What is ascites and how does it affect the body. What are the main causes of ascites and who is at risk. How is ascites diagnosed and what treatment options are available. Can ascites be prevented and what lifestyle changes can help manage the condition.

What is Ascites and How Does it Affect the Body?

Ascites is a medical condition characterized by the accumulation of fluid in the abdominal cavity. This buildup can lead to a range of uncomfortable symptoms and potentially serious complications. But how exactly does ascites affect the body?

The excess fluid in the abdomen can cause:

• Abdominal swelling and distension
• Discomfort and pain
• Difficulty moving and breathing
• Increased risk of abdominal infections
• Potential strain on other organs, including the lungs and kidneys

In severe cases, ascites can significantly impact a person’s quality of life, making everyday activities challenging and potentially leading to further health complications.

Common Causes of Ascites: From Liver Disease to Cancer

While ascites can have various underlying causes, certain conditions are more commonly associated with this fluid buildup. What are the primary culprits behind ascites?

Cirrhosis of the Liver

The most frequent cause of ascites is cirrhosis of the liver. This chronic liver disease results in scarring of liver tissue, which can disrupt normal blood flow and lead to fluid accumulation in the abdomen. Excessive alcohol consumption is a leading cause of cirrhosis, but other factors such as viral hepatitis, nonalcoholic fatty liver disease, and certain genetic conditions can also contribute to its development.

Cancer

Various types of cancer can cause ascites, particularly in advanced or recurrent stages. Cancers that commonly lead to ascites include:

• Ovarian cancer
• Pancreatic cancer
• Liver cancer
• Colon cancer
• Stomach cancer

Other Potential Causes

While liver disease and cancer are the most common culprits, other conditions can also result in ascites:

• Heart failure
• Kidney disease, particularly in patients undergoing dialysis
• Severe malnutrition leading to low protein levels
• Infections in the abdominal cavity
• Pancreatic disorders

Recognizing the Symptoms: When to Suspect Ascites

Identifying ascites early can lead to prompt treatment and better management of the condition. What are the telltale signs of ascites?

Common symptoms include:

1. Abdominal swelling and increased girth
2. Unexplained weight gain
3. A feeling of fullness or heaviness in the abdomen
4. Bloating and indigestion
5. Nausea and occasional vomiting
6. Swelling in the lower legs (edema)
7. Shortness of breath, especially when lying down
8. Development or worsening of hemorrhoids

It’s important to note that symptoms can vary in severity and may develop gradually over time. If you experience persistent abdominal swelling or any combination of these symptoms, it’s crucial to consult a healthcare provider for proper evaluation.

Diagnosing Ascites: Medical Exams and Imaging Techniques

Accurate diagnosis of ascites is essential for determining the underlying cause and developing an effective treatment plan. How do healthcare providers confirm the presence of ascites and identify its origin?

Physical Examination

The diagnostic process typically begins with a thorough physical examination. A healthcare provider may:

• Visually inspect and measure the abdomen
• Perform percussion (tapping) of the abdomen to detect fluid
• Check for other signs of liver disease or systemic illness

Paracentesis

Paracentesis is a procedure in which a sample of the abdominal fluid is extracted using a needle. This fluid is then analyzed to:

• Confirm the presence of ascites
• Check for signs of infection
• Look for cancer cells
• Determine the fluid’s protein content and other characteristics

Imaging Studies

Various imaging techniques can help visualize the ascites and potentially identify its cause:

• Ultrasound: A non-invasive method to detect fluid in the abdomen
• CT scan: Provides detailed images of the abdominal organs and can reveal underlying conditions
• MRI: Offers high-resolution images and can be particularly useful in cases where cancer is suspected

These diagnostic tools, combined with a patient’s medical history and symptom profile, allow healthcare providers to make an accurate diagnosis and develop an appropriate treatment strategy.

Treatment Approaches: Managing Ascites and Addressing Underlying Causes

The management of ascites typically involves a multi-faceted approach aimed at reducing fluid accumulation and addressing the root cause of the condition. What are the primary treatment strategies for ascites?

Dietary Modifications

Dietary changes play a crucial role in managing ascites:

• Sodium restriction: Limiting salt intake can help reduce fluid retention
• Fluid restriction: In some cases, reducing overall fluid intake may be recommended
• Balanced nutrition: Ensuring adequate protein and calorie intake to support liver function and overall health

Medications

Several medications can be prescribed to manage ascites:

• Diuretics: Drugs like furosemide and spironolactone help increase urine output and reduce fluid retention
• Albumin: In some cases, intravenous albumin may be administered to help maintain fluid balance
• Antibiotics: If infection is present or suspected, antibiotics may be necessary

Paracentesis

For severe cases or when other treatments are ineffective, large-volume paracentesis may be performed to remove excess fluid from the abdomen. This procedure can provide immediate relief but does not address the underlying cause of ascites.

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

In complex cases, particularly those related to portal hypertension, a TIPS procedure may be recommended. This involves creating a new connection between blood vessels in the liver to reduce pressure and minimize fluid accumulation.

