What are the common gynecologic causes of ascites in women. How can healthcare professionals differentiate between various gynecologic conditions presenting with ascites. What diagnostic approaches are most effective for identifying the underlying cause of ascites in female patients.

Understanding Ascites: Definition and General Causes

Ascites is a medical condition characterized by the abnormal accumulation of fluid within the peritoneal cavity. While commonly associated with liver disease, congestive heart failure, and nephrotic syndrome, ascites can also be a manifestation of various gynecologic conditions. Understanding the diverse causes of ascites is crucial for healthcare professionals to ensure accurate diagnosis and appropriate treatment.

What exactly is ascites? Ascites refers to the pathological buildup of fluid in the space between the lining of the abdominal wall and the organs within the abdomen. This fluid accumulation can lead to abdominal swelling, discomfort, and in severe cases, difficulty breathing.

Common Non-Gynecologic Causes of Ascites

• Liver cirrhosis
• Congestive heart failure
• Nephrotic syndrome
• Pancreatic disease
• Malnutrition

Gynecologic Conditions Associated with Ascites

When a woman presents with ascites, it is essential to consider gynecologic causes as part of the differential diagnosis. Several gynecologic conditions can lead to the development of ascites, each with its unique characteristics and underlying mechanisms.

Epithelial Ovarian Cancer

Epithelial ovarian cancer is one of the most serious gynecologic causes of ascites. How does ovarian cancer lead to ascites? The malignant cells can produce excess fluid and also block lymphatic drainage, resulting in fluid accumulation within the peritoneal cavity. Ascites in ovarian cancer patients often contains high levels of CA-125, a tumor marker commonly used in diagnosis and monitoring.

Benign Ovarian Fibroma

Ovarian fibromas are benign tumors that can occasionally cause ascites, particularly when associated with Meigs syndrome. This syndrome is characterized by the triad of an ovarian fibroma, ascites, and pleural effusion. Unlike malignant conditions, the ascites in Meigs syndrome typically resolves after removal of the fibroma.

Ovarian Stromal Hyperplasia

Stromal hyperplasia of the ovary is a benign condition that can sometimes lead to ascites formation. The mechanism behind this is not fully understood, but it is thought to be related to hormonal imbalances and increased vascular permeability.

Ovarian Hyperstimulation Syndrome: A Iatrogenic Cause of Ascites

Ovarian hyperstimulation syndrome (OHSS) is a potential complication of fertility treatments, particularly those involving gonadotropin stimulation. How does OHSS cause ascites? The syndrome leads to increased capillary permeability, resulting in fluid shifting from the intravascular space into the third space, including the peritoneal cavity.

Risk Factors for OHSS

• Young age
• Low body mass index
• Polycystic ovary syndrome
• High doses of exogenous gonadotropins
• High estradiol levels during stimulation

Primary Peritoneal Serous Carcinoma: A Rare but Important Consideration

Primary peritoneal serous carcinoma (PPSC) is a malignancy that arises from the peritoneal lining and can present with ascites. PPSC shares many similarities with ovarian cancer, including its tendency to cause ascites and elevate CA-125 levels. How can clinicians differentiate between PPSC and ovarian cancer? The key lies in careful imaging studies and surgical exploration, as PPSC typically spares the ovaries or involves them only superficially.

Endometriosis and Ascites: An Uncommon Presentation

While endometriosis is a common gynecologic condition, its association with ascites is relatively rare. When endometriosis does cause ascites, it is often referred to as endometriosis-associated ascites. What characteristics define this condition? The ascitic fluid in these cases is typically hemorrhagic and may contain endometrial cells.

Why is recognizing endometriosis-associated ascites important? This condition can mimic malignancy, leading to unnecessary aggressive interventions if misdiagnosed. Careful evaluation, including cytology of the ascitic fluid and laparoscopic assessment, is crucial for accurate diagnosis.

Peritoneal Tuberculosis: A Diagnostic Challenge

Peritoneal tuberculosis, while not strictly a gynecologic condition, often presents with symptoms that can be mistaken for gynecologic malignancies. How does peritoneal tuberculosis manifest? It can cause ascites, pelvic masses, and elevated CA-125 levels, making it a important differential diagnosis in women presenting with these findings.

