptoms. Relieving side effects is an important part of cancer care and treatment. This type of care is called palliative care or supportive care. It helps someone, with any type or stage of cancer, feel better.

How is ascites diagnosed?

Your doctor may use one or more of the following tests to locate, diagnose, or plan treatment for ascites:

• Physical examination

• X-ray, which is a picture of the inside of the body

• Ultrasound

• Computerized tomography (CT or CAT) scan, which creates a 3-dimensional picture of the inside of the body using x-rays.

• Paracentesis, which is when a needle removes fluid from the abdomen for testing or to relieve symptoms.

How is ascites managed and treated?

The goal of treatment is to provide relief from uncomfortable symptoms. You may not need treatment if your ascites is not causing discomfort. Ascites treatment may have unpleasant side effects. Talk with your doctor about the benefits and risks of each option before deciding on a treatment plan. The treatment options for ascites include:

Changes to how you eat. For mild discomfort, eating less salt and drinking less water or other liquids may help. Salt helps your body hold onto water. Making diet changes can be a challenge for many people. Talk to your health care team about how to make these changes.

Diuretics. A diuretic is any substance that makes you urinate more often. This can help reduce the amount of fluid built up in your abdomen. Diuretics can be prescribed as medication. Most people do not experience side effects when taking a diuretic, but they can cause a loss of sleep, skin problems, fatigue, and low blood pressure.

Paracentesis. Paracentesis is a procedure to remove the fluid in the abdomen. It is used to diagnose the cause of ascites (see above), but it is also used to treat it. A doctor places a needle attached to a tube into the abdomen. The fluid drains through the needle and into the tube. Often, the fluid buildup will come back after a paracentesis procedure. Your health care team may decide to do another paracentesis procedure or they may decide to use a catheter.

Catheter. A catheter can be used to drain fluid. A catheter is a thin tube of plastic inserted into your pleural fluid. At home, you or your family member use the catheter to regularly drain the fluid into a bottle as instructed by your health care team. Occasionally, it may be recommended that a catheter be inserted inside the body to bypass or divert fluid from the abdomen into another part of the body. This is called a shunt or a peritoneovenous shunt.

Treating the cancer. Surgery or chemotherapy used to treat the cancer can sometimes also relieve ascites symptoms. This is because the cancerous cells stop making as much fluid.

Managing discomfort. Sometimes, problems caused by ascites keep coming back, even with treatment. Your health care team can help manage your discomfort by treating problems like swelling in the legs, constipation, nausea, and breathing problems.

Questions to ask the health care team

Consider asking your health care team these questions about ascites:

• Is ascites a common side effect of the type of cancer I have?

• What are the signs and symptoms of ascites that I should watch out for?

• Will I need any tests to diagnose ascites?

• What treatment options are available for the symptoms of ascites that I have? Which treatment do you recommend?

• What is causing the ascites?

• Who should I talk to about any discomfort or other side effects I am experiencing?

• How can I get in touch with them during business hours and after hours?

Related Resources

Fluid Retention or Edema

Fear of Treatment-Related Side Effects

More Information

JAMA Oncology Patient Page: Ascites or Fluid in the Belly

Ascites – Liver and Gallbladder Disorders

By

Danielle Tholey

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Reviewed/Revised Jan 2023

VIEW PROFESSIONAL VERSION

Ascites is the accumulation of protein-containing (ascitic) fluid within the abdomen.

• Many disorders can cause ascites, but the most common is high blood pressure in the veins that bring blood to the liver (portal hypertension Portal Hypertension Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts… read more ), which is usually due to cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver’s internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar… read more .

• If large amounts of fluid accumulate, the abdomen becomes very large, sometimes making people lose their appetite and feel short of breath and uncomfortable.

• Analysis of the fluid can help determine the cause.

• Usually, a low-sodium diet and diuretics can help eliminate excess fluid.

(See also Overview of Liver Disease Overview of Liver Disease Liver disease can manifest in many different ways. Characteristic manifestations include Jaundice (a yellowish discoloration of the skin and whites of the eyes) Cholestasis (reduction or stoppage… read more .)