Treating Underlying Conditions

Addressing the root cause of ascites is crucial for long-term management:

• Liver disease treatment: This may include antiviral medications for hepatitis, abstinence from alcohol, or management of other liver conditions
• Cancer treatment: If ascites is caused by cancer, oncology treatments such as chemotherapy or targeted therapies may be necessary
• Management of other medical conditions: Treating heart failure, kidney disease, or other underlying issues can help control ascites

Preventing Ascites: Lifestyle Changes and Risk Reduction

While not all cases of ascites can be prevented, certain lifestyle modifications can significantly reduce the risk of developing this condition. How can individuals lower their chances of experiencing ascites?

Liver Health Promotion

Since liver disease is the most common cause of ascites, protecting liver health is crucial:

• Abstain from alcohol or drink in moderation
• Maintain a healthy weight to prevent fatty liver disease
• Exercise regularly to support overall liver function
• Avoid exposure to hepatitis viruses by practicing safe sex and not sharing needles

Dietary Considerations

A healthy diet can play a role in preventing ascites:

• Limit sodium intake to reduce fluid retention
• Consume a balanced diet rich in fruits, vegetables, and whole grains
• Maintain adequate protein intake to support liver function

Regular Health Screenings

Early detection and management of underlying conditions can prevent the development of ascites:

• Undergo regular liver function tests, especially if at risk for liver disease
• Participate in recommended cancer screenings
• Monitor and manage chronic conditions such as heart disease and diabetes

Living with Ascites: Coping Strategies and Quality of Life Considerations

While ascites can be challenging to manage, there are various strategies to help individuals cope with the condition and maintain a good quality of life. What approaches can help those living with ascites?

Symptom Management

Effectively managing symptoms can significantly improve daily life:

• Follow prescribed treatment plans, including medication regimens and dietary restrictions
• Use supportive garments or abdominal binders to alleviate discomfort
• Practice good posture and gentle exercises to improve mobility
• Elevate legs when resting to reduce lower limb swelling

Emotional Support

The psychological impact of living with ascites should not be overlooked:

• Seek support from family, friends, or support groups
• Consider counseling or therapy to address emotional challenges
• Practice stress-reduction techniques such as meditation or deep breathing exercises

Monitoring and Follow-up

Regular monitoring is crucial for managing ascites effectively:

• Keep track of daily weight to detect fluid accumulation early
• Attend all scheduled medical appointments
• Report any new or worsening symptoms promptly
• Maintain open communication with healthcare providers about treatment effectiveness and quality of life concerns

Adapting Daily Activities

Making adjustments to daily routines can help individuals with ascites maintain independence and enjoyment in life:

• Use assistive devices if mobility is compromised
• Plan activities during times of day when energy levels are highest
• Modify work or home environments to accommodate physical limitations
• Explore new hobbies or interests that are compatible with current physical capabilities

By implementing these strategies and working closely with healthcare providers, individuals with ascites can often achieve a balance between managing their condition and maintaining a fulfilling life.

Ascites | Johns Hopkins Medicine

Ascites | Johns Hopkins Medicine

What is ascites?

Ascites is a condition in which fluid collects in spaces within your abdomen. If severe, ascites may be painful. The problem may keep you from moving around comfortably. Ascites can set the stage for an infection in your abdomen. Fluid may also move into your chest and surround your lungs. This makes it hard to breathe.

What causes ascites?

The most common cause of ascites is cirrhosis of the liver. Drinking too much alcohol is one of the most common causes of cirrhosis of the liver.  

Different types of cancer can also cause this condition.  Ascites caused by cancer most often occur with advanced or recurrent cancer. Ascites may also be caused by other problems such as heart conditions, dialysis, low protein levels, and infection.

What are the symptoms of ascites?

These are symptoms of ascites:

• Swelling in the abdomen
• Weight gain
• Sense of fullness
• Bloating
• Sense of heaviness
• Nausea or indigestion
• Vomiting
• Swelling in the lower legs
• Shortness of breath
• Hemorrhoids

How is ascites diagnosed?

Your healthcare provider will do a physical exam and ask about your symptoms. You may also have tests such as:

• Fluid sample. A sample of fluid from your abdomen may be taken using a needle. This fluid will be checked for signs of disease, such as cancer or an infection. This test may help point to the cause of the ascites.
• Imaging. Your healthcare provider may request images of the inside of your abdomen using ultrasound, MRI, or a CT scan. An MRI creates images using a magnetic field and radiofrequency energy. A CT scan creates computerized images using X-rays.

How is ascites treated?

A number of steps may help ease your ascites. Your healthcare provider may tell you to:

• Cut back on your salt intake. Your healthcare provider or a dietitian can show you how to follow a low-sodium diet. Avoid salt substitutes that contain potassium. This is because some medicines used in treating ascites can cause your potassium levels to rise.
• Cut back on the amount of fluids you drink.
• Stop drinking alcohol.
• Take diuretic medicines to help reduce the fluid in your body.
• In certain cases, your doctor may need to remove large amounts of fluid from your abdomen through a needle. This may be done if you have trouble breathing or the diuretic is not working.
• In very complicated situations, you may need to have a special procedure in radiology called TIPS. In this procedure, a connection is made inside the liver between the blood vessels to ease the high pressure causing ascites.