Diagnostic Approaches for Peritoneal Tuberculosis

1. Ascitic fluid analysis for acid-fast bacilli
2. Peritoneal biopsy
3. Polymerase chain reaction (PCR) testing
4. Interferon-gamma release assays

Diagnostic Approach to Ascites in Women

When evaluating a woman with ascites, a systematic approach is essential to determine the underlying cause. What steps should clinicians take to diagnose the etiology of ascites in female patients?

Initial Assessment

• Comprehensive medical history
• Physical examination
• Basic laboratory tests (complete blood count, liver function tests, renal function tests)
• Serum-ascites albumin gradient (SAAG)

Imaging Studies

Imaging plays a crucial role in the evaluation of ascites. Which imaging modalities are most useful?

• Ultrasound: Provides real-time visualization of fluid and can guide paracentesis
• Computed Tomography (CT): Offers detailed images of abdominal and pelvic structures
• Magnetic Resonance Imaging (MRI): Provides high-resolution images and can be particularly useful for characterizing pelvic masses

Ascitic Fluid Analysis

Paracentesis and subsequent analysis of the ascitic fluid can provide valuable diagnostic information. What parameters should be evaluated in ascitic fluid?

• Cell count and differential
• Protein content
• Lactate dehydrogenase (LDH) levels
• Cytology for malignant cells
• Culture for bacterial or mycobacterial growth

Management Strategies for Gynecologic Causes of Ascites

The management of ascites in women with gynecologic conditions depends on the underlying cause. What are the key principles in treating ascites of gynecologic origin?

Treatment Approaches

• Surgical intervention: Often necessary for ovarian tumors or endometriosis
• Chemotherapy: Primary treatment for malignant conditions like ovarian cancer or PPSC
• Supportive care: Including paracentesis for symptom relief and nutritional support
• Hormonal therapy: May be beneficial in cases of endometriosis-associated ascites
• Antimicrobial therapy: Essential for peritoneal tuberculosis

How does the management of benign causes of ascites differ from malignant causes? Benign conditions often resolve with targeted treatment of the underlying cause, while malignant conditions typically require more aggressive, multimodal approaches.

Prognosis and Follow-up

The prognosis for women with ascites varies significantly depending on the underlying cause. What factors influence the long-term outlook for these patients?

• Nature of the underlying condition (benign vs. malignant)
• Stage of disease at diagnosis
• Response to initial treatment
• Overall health status of the patient

How should clinicians approach follow-up care for women with resolved ascites? Regular monitoring is crucial to detect recurrence early and assess for potential complications. This may include periodic imaging studies, tumor marker assessments (in cases of malignancy), and clinical examinations.

Recent Advances in Diagnosis and Management

The field of gynecologic oncology and related disciplines continues to evolve, bringing new insights into the diagnosis and management of ascites. What recent developments have impacted the approach to ascites in women?

Diagnostic Innovations

• Improved molecular testing for malignant cells in ascitic fluid
• Advanced imaging techniques, such as diffusion-weighted MRI
• Novel biomarkers for specific gynecologic conditions

Therapeutic Advancements

• Targeted therapies for ovarian cancer, potentially reducing ascites formation
• Improved management protocols for OHSS prevention
• Minimally invasive surgical techniques for diagnostic and therapeutic purposes

How have these advancements impacted patient outcomes? While more research is needed, early evidence suggests that these innovations are leading to earlier diagnoses, more targeted treatments, and potentially improved quality of life for women with ascites of gynecologic origin.

The Role of Multidisciplinary Care

Given the complex nature of ascites and its various potential causes, a multidisciplinary approach to care is often beneficial. How can collaboration between different specialties improve outcomes for women with ascites?

Key Team Members

• Gynecologists and gynecologic oncologists
• Radiologists
• Pathologists
• Medical oncologists
• Gastroenterologists
• Interventional radiologists

What are the benefits of a multidisciplinary approach? By bringing together experts from various fields, patients can receive comprehensive care that addresses all aspects of their condition. This collaborative approach can lead to more accurate diagnoses, optimized treatment plans, and improved overall outcomes.

Patient Education and Support

Dealing with ascites can be challenging for patients, both physically and emotionally. How can healthcare providers best support women diagnosed with ascites of gynecologic origin?

Key Areas of Patient Education

• Understanding the underlying cause of ascites
• Treatment options and potential side effects
• Symptom management strategies
• Nutritional guidance
• Importance of follow-up care

Why is patient education crucial in managing ascites? Empowering patients with knowledge about their condition can improve treatment adherence, reduce anxiety, and enhance overall quality of life. Additionally, well-informed patients are better equipped to recognize potential complications or recurrence early, leading to more timely interventions.