The most common cause of ascites is

• Liver disease

Less common causes of ascites include disorders unrelated to the liver, such as cancer, heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or… read more , kidney failure Chronic Kidney Disease Chronic kidney disease is a slowly progressive (months to years) decline in the kidneys’ ability to filter metabolic waste products from the blood. Major causes are diabetes and high blood pressure. .. read more , inflammation of the pancreas (pancreatitis Overview of Pancreatitis Pancreatitis is inflammation of the pancreas. The pancreas is a leaf-shaped organ about 5 inches (about 13 centimeters) long. It is surrounded by the lower edge of the stomach and the first… read more ), and tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs, but almost any organ can be involved. Tuberculosis… read more affecting the lining of the abdomen.

Ascites tends to occur in long-standing (chronic) rather than in short-lived (acute) liver disorders. It most commonly results from

Portal hypertension usually results from cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver’s internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar… read more (severe scarring of the liver), which is most commonly caused by consumption of large amounts of alcohol, by fatty liver Fatty Liver Fatty liver is an abnormal accumulation of certain fats (triglycerides) inside liver cells. People with fatty liver may feel tired or have mild abdominal discomfort but otherwise have no symptoms… read more , or by chronic viral hepatitis Overview of Chronic Hepatitis Chronic hepatitis is inflammation of the liver that lasts at least 6 months. Common causes include hepatitis B and C viruses and certain drugs. Most people have no symptoms, but some have vague… read more .

Ascites may occur in other liver disorders, such as severe alcoholic hepatitis without cirrhosis, other kinds of chronic hepatitis, and obstruction of the hepatic vein (Budd-Chiari syndrome Budd-Chiari Syndrome Budd-Chiari syndrome is caused by blood clots that completely or partially block blood flow from the liver. The blockage may occur anywhere from the small and large veins that carry blood from. .. read more ).

In people with a liver disorder, ascitic fluid leaks from the surface of the liver and intestine and accumulates within the abdomen. A combination of factors is responsible. They include the following:

• Portal hypertension Portal Hypertension Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts… read more

• Fluid retention by the kidneys

• Alterations in various hormones and chemicals that regulate body fluids

Also, albumin usually leaks from blood vessels into the abdomen. Normally, albumin, the main protein in blood, helps keep fluid from leaking out of blood vessels. When albumin leaks out of blood vessels, fluid also leaks out.

Small amounts of fluid within the abdomen usually cause no symptoms. Moderate amounts may increase the person’s waist size and cause weight gain. Massive amounts may cause abdominal swelling (distention) and discomfort. The abdomen feels taut, and the navel is flat or even pushed out.

The swollen abdomen puts pressure on the stomach, sometimes leading to loss of appetite, and pressure on the lungs, sometimes leading to shortness of breath.

In some people with ascites, the ankles swell because excess fluid accumulates there (causing edema Swelling Swelling is due to excess fluid in the tissues. The fluid is predominantly water. Swelling may be widespread or confined to a single limb or part of a limb. Swelling is often in the feet and… read more ).

Spontaneous bacterial peritonitis (infection of the ascitic fluid that develops for no apparent reason) sometimes occurs. This infection is common among people with ascites and cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver’s internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar… read more , especially people who drink large amounts of alcohol.

If spontaneous bacterial peritonitis develops, people usually have abdominal discomfort, and the abdomen may feel tender. People may have a fever and feel generally unwell. They may become confused, disoriented, and drowsy. Untreated, this infection can be fatal. Survival depends on early treatment with appropriate antibiotics.

• A doctor’s evaluation

• Sometimes an imaging test such as ultrasonography

• Sometimes analysis of ascitic fluid

When a doctor taps (percusses) the abdomen, the fluid makes a dull sound. If the person’s abdomen is swollen because the intestines are distended with gas, the tapping makes a hollow sound. However, a doctor may not be able to detect ascitic fluid unless the volume is about a quart or more.

If doctors are uncertain whether ascites is present or what is causing it, they may do ultrasonography or computed tomography (CT; see Imaging Tests of the Liver and Gallbladder Imaging Tests of the Liver and Gallbladder Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography. .. read more ). In addition, a small sample of ascitic fluid can be withdrawn by inserting a needle through the wall of the abdomen—a procedure called diagnostic paracentesis Paracentesis Paracentesis is the insertion of a needle into the abdominal cavity for the removal of fluid. Normally, the abdominal cavity contains only a small amount of fluid. However, fluid can accumulate… read more . Laboratory analysis of the fluid can help determine the cause.