What are the complications of ascites?

Ascites can make eating, drinking, and moving around difficult. It can also make it hard to breathe. Ascites can lead to abdominal infections, which may cause kidney failure. It can also cause umbilical or inguinal hernias.

Can ascites be prevented?

Certain steps to help you avoid cirrhosis of the liver and cancer can prevent ascites. These include:

• Stop drinking alcohol.
• Maintain a healthy weight.
• Exercise regularly.
• Stop smoking.
• Limit salt in your diet.
• Practice safe sex to decrease your chance of getting hepatitis.
• Do not use recreational drugs to decrease your chance of getting hepatitis.

Living with ascites

Be sure to follow your healthcare provider’s advice for lowering your salt intake. You’ll need to do this even if you’re taking diuretic drugs to reduce fluid in your body. Also, weigh yourself daily and call your healthcare provider if you gain too much weight.

Key points

• Ascites is a condition in which fluid collects in spaces within your abdomen.
• As fluid collects in the abdomen, it can affect your lungs, kidneys, and other organs.
• Ascites causes abdominal pain, swelling, nausea, vomiting, and other difficulties.
• Stopping all alcohol intake, maintaining a healthy weight, exercising, not smoking, and limiting salt intake can help prevent cirrhosis or cancer that may lead to ascites.
• Ascites can’t be cured but lifestyle changes and treatments may decrease complications.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the names of new medicines, treatments, or tests, and any new instructions your provider gives you.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

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Related Topics

Pelvic mass, ascites, hydrothorax: a malignant or benign condition? Meigs syndrome with high levels of CA 125

Prz Menopauzalny. 2021 Jun; 20(2): 103–107.

Published online 2021 May 25. doi: 10.5114/pm.2021.106100

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Author information Article notes Copyright and License information Disclaimer

Introduction

Abdominal-pelvic mass, ascites and pleural effusion are suggestive of malignant metastatic ovarian cancer. This triad is also present in a rare benign condition called Meigs syndrome. Rarely this condition is associated with an increased CA 125 level.

Case report

A 62-year-old woman with a history of abdominal pain underwent an ultrasound (US) examination and a chest X-ray. The imaging revealed the presence of a large pelvic mass and ascites with a monolateral pleural effusion and a high level of the tumor marker CA 125. The patient underwent a total abdominal hysterectomy, salpingoophorectomy, removal of the pelvic mass, pelvic lymphadenectomy and peritoneal biopsies. The histology showed an ovarian fibrothecoma.

Discussion

The US analysis according to international ovarian tumor analysis simple rules revealed “inconclusive results”; the logistic regression model LR2 and Adnex suggested a high risk of malignancy. The presence of ascites and the size of the lesion associated with a high level of CA 125 affected the correct assessment of the risk of malignancy, exposing the patient to overtreatment

Conclusions

Meigs syndrome is characterized by the resolution of symptoms after surgical removal of the pelvic mass. However, it mimics the clinical picture of a malignant metastatic ovarian cancer. Clinicians have to exclude ovarian cancer and recognize the syndrome to reduce inappropriate procedures.

Keywords: Meigs syndrome, CA 125, pelvic mass, ascites, hydrothorax, fibrothecoma, ovarian cancer

Meigs syndrome is a rare gynecological condition characterized by the presence of a benign ovarian solid tumor accompanied by ascites and hydrothorax. Rarely it is associated with high levels of CA 125. Meigs syndrome is more common in postmenopausal women with an average age of about 50 years. Even though it is extremely rare in women aged less than 30 years, some cases have been reported in children aged 4 and 9 years. Surgery is necessary to confirm the diagnosis. Histologically, the majority of cases are represented by fibroma, but thecoma, cystadenoma and granulosa cell tumor are also described. The typical features of the syndrome, ascites and pleural effusion, resolved completely after the surgical removal of the tumor. Although it mimics a malignant condition, Meigs syndrome is a benign disease [1, 2], characterized by a good prognosis.

A Caucasian 62-year-old woman referred to our department due to an abdominal pain since a few days before, associated with nausea and vomiting. She also presented with dysphagia and cachexia. No hirsutism, skin discoloration or other signs of hormonal dysregulation were detected. A history of painless, progressive abdominal distension and increasing weight of more than 15 kg in one year were reported, reaching a body mass index of 30. 5. Her anamnesis was substantially silent and she did not have familiarity for gynecological cancer or pathology. At admission a very distended abdomen was detected upon examination, while massive ascites was observed at the office ultrasound (US) scan. During hospitalization the patient complained of progressive dyspnea, especially in supine decubitus.