Support Resources

What support resources should be made available to women with ascites?

• Patient support groups
• Psychosocial counseling services
• Nutritional counseling
• Palliative care services (when appropriate)
• Financial counseling and support

How can these resources benefit patients? By addressing the multifaceted impact of ascites on a woman’s life, comprehensive support services can help patients navigate the challenges of their condition more effectively, leading to improved overall well-being and quality of life.

Differential diagnosis of gynecologic organ-related diseases in women presenting with ascites

Review

. 2008 Dec;47(4):384-90.

doi: 10.1016/S1028-4559(09)60003-6.

Ming-Huei Cheng 
¹
, Ming-Shyen Yen, Kuan-Chong Chao, Bor-Ching Sheu, Peng-Hui Wang

Affiliations

Affiliation

• ¹ Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, and Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.

• PMID:

  19126502

• DOI:

  10.1016/S1028-4559(09)60003-6

Free article

Review

Ming-Huei Cheng et al.

Taiwan J Obstet Gynecol.

2008 Dec.

Free article

. 2008 Dec;47(4):384-90.

doi: 10.1016/S1028-4559(09)60003-6.

Authors

Ming-Huei Cheng 
¹
, Ming-Shyen Yen, Kuan-Chong Chao, Bor-Ching Sheu, Peng-Hui Wang

Affiliation

• ¹ Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, and Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.

• PMID:

  19126502

• DOI:

  10.1016/S1028-4559(09)60003-6

Abstract

Ascites is a pathologic accumulation of fluid within the peritoneal cavity, and usually develops as a result of liver disease, congestive heart failure or nephrotic syndrome. Ascites is also a common manifestation of some gynecologic diseases. It is important that health care workers consider gynecologic problems among the potential differential diagnoses in patients presenting with ascites. Various kinds of ovarian diseases, such as epithelial ovarian cancer, benign ovarian fibroma, stromal hyperplasia, ovarian hyperstimulation syndrome, primary peritoneal serous carcinoma, endometriosis and peritoneal tuberculosis, should be kept in mind when women are found to have ascites.

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Publication types

MeSH terms

Ascites – StatPearls – NCBI Bookshelf

Continuing Education Activity

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. It is the most common complication of cirrhosis and occurs in about 50% of patient with decompensated cirrhosis in 10 years. The development of ascites denotes the transition from compensated to decompensated cirrhosis. Mortality increases from complications such as spontaneous bacterial peritonitis and hepatorenal syndrome. Mortality ranges from 15% in a year to 44% in 5 years. This activity describes the evaluation, diagnosis, and management of ascites and highlights the role of team-based interprofessional care for affected patients.

Objectives:

• Identify the etiology of ascites.

• Review the workup of a patient with ascites.

• Outline the treatment and management options available for ascites.

• Describe interprofessional team strategies for improving care coordination in the evaluation and treatment of ascites to improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. It is the most common complication of cirrhosis and occurs in about 50% of patient with decompensated cirrhosis in 10 years. The development of ascites denotes the transition from compensated to decompensated cirrhosis. Mortality increases from complications such as spontaneous bacterial peritonitis and hepatorenal syndrome. Mortality ranges from 15% in a year to 44% in 5 years.[1][2][3]

In most healthy individuals, there is very little free intraperitoneal fluid; some women may have about 20 ml during the menstrual cycle.

Etiology

In the United States, the most common disease that causes patients to get ascites is cirrhosis, which accounts for approximately 80% of cases. Other causes of ascites include cancer, 10%; heart failure, 3%; tuberculosis, 2%; dialysis, 1%; pancreatic disease, 1%; and others, 2%. Up to 19% of patients with cirrhosis will have hemorrhagic ascites; this may develop spontaneously with 72% of the cases most likely due to bloody lymph and 13% due to hepatocellular carcinoma. It can also develop following paracentesis.[4][5]

Other causes of asictes include:

Epidemiology

Patients with cirrhotic ascites have a 3-year mortality rate of approximately 50%. Refractory ascites carries a poor prognosis, with a 1-year survival rate of less than 50%. Males have little intraperitoneal fluid, females have approximately 20 mL, depending on the phase of their menstrual cycle.

Pathophysiology

The first abnormality that develops is portal hypertension in the case of cirrhosis. Portal pressure increases above a critical threshold and circulating nitric oxide levels increase, leading to vasodilatation. As the state of vasodilatation becomes worse, the plasma levels of vasoconstrictor sodium-retentive hormones elevate, renal function declines, and ascitic fluid forms, resulting in hepatic decompensation.