• A low-sodium diet

• Diuretics

• Removal of ascitic fluid (therapeutic paracentesis)

• Sometimes surgery to reroute blood flow (portosystemic shunting) or liver transplantation

• For spontaneous bacterial peritonitis, antibiotics

The basic treatment for ascites is a low-sodium diet with a goal of 2,000 mg or less of sodium per day.

If diet is ineffective, people are usually also given drugs called diuretics (such as spironolactone or furosemide). Diuretics make the kidneys excrete more sodium and water into the urine so people urinate more.

If ascites becomes uncomfortable or makes breathing or eating difficult, the fluid may be removed through a needle inserted into the abdomen—a procedure called therapeutic paracentesis. The fluid tends to reaccumulate unless people also follow a low-sodium diet and take a diuretic. Because a large amount of albumin is usually lost from the blood into the abdominal fluid, albumin may be given intravenously.

If large amounts of fluid accumulate frequently or if other treatments are ineffective, a portosystemic shunt or liver transplantation Liver Transplantation Liver transplantation is the surgical removal of a healthy liver or sometimes a part of a liver from a living person and then its transfer into a person whose liver no longer functions. (See… read more may be needed. The portosystemic shunt Portosystemic shunting Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts… read more connects the portal vein or one of its branches with a vein in the general circulation and thus bypasses the liver. However, placement of the shunt is an invasive procedure and can cause problems, such as deterioration of brain function (hepatic encephalopathy Hepatic Encephalopathy Hepatic encephalopathy is deterioration of brain function that occurs in people with severe liver disease because toxic substances normally removed by the liver build up in the blood and reach… read more ) and deterioration of liver function.

If spontaneous bacterial peritonitis is diagnosed, people are given antibiotics such as cefotaxime. Because this infection often recurs within a year, a different antibiotic (such as norfloxacin) is given after the initial infection resolves to prevent the infection from recurring.

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Onco Wiki – Treatment of symptoms of endometrial cancer

Patients with a widespread tumor process sometimes complain of:

• pain in the pelvis or abdomen,
• urinary problems,
• appearance of blood during urination or defecation,
• sharp weakness.

Palliative care should be sought if these symptoms are present. Specialists in this field, along with other doctors, can significantly alleviate the manifestations of the disease. Early initiation of palliative care improves the quality of life and psychological well-being of the patient and her loved ones.

Ascites

Ascites is an accumulation of fluid in the abdominal cavity and small pelvis. In oncological diseases, it occurs due to damage by metastases to the peritoneum, the internal lining that covers the walls of the abdominal cavity and the organs located in it. Malignant cells disrupt lymph flow and impair fluid absorption.

Symptoms of ascites

With a small amount of fluid in the abdominal cavity, the patient does not feel it at all, and ascites becomes an accidental finding during instrumental studies.

With a significant amount of fluid, pains appear, an increase in the abdomen. In the abdominal cavity, 5-10 liters of fluid can accumulate, in severe cases – up to 20 liters. The abdomen can be very large. In the standing position, due to the weight of the liquid, the stomach sinks down, and in the prone position it becomes flattened, as the liquid spreads on the sides. The pressure of the liquid on the organs disrupts the functioning of the intestines, making it difficult to urinate.

Treatment of ascites

Your doctor may prescribe conservative medical therapy – diuretics (diuretics) to increase the removal of fluid from the body. When conservative therapy no longer helps, they resort to surgical treatment.

The procedure is called laparocentesis. A puncture is made in the abdominal wall and fluid is pumped out. After removing some of the ascitic fluid, the catheter may be left for several days for further outflow.

Pain

Pain is the most common complaint in the development of any advanced cancer.

Causes of pain in endometrial cancer:

• metastases and their complications, for example, large metastases in the liver due to stretching of the capsule that covers the organ from the outside;
• germination of the primary tumor in nearby organs – the bladder, rectum, nerves and blood vessels;
• ascites;
• Bone metastases and their complications, eg pathological fractures.

Whom should I contact for treatment?