Investigations

In the suspicion of a malignant ovarian mass, diagnostic investigations were performed. Ovarian markers showed increased levels of CA 125 (1744.3 mUI/ml), with normal levels of carcinoembryonic antigen (4.2 ng/ml), AFP (3.5 ng/ml) and Ca 19.9 (19.2 UI/ml). The office transabdominal (TA) US showed the presence of massive ascites. A second level US (transvaginal and TA) revealed a 20 cm in diameter mobile solid mass with smooth surface with color score 2 and acoustic shadows in the right adnexal region [3]. There was no sign of pelvic structures’ infiltration or abdominal carcinomatosis (). The uterus was within the normal range and a small fibroma was described.

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A – Ultrasound (US) transabdominal image showing the right adnexal mass and acoustic shadows, B – US transvaginal image showing massive ascites in the pouch of Douglas and a normal uterus

Thoracic and abdominal computed tomography (CT) scans were performed for a better assessment. They revealed conspicuous peritoneal effusion and an abdominal mass of about 17 cm of doubtful origin. A non-homogeneous uterine neoformation of about 43 mm was described and interpreted as a fibroleiomyoma. A chest and chest CT scan confirmed a modest level of monolateral left hydrothorax ().

Differential diagnosis

The combination of ascites, pelvic mass and high levels of CA 125 raised suspicion of a potential ovarian malignancy. The differential diagnosis for the presenting signs and symptoms included malignant ovarian tumor, other bowel or lung cancers, nephrotic syndrome, congestive cardiac failure, liver cirrhosis and tuberculosis [4]. This disease represents a diagnostic and therapeutic challenge for the gynecologist.

Treatment

Due to the progressive dyspnea, the patient was submitted urgently to a preliminary laparoscopic exploration at the subsequent laparotomic access (xypho-pubic or navel-pubic laparotomy) and the radical nature of the intervention. During laparoscopy we performed multiple biopsies and the aspiration of 20 liters of ascitic fluid. Laparoscopic exploration showed stomach, liver, peritoneum, bowel and omentum free of disease. In the right iliac fossa a 20 cm capsulated solid polylobate smooth neoformation was found. The patient was then submitted to a laparotomic hysterectomy, bilateral adnexectomy, asportation of the pelvic mass and multiple biopsies. There was no pelvic or aortic lymphadenomegaly. Histological examination diagnosed an ovarian fibrothecoma with large fibrohyaline areas. The cytologic examination of ascites and hydrothorax did not show any cells suggestive of malignancy.

Outcome and follow-up

The postoperative period was characterized by complete resolution of hydrothorax () and ascites with reduced levels of CA 125 (227.1 mUI/ml) at only 10 days after surgery. CA 125 was within the normal range at one month later. The patient underwent gynecological follow-up examination and US at 1 and 6 months after surgery. Both follow-ups were negative. The patient was asymptomatic and in good health.

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A, B – chest X-ray scans in which a left monolateral hydrothorax is noticeable

Meigs syndrome is characterized by the presence of a benign ovarian solid tumor accompanied by ascites and hydrothorax. Rarely this condition could be associated with high CA 125 levels. Although it mimics a malignant condition, Meigs syndrome is a benign disease [1, 2, 5].

The postmenopausal findings of ascites, solid monoor bilateral adnexal mass, pleural effusion and elevated serum CA 125 are highly suggestive for malignant ovarian tumor. In fact, CA 125 is increased in 80% of advanced epithelial ovarian cancers [6, 7]. Nevertheless, it could be raised during menstruation or pregnancy and in some benign conditions such as endometriosis, peritonitis or cirrhosis, particularly with ascites. Probably in this case its elevation is due to inflammation and secretion from mesothelium cells, and it also happens in pseudo-Meigs syndrome [8, 9].

This disease is usually characterized by the presence of an ovarian fibroma or a fibrothecoma, which is rarely associated with increased levels of tumor markers [10]. Ovarian fibroma is a benign tumor, which accounts for approximately 3% of all ovarian tumors and may be pure and non-secreting. Meigs syndrome occurs in 1–10% of cases associated with this tumor. Ovarian fibroma is the most frequently observed in this syndrome, at the rate of 80–85% [10]. Sometimes thecoma elements (fibrothecomas) are present and responsible for estrogen secretion [11]. Thecomas and fibrothecomas represent 10% of tumors associated with Meigs syndrome. Fibrothecoma is a benign ovarian stromal tumor, usually seen as a unilateral lesion [10]. In contrast, pseudo-Meigs syndrome is characterized by ascites and pleural fluid secondary to other pelvic or abdominal tumors. This condition was further subclassified into 2 categories: benign pseudo-Meigs syndrome and malignant pseudo-Meigs syndrome. The first term was used for patients with symptoms related to any benign pelvic or abdominal tumors located outside the ovaries, fallopian tubes, and broad ligaments, whereas the second refers to patients with malignant pelvic or abdominal tumors (primary or metastatic) [12]. In Meigs syndrome, by definition, peritoneal or pleural spread of the tumor must be excluded (negative pleural and peritoneal fluid cytology and/or no malignant involvement in biopsy samples) and both ascites and hydrothorax should resolve after tumor removal [13].