Through the production of proteinous fluid by tumor cells lining the peritoneum, peritoneal carcinomatosis also can cause ascites. In high-output or low-output heart failure or nephrotic syndrome, effective arterial blood volume is decreased, and the vasopressin, renin-aldosterone, and sympathetic nervous systems are activated, leading to renal vasoconstriction and sodium and water retention.[6]

History and Physical

Patients typically report progressive abdominal distension that may be painless or associated with abdominal discomfort, weight gain, early satiety, shortness of breath, and dyspnea resulting from fluid accumulation and increased abdominal pressure. Symptoms such as fever, abdominal tenderness, and confusion can be seen in spontaneous bacterial peritonitis.

Patients with malignant ascites can have symptoms related to malignancy, which may include weight loss. On the other hand, patients with ascites due to heart failure may report dyspnea, orthopnea, and peripheral edema, and those with chylous ascites report diarrhea, steatorrhea, malnutrition, edema, nausea, enlarged lymph nodes, early satiety, fevers, and night sweats.

Patients with ascites typically will have flank dullness on examination, shifting dullness, a fluid wave, evidence of pleural effusions, and findings related to the underlying cause of the ascites, such as stigmata of cirrhosis (cirrhosis includes spider angioma, palmar erythema, and abdominal wall collaterals.

Spider angiomata, jaundice, muscle wasting, gynecomastia, and leukonychia are present in patients with advanced liver disease.

An umbilical nodule that is not bowel or omental, such as a Sister Mary Joseph nodule, provides evidence for cancer as the cause of ascites. In heart failure, physical examination findings may include jugular venous distension, pulmonary congestion, or peripheral edema.

Evaluation

Diagnostic abdominal paracentesis with the appropriate ascitic fluid analysis is probably the most rapid and cost-effective method of diagnosing the cause of ascites.[7][8]

The initial tests that should be performed on the ascitic fluid include a blood cell count, with both a total nucleated cell count and polymorphonuclear neutrophils (PMN) count, and a bacterial culture by bedside inoculation of blood culture bottles.

Ascitic fluid protein and albumin are measured simultaneously with the serum albumin level to calculate the serum-ascites albumin gradient (SAAG).

The presence of a gradient greater or equal to 1.1 g/dL (greater or equal to 11 g/L) predicts that the patient has portal hypertension with 97% accuracy. This is seen in cirrhosis, alcoholic hepatitis, heart failure, massive hepatic metastases, heart failure/pericarditis, Budd-Chiari syndrome, portal vein thrombosis, and idiopathic portal fibrosis. A gradient less than 1.1 g/dL (less than 11 g/L) indicates that the patient does not have portal hypertension and occurs in peritoneal carcinomatosis, peritoneal tuberculosis, pancreatitis, serositis, and nephrotic syndrome.

Additional tests may be performed only if a specific diagnosis is suspected clinically. LDH and glucose level should be determined in suspected cases of secondary peritonitis. Other tests to consider include amylase (greater than 1000 U/L suggests pancreatic ascites). Mycobacterial culture should be performed only if tuberculosis is strongly suspected. Other ascitic fluid indices such as lactate and pH offer little to no additional information.

Chest x-ray may reveal elevated diaphragm.

Ultrasound is the most sensitive test to detect ascites. It will reveal homogenous freely mobile anechoic collection in the peritoneal cavity. The smallest amount of fluid is usually seen in Morison pouch.

CT scan can also be used to detect ascites and may also help determine for presence of any masses.

Treatment / Management

Appropriate treatment of ascites depends on the cause of fluid retention. The goals of therapy in patients with ascites are to minimize the ascitic fluid volume and decrease peripheral edema, without causing intravascular volume depletion.[9][10][11]

Sodium restriction and diuretics form the basis of treatment

In cases of  high-albumin-gradient ascites which occurs in cirrhosis, the treatment of ascites in these patients  includes abstinence from alcohol, restricting dietary sodium to 88 mEq (2000 mg)  per day, and treating with diuretics (spironolactone and furosemide in a ratio of 100:40 mg/day)

Patient with a treatable liver condition, such as autoimmune hepatitis, chronic hepatitis B with reactivation, hemochromatosis, or Wilson disease, should receive specific therapy for these diseases. Occasionally, cirrhosis due to causes other than alcohol or hepatitis B is reversible; however, these diseases are usually less reversible than in alcoholic liver disease, and by the time ascites is present, these patients may be better candidates for liver transplantation than for protracted medical therapy.