In case of a pain syndrome, they try to eliminate its cause, and if this is not possible, to relieve the pain. Pain therapy is selected by an algologist, a palliative doctor and an oncologist in charge.

The attending physician can choose the initial treatment and coordinate further steps – refer to narrower specialists. Their help may be required at the initial choice of pain relief and in the event that the selected pain treatment ceases to help.

To reduce bone pain in metastases, the oncologist refers to a radiotherapist for radiation therapy to the affected area.

Blood in the urine or stool

If the tumor has grown into the bladder and intestines, blood may appear in the urine and stool. Such symptoms must be reported to the doctor. If active bleeding develops (that is, blood does not appear as streaks in the feces, but flows freely), resort to surgical treatment.

Metastatic symptoms

Lung metastases cause cough, chest pain and shortness of breath. If such symptoms appear, a computed tomography (CT) scan of the chest organs may be additionally prescribed.

Metastases in the liver are manifested by pain in the right hypochondrium, abnormal blood tests. Abdominal CT can confirm or exclude the presence of metastases.

If symptoms of the spread of the disease appear during treatment, this is a reason for additional research. When confirming the progression of old foci and the appearance of metastases, a change in treatment is likely to be required.

Conclusions

• With the development of endometrial cancer, patients complain of pain in the pelvis or abdomen, problems with urination, severe weakness, blood during urination or defecation.
• It is important not to neglect the help of palliative care professionals.
• Report any new or unusual symptoms to the physician as the disease progresses

What else to read?

• Reminder: pain scale for patients from the Pro Palliative website. Helps to learn to determine the intensity of the pain syndrome.
• Learn more about ascites in cancer and non-cancer patients from the Pro Palliative website.
• Compilation of materials from the Pro Palliative website on the treatment of pain.
• Material from the Johns Hopkins clinic website about ascites (in English).
• Material from the Osmosis website about ascites (in English).

Yulia Tyutrina

Oncologist, chemotherapist, graduate of the Higher School of Oncology

December 7, 2022

Fluid behind the uterus on ultrasound

Sometimes during a pelvic ultrasound, the diagnostician may find fluid in the retrouterine (Douglas) space.

As a rule, in such a situation there is nothing to worry about – a small amount of fluid may indicate successful ovulation, puberty or a recent period. However, sometimes there are cases when such a formation is a sign of a serious illness.

Determining the volume of fluid behind the uterus by ultrasound

It is extremely difficult to determine the exact volume of such a formation using ultrasound, since the fluid spreads between the organs. To clarify the amount of liquid, the length of the vertical level of formation is analyzed. So, today the following criteria for assessing the amount of fluid in the retrouterine space have been developed:

• at a height of up to 10 mm, the formation is insignificant;
• with a height of 10 to 50 mm – moderate;
• with a height of more than 50 mm – significant.

The data obtained must be compared with the patient’s menstrual cycle. Additional tests may be needed if the doctor is concerned about the cause of fluid behind the uterus.

What does fluid behind the uterus mean on ultrasound?

The presence of a small amount of fluid behind the uterus in the middle of the menstrual cycle is considered normal. As a rule, this indicates pregnancy. In addition, small volumes of blood can flow into the retrouterine space during periods of menstruation, which is also absolutely natural.

However, sometimes serious diseases (endometritis, peritonitis, endometriosis, purulent salpingitis, oophoritis, adnexitis and others), ectopic pregnancy, neoplasms on the ovaries, etc. can sometimes be the causes of fluid behind the uterus.

To accurately determine the nature of such liquid formations, additional examinations are carried out: puncture (a sample of the component through laparoscopy), a laboratory blood test, a smear from the vagina.

Inflammatory process

If fluid behind the uterus is found against the background of elevated body temperature and pain in the lower abdomen, then this probably indicates inflammation of one of the organs of the genitourinary system (uterus, ovaries, bladder and fallopian tube). In such cases, depending on the stage of the disease, the doctor prescribes either antibiotics or surgery to remove the pus.

What to do if fluid is detected behind the uterus by ultrasound

Fluid behind the uterus is only a sign that indicates a specific process in the body, therefore, treatment should be aimed at eliminating the cause, not the effect.

Therefore, if an ultrasound has detected fluid, then this symptom alone cannot be used to make a diagnosis, and the doctor prescribes additional examinations and tests.