The pathogenesis of the disease is unknown. The production of ascitic fluid in Meigs syndrome could be due to an imbalance between vascular supply and lymphatic drainage. An alternative hypothesis is the inflammatory origin of the process, with elevation of several inflammatory molecules including cytokines, vascular endothelial growth factor, fibroblast growth factor, interleukin (IL)-1b, IL-6, and IL-8. The detailed underlying mechanism is still unclear. Furthermore, the etiology of pleural effusion is uncertain. It is probably due to the passage of ascitic fluid into the pleural space through the diaphragm or diaphragmatic lymphatic vessels, which are more common on the right side [13, 14]. Indeed, in Meigs syndrome the hydrothorax is mainly unilateral and occurs most often on the right side (75%), rarely on the left side, and sometimes it is bilateral. The size of the pleural effusion is largely independent of the amount of ascites [14].

The general condition of the patient can be of variable severity. The classical triad (ascites, abdominal mass, and hydrothorax) may be a chance discovery during a routine gynecological examination or become symptomatic, causing abdominal tension with bloating and weight gain, respiratory distress associated with cough or abdominal pain secondary to adnexal torsion. In the literature, most patients present with an ovarian asymptomatic large, solid, unilateral mass, mostly left-sided.

Meigs syndrome always requires surgical treatment. A prompt differential diagnosis between benignity and malignancy has to be made in order to choose the appropriate management.

Ovarian tumors are common in women of all ages. It has been estimated that in the female population, the lifetime risk of undergoing surgery for a suspected ovarian neoplasm is 5–10% [15]. However, the incidence of ovarian cancer is low, even though it represents the most lethal gynecological malignancy [15]. In order to ensure that ovarian cancer patients access appropriate treatment to improve the outcome of this disease, accurate characterization before any surgery on ovarian pathology is essential. For this reason, the work of the International Ovarian Tumor Analysis (IOTA) collaboration in standardizing terminology, definitions and characteristics that must be described in adnexal pathology is critical [3]. Being based on diagnostic algorithms, the group developed and validated risk prediction models (simple rules, LR1, LR2, Adnex) on a large sample of patients; these are highly diagnostic and therefore superseded previous algorithms. Even if the assessment according to IOTA rules by an experienced examiner is subjective, it is still widely considered as the most accurate method for classification of preoperative adnexal masses. IOTA risk prediction models showed a high predictive value compared to other, non-IOTA algorithms [16]. The “simple rules” have been shown to apply to over 75% of masses and have been successfully externally validated and implemented in a national protocol [17, 18]. Nevertheless, in our case, the analysis according to IOTA simple rules revealed “inconclusive results”; the logistic regression model LR2 and Adnex [17] suggested a high risk of malignancy. In fact, the presence of ascites and the size of the lesion affected the correct assessment of the risk of malignancy because these are usually characteristics of malignant ovarian cancer. It is also reasonable and evidence-based to believe that the lesion size affects diagnostic performance of IOTA prediction models in discriminating between malignant and benign ovarian pathology [19].

Moreover, the prevalence of different types of histology affects the performance of subjective assessment in correctly classifying adnexal masses as benign or malignant [20, 21]. In this patient, the “subjective assessment” according to IOTA rules by an expert US examiner [16] was used to understand the nature of the mass. This ovarian mass was very large, solid and accompanied by ascites, but presented acoustic shadowing, a smooth external surface, mobility and a low color score (color score 2 according to IOTA terms) [3]. The mass could seem benign, as it was. Type I ovarian tumors (low-grade serous, low-grade endometrioid, clear cell, and mucinous) are slow growing, reaching a large size while still confined to the ovary, and are thus likely to be detected early by transvaginal US. Unfortunately, these lesions constitute only 25% of ovarian cancers and account for only approximately 10% of ovarian cancer deaths. On the other hand, type II ovarian tumors (high-grade serous and undifferentiated carcinomas and carcinosarcomas) represent 75% of all ovarian carcinomas and are responsible for 90% of ovarian cancer deaths and may originate outside the ovary. These tumors are almost never confined to the ovary at first evaluation, making an early diagnosis still a challenge [16]. Usually, the CT scan does not diagnose with certainty the origin of the masses. A diagnostic laparoscopy is useful in patients with potentially malignant tumors, and the tumor resection can also be performed if there are signs of malignancy [22, 23]. Depending on the patient’s age, a unilateral salpingo-oophorectomy is

commonly performed for the treatment of an ovarian type I tumor. For women who desire

preservation of the ovary, an ovarian cystectomy may be performed with complete excision of the fibromatous tissue [24, 25]. However, the optimal approach for its management has still not been sufficiently investigated [26]. Meigs syndrome is curable by tumor resection and should be differentiated from malignancy. The connection between the pelvic tumor and ascites is confirmed by the rapid resolution of symptoms due to the complete disappearance of ascites and/or the fluid in the pleura following the surgical removal of the tumor with a complete “restitutio ad integrum”. The prognosis of Meigs syndrome is favorable, recurrence of peritoneal and pleural fluid after complete removal of the tumor is unlikely to occur, and life expectancy after surgical removal is the same as in the general population [2]. So, fast surgical management of the patients is mandatory. The main limitation of our management is that our therapeutic approach has been radical despite the presence of the classical triad of symptoms suggestive for Meigs syndrome. Otherwise, the main strength of our management is that all clinical, instrumental and histological findings were essential to formulate the correct diagnosis, ensuring the complete regression of the patient’s symptoms. The major message related to this case report is that abdominal tumor, ascites, pleural effusion and elevated CA 125 – symptoms strongly suggesting disseminated malignancy – do not necessarily mean advanced malignant disease.