Low-albumin-gradient ascites commonly occurs in non-ovarian peritoneal carcinomatosis. These patients often benefit from an outpatient therapeutic paracentesis. Patients with ovarian malignancy may benefit from surgical debulking and chemotherapy. 

TB peritonitis is treated with anti-tuberculous medications, while pancreatic ascites and postoperative lymphatic leak from a distal splenorenal shunt or radical lymphadenectomy may resolve spontaneously.

Chlamydia peritonitis is cured with antibiotics using doxycycline and ascites caused by lupus serositis may respond to glucocorticoids.

Over the years many types of active and passive pumps have been developed but none works reliably. They are prone to obstruction, mechanical failure, and leaks.

Therapeutic paracentesis is often done for symptom relief or in patients with tense ascites. Supplements of albumin should be administered at the same time to prevent hypotension. Terlipressin is recommended instead of albumin, if available.

Transjugular intrahepatic portosystemic shunt is an effective treatment for patients who do not respond to diuretics.

Differential Diagnosis

• Liver Failure

• Biliary disease

• Alcoholic liver disease

• Cirrhosis

• Dilated Cardiomyopathy

• Liver cancer

• Portal hypertension

• Viral hepatitis

• Nephrotic syndrome

Prognosis

The prognosis of patients with ascites depends on the cause and chronicity. Disorders that are acute and respond to treatment have a much favorable prognosis, compared to disorders that do not respond.

Complications

Spontaneous bacterial peritonitis

Complications related to paracentesis

• Infection

• Electrolyte imbalance

• Bowel perforation

• Bleeding

• Leak of fluid through abdominal wall

• Injury to the kidneys

Postoperative and Rehabilitation Care

Patients with ascites need long-term monitoring to assess the effectiveness of treatment. The body weight and urinary sodium levels should be monitored in all patients treated with furosemide.

The goal of treatment is to ensure there is minimal edema and the patient is able to perform some daily living activities.

A low sodium diet is recommended.

Consultations

• Gastroenterologist

• Hepatologist

• General Surgeon

Deterrence and Patient Education

• Limit alcohol intake

• Hepatitis B vaccination

• Sodium restriction is recommended (2000 mg/d)

Pearls and Other Issues

Transfusion of blood products (fresh frozen plasma or platelets) routinely before paracentesis in patients with cirrhosis and coagulopathy, presumably to prevent hemorrhagic complications, is not supported by data

Contraindications to paracentesis include coagulopathy in the presence of DIC, massive ileus with bowel distension unless the procedure is image-guided to guarantee that the bowel is not entered.

Complications of ascites may include but are not limited to the following: Spontaneous bacterial peritonitis, cellulitis, tense ascites, pleural effusion, and abdominal wall hernias.

Enhancing Healthcare Team Outcomes

While it may appear that ascites is a GI related problem, the pathology affects almost all organ systems and has very high morbidity and mortality. Ascites is not a benign disorder and depending on the cause can have a mortality exceeding 20%. [12]To prevent complications and improve the quality of life, a streamlined protocol for management is vital.[3][13] (Level V)

Countless articles on an interprofessional approach have been published so that the morbidity and mortality can be improved. Besides the gastroenterologist the following interprofessional group of health professionals is highly recommended:

• Pharmacist to oversee all medications and be alert for drugs that cause liver injury

• Nurses to monitor body weight, abdominal girth, prevent deep vein thrombosis, encourage ambulation and educate the patient and family about the importance of a low sodium diet

• Internist to monitor coagulation parameters and general health of the patient

• Surgeon in case the patient needs decompression of the portal system or a liver transplant

• Nephrologist to monitor renal function

• Dietitian to promote nutrition

• Neurologist to assess mental status

• Radiologist to perform TIPS in patients resistant to diuretics

• Physical therapist to encourage ambulation

Outcomes and Evidence-based Medicine

Overall the prognosis is much worse for patients who have decompensated cirrhosis compared to those with compensated cirrhosis. Even patients who are ambulatory and have cirrhotic ascites have a 3-year mortality rate of 50%. Patients with refractory ascites have a 1-year survival of less than 50%. There are many evidence-based studies on managing patients with ascites.[14] (Level V). The bottom line is that aggressive care of these patients is critical if one wants to avoid the high mortality. Ascites patients are complex to manage and thus the need for an interprofessional team to ensure that the patient gets the right treatment, including a liver transplant.