Clinicians should consider the uncommon Meigs syndrome in the case of a pelvic mass suggestive for an ovarian fibroma/fibrothecoma at US examination, ascites and hydrothorax, especially in the case of low levels of CA 125. Meigs syndrome is often misdiagnosed as a malignant condition in the presence of high levels of CA 125. Life expectancy and prognosis of Meigs syndrome are favorable with the complete “restitutio ad integrum” after surgical removal of the pelvic mass and the subsequent hydrothorax and ascites resolution.

This work was supported by a grant from the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy. Grant number: RC 08/20.

Disclosure

The authors report no conflict of interest.

1. Turan YH, Demirel LC, Ortaç F. Elevated CA 125 in Meigs ‘syndrome. Int J Gynecol Obstet. 2004;43:64–65. [PubMed] [Google Scholar]

2. Abad A, Cazorla E, Ruiz F, Aznar I, Asins E, Llixiona J. Meigs ‘syndrome with elevated CA 125: case report and review of the literature. Eur J Obstet Gynecol Reprod Biol. 1999;82:97–99. [PubMed] [Google Scholar]

3. Timmerman D, Valentin L, Bourne TH, Collins WP, Verrelst H, Vergote I. International Ovarian Tumor Analysis (IOTA) Group Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet Gynecol. 2000;16:500–505. [PubMed] [Google Scholar]

4. Saha S, Robertson M. Meigs’ and pseudo-Meigs ‘syndrome. Australas J Ultrasound Med. 2012;15:29–31. [PMC free article] [PubMed] [Google Scholar]

5. Park JW, Bae JW. Postmenopausal Meigs’ syndrome in elevated CA 125: a case report. J Menopausal Med. 2015;21:56–59. [PMC free article] [PubMed] [Google Scholar]

6. Jacobs I, Bast RC., Jr The CA 125 tumour-associated antigen: a review of the literature. Hum Reprod. 1989;4:1–12. [PubMed] [Google Scholar]

7. Kudlacek S, Schieder K, Kölbl H, et al. Use of CA 125 monoclonal antibody to monitor patients with ovarian cancer. Gynecol Oncol. 1989;35:323–329. [PubMed] [Google Scholar]

8. Pauls M, MacKenzie H, Ramjeesingh R. Hydropic leiomyoma presenting as a rare condition of pseudo-Meigs ‘syndrome: literature review and a case of a pseudo-Meigs ‘syndrome mimicking ovarian carcinoma with elevated CA 125. BMJ Case Rep. 2019;12 bcr-2018-226454. [PMC free article] [PubMed] [Google Scholar]

9. Bognoni V, Quartuccio A, Jr, Quartuccio A. Sindrome di Meigs con elevati livelli sierici di CA 125. Caso clinico e review della letteratura [Meigs ‘syndrome with high blood levels of CA 125. Clinical case and review of the literatureø] Minerva Ginecol. 1999;51:509–512. [PubMed] [Google Scholar]

10. Cissé CT, Ngom PM, Sangare M, Ndong M, Moreau JC. Fibrome de l’ovaire associé à un syndrome de Demons-Meigs et à une élévation du CA 125 [Ovarian fibroma associated with Demons-Meigs ‘syndrome and elevated CA 125] J Gynecol Obstet Biol Reprod (Paris) 2004;33:251–254. [PubMed] [Google Scholar]

11. Loué VA, Gbary E, Koui S, Akpa B, Kouassi A. Bilateral ovarian fibrothecoma associated with ascites, bilateral pleural effusion, and marked elevated serum CA 125. Case Rep Obstet Gynecol. 2013;2013:189072. [PMC free article] [PubMed] [Google Scholar]

12. Mui MP, Tam KF, Tam FK, Ngan HY. Coexistence of struma ovarii with marked ascites and elevated CA 125 levels: case report and literature review. Arch Gynecol Obstet. 2009;279:753–757. [PubMed] [Google Scholar]

13. Agranoff D, May D, Jameson C, Knowles GK. Pleural effusion and a pelvic mass. Postgrad Med J. 1998;74:265–267. [PMC free article] [PubMed] [Google Scholar]

14. Miyoshi A, Miyatake T, Hara T, et al. Etiology of ascites and pleural effusion associated with ovarian tumors: literature review and case reports of three ovarian tumors presenting with massive ascites, but without peritoneal dissemination. Case Rep Obstet Gynecol. 2015;2015:414019. [PMC free article] [PubMed] [Google Scholar]

15. Froyman W, Wynants L, Landolfo C, et al. Validation of the performance of international ovarian tumor analysis (IOTA) methods in the diagnosis of early stage ovarian cancer in a non-screening population. Diagnostics (Basel) 2017;7:32. [PMC free article] [PubMed] [Google Scholar]

16. Kaijser J, Bourne T, Valentin L, et al. Improving strategies for diagnosing ovarian cancer: a summary of the international ovarian tumor analysis (IOTA) studies. Ultrasound Obstet Gynecol. 2013;41:9–20. [PubMed] [Google Scholar]

17. Timmerman D, Ameye L, Fischerova D, et al. Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA Group. BMJ. 2010;341:c6839. [PMC free article] [PubMed] [Google Scholar]

18. Westwood M, Ramaekers B, Lang S, et al. Risk scores to guide referral decisions for people with suspected ovarian cancer in secondary care: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2018;22:1–264. [PMC free article] [PubMed] [Google Scholar]

19. Di Legge A, Testa AC, Ameye L, et al. Lesion size affects diagnostic performance of IOTA logistic regression models, IOTA simple rules and risk of malignancy index in discriminating between benign and malignant adnexal masses. Ultrasound Obstet Gynecol. 2012;40:345–354. [PubMed] [Google Scholar]

20. Sokalska A, Timmerman D, Testa AC, et al. Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses. Ultrasound Obstet Gynecol. 2009;34:462–470. [PubMed] [Google Scholar]

21. Valentin L, Ameye L, Savelli L, et al. Adnexal masses difficult to classify as benign or malignant using subjective assessment of gray scale and Doppler ultrasound findings: logistic regression models do not help. Ultrasound Obstet Gynecol. 2011;38:456–465. [PubMed] [Google Scholar]

22. Nezhat FR, Pejovic T, Finger TN, Khalil SS. Role of minimally invasive surgery in ovarian cancer. J Minim Invasive Gynecol. 2013;20:754–765. [PubMed] [Google Scholar]

23. Romano F, Rizzo M, Stabile G, et al. Laparoscopic and laparotomic guided ureteral stenting during gynecological surgery without use of imaging: Safety and feasibility in a single institutional case series. Eur J Obstet Gynecol Reprod Biol. 2020;251:125–128. [PubMed] [Google Scholar]

24. Ditto F, Martinelli D, Lorusso D, et al. Fertility sparing surgery in early stage epithelial ovarian cancer. J Gynecol Oncol. 2014;25:320–327. [PMC free article] [PubMed] [Google Scholar]

25. Stabile G, Zinicola G, Romano F, Buonomo F, Mangino FP, Ricci G. Management of non-tubal ectopic pregnancies: a single center experience. Diagnostics (Basel) 2020;10:652. [PMC free article] [PubMed] [Google Scholar]

26. Macciò C, Madeddu P, Kotsonis P, et al. Large twisted ovarian fibroma associated with Meigs’ syndrome, abdominal pain and severe anemia treated by laparoscopic surgery. BMC Surg. 2014:14:38. [PMC free article] [PubMed] [Google Scholar]

Ascites: diagnosis and treatment

Ascites is an abnormal accumulation of fluid in the abdominal cavity. Among patients with ascites, the majority suffer from cirrhosis and portal hypertension. Ascites associated with malignant neoplasms is much less common: in about 7% of patients. Some patients have two causes of ascites at once – for example, cirrhosis and peritoneal carcinomatosis (multiple metastases in the peritoneum).

Why does ascites develop?

Ascites associated with malignancy can be seen in many tumors, including malignancies of the ovary, breast, colon, lung, pancreas, and liver. Lymphoma can also be complicated by ascites.

Ascites usually develops in the setting of recurrent or advanced cancer. Before ascites develops, patients may have peritoneal or hepatic metastases, enlarged intra-abdominal lymph nodes, or large tumor volume

The origin of the primary tumor influences the development of ascites.

• Malignant tumors of the ovary and bladder, as well as peritoneal mesothelioma, usually cause peritoneal carcinomatosis. In such cases, fluid accumulation is the result of blockage of draining lymphatic channels and increased vascular permeability.

• Cancer of the colon, stomach, breast, pancreas, and lung can cause peritoneal carcinomatosis and/or massive liver metastases, resulting in ascites, either due to fluid-producing tumor cells in the abdomen due to obstruction/compression of the portal veins leading to portal hypertension, or liver failure.

• Lymphomas may cause lymph node obstruction with accumulation of ascites, or symptomatic serous effusions.

Ascites in liver tumors

Ascites in patients with liver disease is usually due to hepatocellular carcinoma rather than liver metastases. The development of ascites may be the first sign of primary hepatocellular carcinoma of the liver.

The four most common ascites associated with hepatocellular carcinoma of the liver:

• in patients with chronic hepatitis B acquired in infancy or childhood,

• in patients with non-alcoholic fatty liver disease,

• in patients with chronic hepatitis C,

• in patients with alcoholic cirrhosis.