Review Questions

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Figure

Abdominal ascites. Contributed by Elisa M. Aponte

Figure

Paracentesis, bowel, ascites. Contributed by MyPhuong Mitarai

Figure

Pocket of ascites ideal for paracentesis. Contributed by Maria O’Rourke

References

1.

Lee JC, Kim JS, Kim HW, Cho IK, Lee J, Jang ES, Lee SH, Hwang JH, Kim JW, Jeong SH, Kim J. Outcome of endoscopic retrograde cholangiopancreatography in patients with clinically defined decompensated liver cirrhosis. J Dig Dis. 2018 Oct;19(10):605-613. [PubMed: 30126061]

2.

Privitera G, Figorilli F, Jalan R, Mehta G. Portosystemic Shunt Embolization and Recurrent Ascites: A Single-Center Case Series. Gastroenterology. 2018 Nov;155(5):1649-1650. [PubMed: 30118744]

3.

Sarin SK, Choudhury A. Management of acute-on-chronic liver failure: an algorithmic approach. Hepatol Int. 2018 Sep;12(5):402-416. [PubMed: 30116993]

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Conangla-Planes M, Serres X, Persiva O, Augustín S. Imaging diagnosis of portal hypertension. Radiologia (Engl Ed). 2018 Jul-Aug;60(4):290-300. [PubMed: 29472014]

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Kibrit J, Khan R, Jung BH, Koppe S. Clinical Assessment and Management of Portal Hypertension. Semin Intervent Radiol. 2018 Aug;35(3):153-159. [PMC free article: PMC6078702] [PubMed: 30087517]

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Fukui H, Kawaratani H, Kaji K, Takaya H, Yoshiji H. Management of refractory cirrhotic ascites: challenges and solutions. Hepat Med. 2018;10:55-71. [PMC free article: PMC6039068] [PubMed: 30013405]

7.

Szkodziak PR, Czuczwar P, Wrona W, Paszkowski T, Szkodziak F, Woźniak S. Ascites Index – a novel technique to evaluate ascites in ovarian hyperstimulation syndrome: a concept-proof study. Ginekol Pol. 2018;89(4):182-8. [PubMed: 29781072]

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Long B, Koyfman A. The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med. 2018 Apr;36(4):689-698. [PubMed: 29290508]

9.

Burgos AC, Thornburg B. Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites: Review and Update of the Literature. Semin Intervent Radiol. 2018 Aug;35(3):165-168. [PMC free article: PMC6078698] [PubMed: 30087519]

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Adebayo D, Neong SF, Wong F. Refractory Ascites in Liver Cirrhosis. Am J Gastroenterol. 2019 Jan;114(1):40-47. [PubMed: 29973706]

11.

Storni F, Stirnimann G, Banz V, De Gottardi A. Treatment of Malignant Ascites Using an Automated Pump Device. Am J Gastroenterol. 2018 Jul;113(7):1060-1061. [PubMed: 29867179]

12.

Strunk H, Marinova M. Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature. Rofo. 2018 Aug;190(8):701-711. [PubMed: 30045395]

13.

Siddique SM, Lane-Fall M, McConnell MJ, Jakhete N, Crismale J, Porges S, Khungar V, Mehta SJ, Goldberg D, Li Z, Schiano T, Regan L, Orloski C, Shea JA. Exploring opportunities to prevent cirrhosis admissions in the emergency department: A multicenter multidisciplinary survey. Hepatol Commun. 2018 Mar;2(3):237-244. [PMC free article: PMC5831018] [PubMed: 29507899]

14.

Ede CJ, Nikolova D, Brand M. Surgical portosystemic shunts versus devascularisation procedures for prevention of variceal rebleeding in people with hepatosplenic schistosomiasis. Cochrane Database Syst Rev. 2018 Aug 03;8(8):CD011717. [PMC free article: PMC6524620] [PubMed: 30073663]

Disclosure: Maria Chiejina declares no relevant financial relationships with ineligible companies.

Disclosure: Pujitha Kudaravalli declares no relevant financial relationships with ineligible companies.

Disclosure: Hrishikesh Samant declares no relevant financial relationships with ineligible companies.