Under these conditions, ascites often develops when the volume of the tumor increases to such an extent that it replaces a critical part of the functional mass of the liver or leads to thrombosis of the portal vein.

Symptoms of ascites

Patients often seek medical attention because of abdominal pain, shortness of breath or early satiety, often swelling of the legs develops. Abdominal pain can be caused by a combination of factors, including nerve invasion by the tumor, distension of the liver capsule, or, in patients with large ascites, distension of the abdominal wall. Since ascites usually develops in the setting of a large tumor mass, patients usually lose weight before ascites develops (despite the added weight from the ascitic fluid itself).

Diagnosis of ascites

Diagnosis of ascites associated with malignancy is based on clinical presentation, imaging, puncture, and analysis of ascitic fluid.

Established cancer patients who develop ascites often do not require extensive evaluation. Since the development of ascites associated with malignancy is a poor prognostic sign, the diagnostic approach should focus on the rapid assessment and evacuation of ascites, with treatment aimed at improving the patient’s quality of life. On the other hand, the presence of ascites in a woman with epithelial ovarian cancer is not necessarily associated with a very poor prognosis.

Physical examination provides a rough estimate of the level of ascites accumulation. Patients with suspected malignant ascites should be examined to confirm the presence of ascites. The examination begins with an ultrasound of the abdominal organs, if necessary, a CT or MRI examination of the abdominal organs is connected.

Laparocentesis (puncture of the peritoneal wall) with the appropriate analysis of ascitic fluid is the most effective way to confirm the presence of ascites, diagnose its cause and determine if the fluid is infected and contains malignant cells.

Treatment of ascites

The main treatment for peritoneal carcinomatosis is therapeutic laparocentesis (evacuation of fluid from the abdominal cavity). The exception is ascites in ovarian cancer. For patients who cannot tolerate repetitive laparocentesis, peritoneal ports and catheters may be recommended. Patients with portal hypertension (those with massive liver metastases, cirrhosis with hepatocellular carcinoma, or malignant Budd-Chiari syndrome) may be given diuretics (drugs that increase urine output).

In patients with ascites from ovarian cancer, treatment options include cytoreductive surgery (removal of as much of the tumor and metastases as possible) and chemotherapy.

EMC Institute of Oncology, Moscow, st. Shchepkin, provides comprehensive care to patients with ascites according to modern international standards. Ascites can be evacuated both in a hospital and on an outpatient basis. Sometimes, in difficult cases, with poor tolerance of manipulation or at will, the patient can be hospitalized.

Hospitalization in EMC can be emergency – 24 hours a day, surgeons on duty are ready to assist in the evacuation of ascites.

causes and diagnosis, pelvic ultrasound

Sometimes, after an ultrasound examination, the doctor makes a note that the patient has fluid in the pelvis. In some cases, the presence of free fluid does not indicate any disease. This may indicate that the woman has ended ovulation, and after a while there will be no more fluid.

Unfortunately, more often the fluid in the pelvis indicates the development of pathology in the female genital organs. You can determine the disease after the procedure of ultrasound examination. The patient may feel some symptoms indicating the onset of the development of the disease. This is an increased body temperature, pulling or sharp pains in the lower abdomen, menstrual cycle failure.

Causes of fluid in the pelvis

Fluid accumulates in the pelvic region from the organ in which the pathology develops and the inflammatory process begins. Also, fluid may appear after an abortion. To find the cause of the disease, it is necessary to undergo an ultrasound of the pelvis. What diseases can be indicated by the presence of fluid in the pelvis.

• Endometriosis.

• Infectious disease leading to inflammation of the ovaries or uterus.

• Ascites. This is the accumulation of fluid caused by a malignant tumor.

• Ectopic pregnancy.

• Internal bleeding in the abdomen.

• Benign formation on the internal genital organs.

Before starting treatment, it is necessary to identify the affected organ and the cause of the inflammatory process. Only after an accurate diagnosis is made can treatment begin.

Treatment

After diagnosing fluid in the pelvis and identifying the affected organ, it is necessary to prescribe an effective treatment. It will be individual for each patient. As a rule, they begin with drug therapy. Most often prescribed:

• Antibiotics. They are used when there is an infection in the body. Thanks to them, the inflammatory process passes, which often causes the appearance of fluid in the pelvic area.

• Painkillers and anti-inflammatory drugs. Relieve inflammation and pain.

• Hormonal preparations. They are prescribed for violation of the menstrual cycle, as well as for diseases of the ovaries.

• Enzymes. Help fight inflammation.

• Vitamin complexes. Strengthen the immune system and the overall resistance of the body to infections.

All drugs should be taken strictly according to the doctor’s prescription, based on the diagnosis and taking into account contraindications, individual intolerance.

Prevention of fluid accumulation in the pelvis

Fluid in the small pelvis accumulates due to a disease of the internal organs of the small pelvis. Therefore, in order to avoid problems with the health of female internal genital organs, it is necessary to take preventive measures.

The main thing that women need to do is to lead a healthy lifestyle. Do not drink alcohol and do not smoke, these addictions adversely affect women’s health.