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Ascites is a pathological condition characterized by the accumulation of excess fluid in the abdominal cavity. A similar problem often occurs with cancer, cirrhosis of the liver, and cardiovascular disorders. Fluid in the abdominal cavity accumulates gradually, so many patients do not pay much attention to the changes that have appeared, explaining this by weight gain or other reasons.

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ASCITIS: CAUSES

This pathology is characterized by accumulation of fluid in the abdominal cavity . Such a violation occurs as a result of several reasons:

• oncological diseases;
• peritonitis;
• pathologies of the liver and hepatic vessels;
• cardiac disorders;
• benign neoplasms.

Most often, the disorder develops in cancers of the intestine, ovary, pancreas, and stomach. Also, the rapid development and complex course of ascites is observed in liver cancer and the detection of metastatic foci in it.

ASCYTES: SYMPTOMS

At the initial stages, the disease practically does not manifest itself externally and is detected, as a rule, by chance during an ultrasound examination. Characteristic symptoms become noticeable when the volume of accumulated fluid exceeds one liter. The patient begins to feel heaviness and dull pain in the abdomen. With further progression, it becomes difficult for a person to breathe, digestive disorders develop (nausea, intestinal disorders, belching), urination is disturbed. In severe cases, there is a sharp deterioration in the general condition, the appearance of shortness of breath, in some cases an umbilical hernia develops.

The accumulation of 5-15 liters of fluid causes compression of the organs located in the abdominal cavity, pushing the diaphragm. Prolonged ascites in cancer contributes to swelling of the legs due to impaired lymph flow. The reverse flow of lymph from the affected lymph nodes to the internal organs causes the entry of malignant cells into them and the formation of metastases.

Signs of advanced ascites are visible to the naked eye: enlargement and deformation of the abdomen, its sagging when the patient is standing, and flattening, bulging on the sides (“frog belly”) when lying down. With insufficient weight, bulging of the navel is observed.

ASCYTES: TREATMENT

Treatment of ascites in cancer patients includes:

• drug therapy with diuretics, aldosterone antagonists – applicable in mild to moderate ascites, often ineffective in malignant pathologies. The patient is prescribed spironolactone and furosemide;
• laparocentesis for ascites — ultrasound-guided puncture of the abdominal wall and pumping out the fluid. After laparocentesis, temporary or permanent peritoneal catheters are placed. Depending on the volume, the accumulated fluid is removed immediately or gradually, through the installed catheter. This method is the main one for the treatment of large and giant ascites in oncological diseases;
• palliative surgery.

Also prescribed diet for ascites :

• exclusion from the diet of salt;
• daily intake of no more than 600-700 milliliters of liquid;
• exclusion of fried, spicy, salty, fatty foods, sweets, muffins;
• prohibition of alcoholic beverages, coffee, carbonated water;
• restriction of dishes from cabbage, legumes, radishes, mushrooms, onions – prevention of flatulence.

© Authors of the article:
Leshchenko Yury Nikolaevich
Dobry Prognoz Medical Center
,
Shepil Alexander Vladimirovich
Dobry Prognoz Medical Center

Chief Physician

PHYSICIANS WHO TREAT ASCYTES

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Konstantin Viktorovich

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Leonid Pavlovich

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• Over 37 years of experience

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Leshchenko
Yuri Nikolaevich

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causes, forms, diagnosis and treatment

Ascites is a disease in which the formation and accumulation of peritoneal fluid in the abdominal cavity occurs. It usually develops along with another more complex disease, which provokes ascites. These can be various pathologies in endocrinology, gastroenterology, urology, gynecology, rheumatology, lymphology, cardiology and oncology.

In an organism weakened by a disease, the process of blood perspiration through the walls of blood vessels occurs. In a normal non-pathological regime in a healthy body, the intestines and neighboring organs are lubricated for their mutual sliding without gluing and adhesion. The exudate is gradually absorbed by the peritoneum itself and removed from the body. Due to illness, it begins to fill the space between the organs, creating pressure, displacing the organs, disrupting their work, swelling and increasing the volume of the abdomen.

The goal of treating ascites is to eliminate the cause of the increased fluid production. The main emphasis is on the use of diuretics and the removal of fluid through the kidneys and bladder. In complex forms, the transudate is removed from the peritoneum with a puncture.

Causes of ascites

In men, the development of ascites mainly occurs as a result of cirrhosis of the liver. The disease develops due to protein deficiency and inflammatory processes in the peritoneum, as well as an increase in blood pressure in the hepatic vein.

There is a group of diseases that provokes the development of ascites:

• fungal and parasitic peritonitis;

• abdominal mesothelioma;

• polyserositis, rheumatoid arthritis;

• lupus erythematosus;

• metastases of malignant tumors of an oncological nature;

• hepatosis, hepatitis of the liver;

• heart failure;

• constriction, blockage and obstruction of veins;

• chronic renal glomerulonephritis;

• blood diseases;

• pancreatitis;

• diseases of the female reproductive system.

Classification of ascites

There are three main degrees depending on the volume of fluid formed:

• mild – manifestations are determined by the results of ultrasound;

• medium – there is a slight visible change in the size of the abdomen;

• severe – a complex process of formation of a large amount of fluid, a significant increase in the abdomen.

If the gradually forming transudate is relatively sterile and there are no signs of hepatorenal syndrome, ascites is an uncomplicated form of the disease. In the case of the development of inflammatory processes and the penetration of infection, a deterioration in the functioning of organs is observed, complications begin.

The disease is assessed by the response to drug therapy:

Symptoms of ascites

The very first sign of the onset of ascites is often problems with an increase in the abdomen at the waist. There is also an increase in body weight.

At the beginning of the development of the disease and in severe form, the following symptoms appear:

• increased fatigue, constant lack of strength;

• heaviness and bloating in the abdomen;

• pain in right side of body;

• heartburn, nausea, belching;

• flatulence;

• severe respiratory failure, shortness of breath;

• swelling and bluing of the extremities;

• prolonged subfebrile condition.

The formation of large volumes of fluid leads to enlargement of the veins and swelling of the navel.

In case of liver pathology, in addition to changes in the size of the abdomen, there is yellowness of the skin and mucous membranes of the eyes, dark urine, discolored feces, bruising and bruising. A further complication of the disease is accompanied by fatigue, heavy sweating at night, weight loss, a prolonged increase in temperature of 37–38 ° C for a long period of time.

Cardiovascular disease due to obstructed blood distribution also causes fluid to accumulate in the peritoneum. Visits to the cardiologist help to detect the development of ascites in time. In case of heart disease, the patient is accompanied by periodic weakness and shortness of breath, instability of blood pressure readings, and a strong dry cough at night. Severe edema is formed on the legs. In oncology, the course of ascites is affected by the degree of aggressiveness of the neoplasm.

Complications

In the case of bacterial infection of the ascitic fluid, an inflammatory process begins, turning into peritonitis, with the manifestation of complications:

• umbilical and inguinal hernia;

• diaphragmatic hernia;

• varicose veins of the rectum and esophagus;

• displacement of the heart, increased pressure in the jugular vein;

• pleural effusion;

• internal bleeding.

Diagnosis

Ascites in women is detected by a gynecologist during a two-handed vaginal examination. A coloproctologist may examine the rectum and find fluid in the pouch of Douglas. The fluid in the peritoneum is detected by taking pushes with the palm of the side of the abdomen while tapping the opposite wall.

To detect the development of ascites, it is necessary to perform an extended diagnosis with the study of other causes of abdominal enlargement: pregnancy, obesity, cyst, large neoplasms. For this, instrumental studies are carried out:

• abdominal ultrasound;

• Ultrasound of the pelvic organs;

• USDG of venous and lymphatic vessels;

• CT scan of the abdomen;

• hepatoscintigraphy;

• diagnostic laparocentesis.

Laboratory diagnosis of the disease includes:

• clinical blood test with expanded leukoformula and measurement of ESR;

• blood biochemistry with the determination of the level of potassium, sodium, calcium, creatinine, ALT, AST, LDH, glucose, total protein in it;

• general and biochemical analysis of urine.

Treatment

The main recommendations are to limit physical activity, reduce fluid intake, stay in bed and maintain a salt-free diet.

Drug treatment mainly involves the use of diuretics. Since protein will also be excreted from the body with large fluid losses, albumin solutions are administered intravenously.

If during dropsy there is a strong compression of the internal organs, it is necessary to take measures to remove the resulting exudate with a needle with a puncture of the abdominal cavity. Laparocentesis can cause complications, requires special control and is performed only if an emergency intervention is necessary.

In the treatment of the underlying disease, the presence of an additional complex inflammatory form of dropsy of the abdominal cavity significantly aggravates the course of the underlying disease and significantly reduces the chances of its cure. Survival for complex ascites is very low, below 50% at 2 years.