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Ascites Clinical Presentation

  • Author: Rahil Shah, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Jan 03, 2016
 

History

Patients with ascites often state that they have recently noticed an increase in their abdominal girth.

Because most cases of ascites are due to liver disease, patients with ascites should be asked about risk factors for liver disease. These include the following:

  • Long-term heavy alcohol use
  • Multiple sexual partners
  • Homosexual activity with a male partner, or heterosexual activity with a bisexual male
  • Transfusion with blood not tested for hepatitis virus: in the United States, screening of donated blood for hepatitis B virus (HBV) began in 1972; reliable testing of the blood supply for hepatitis C virus (HCV) began in 1992 in developed countries
  • Tattoos
  • Living or birth in an area endemic for hepatitis

Patients with alcoholic liver disease who alternate between heavy alcohol consumption and abstention (or light consumption) may experience ascites in a cyclic fashion.

When a patient with a very long history of stable cirrhosis develops ascites, the possibility of superimposed hepatocellular carcinoma (HCC) should be considered.

Obesity, hypercholesterolemia, and type 2 diabetes mellitus are recognized causes of nonalcoholic steatohepatitis, which can progress to cirrhosis.

Patients with a history of cancer, especially gastrointestinal cancer, are at risk for malignant ascites. Malignancy-related ascites is frequently painful, whereas cirrhotic ascites is usually painless.

Patients who develop ascites in the setting of established diabetes or nephrotic syndrome may have nephrotic ascites.

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Physical

The physical examination in a patient with ascites should focus on the signs of portal hypertension and chronic liver disease.

  • Physical findings suggestive of liver disease include jaundice, palmar erythema, and spider angiomas.
  • The liver may be difficult to palpate if a large amount of ascites is present, but if palpable, the liver is often found to be enlarged. The puddle sign may be present when as little as 120 mL of fluid is present. When peritoneal fluid exceeds 500 mL, ascites may be demonstrated by the presence of shifting dullness or bulging flanks. A fluid-wave sign is notoriously inaccurate.
  • Elevated jugular venous pressure may suggest a cardiac origin of ascites. A firm nodule in the umbilicus, the so-called Sister Mary Joseph nodule, is not common but suggests peritoneal carcinomatosis originating from gastric, pancreatic, or hepatic primary malignancy.
  • A pathologic left-sided supraclavicular node (Virchow node) suggests the presence of upper abdominal malignancy.
  • Patients with cardiac disease or nephrotic syndrome may have anasarca.
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Causes

Normal peritoneum

Portal hypertension (serum-ascites albumin gradient [SAAG] >1.1 g/dL)

  • Hepatic congestion, congestive heart failure, constrictive pericarditis, tricuspid insufficiency, Budd-Chiari syndrome
  • Liver disease, cirrhosis, alcoholic hepatitis, fulminant hepatic failure, massive hepatic metastases

Hypoalbuminemia (SAAG <1.1 g/dL)

  • Nephrotic syndrome
  • Protein-losing enteropathy
  • Severe malnutrition with anasarca

Miscellaneous conditions (SAAG <1.1 g/dL)

  • Chylous ascites (11%) [3] : The extent of abdominal surgery is the main predictor for the risk of chylous ascites
  • Pancreatic ascites
  • Bile ascites
  • Nephrogenic ascites
  • Urine ascites
  • Ovarian disease

Diseased peritoneum (SAAG < 1.1 g/dL)

Infections

  • Bacterial peritonitis
  • Tuberculous peritonitis
  • Fungal peritonitis
  • Human immunodeficiency virus (HIV)-associated peritonitis

Malignant conditions

  • Peritoneal carcinomatosis
  • Primary mesothelioma
  • Pseudomyxoma peritonei
  • Hepatocellular carcinoma

Other rare conditions

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Contributor Information and Disclosures
Author

Rahil Shah, MD Consulting Staff, Lebanon Endoscopy Center

Rahil Shah, MD is a member of the following medical societies: American College of Gastroenterology, American Society for Gastrointestinal Endoscopy

Disclosure: Received consulting fee from Takeda for speaking and teaching.

Coauthor(s)

Janice M Fields, MD, FACG, FACP Assistant Professor of Internal Medicine, Oakland University William Beaumont School of Medicine; Consulting Staff, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital, St John Macomb-Oakland Hosptial

Janice M Fields, MD, FACG, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Robert J Fingerote, MD, MSc, FRCPC Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Ontario

Robert J Fingerote, MD, MSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Association

Disclosure: Nothing to disclose.

References
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  2. Fede G, D'Amico G, Arvaniti V, Tsochatzis E, Germani G, Georgiadis D, et al. Renal failure and cirrhosis: a systematic review of mortality and prognosis. J Hepatol. 2011 Dec 12. [Medline].

  3. Weniger M, D'Haese JG, Angele MK, Kleespies A, Werner J, Hartwig W. Treatment options for chylous ascites after major abdominal surgery: a systematic review. Am J Surg. 2016 Jan. 211 (1):206-13. [Medline].

  4. Han CM, Lee CL, Huang KG, et al. Diagnostic laparoscopy in ascites of unknown origin: Chang Gung Memorial Hospital 20-year experience. Chang Gung Med J. 2008 Jul-Aug. 31(4):378-83. [Medline]. [Full Text].

  5. Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results?. JAMA. 2008 Mar 12. 299(10):1166-78. [Medline].

  6. [Guideline] Runyon BA, American Association for the Study of Liver Diseases. Management of adult patients with ascites due to cirrhosis: update 2012. National Guideline Clearinghouse. Available at http://guideline.gov/content.aspx?id=45103&search=ascites. Accessed: Nov 6, 2014.

  7. Gines P, Cardenas A. The management of ascites and hyponatremia in cirrhosis. Semin Liver Dis. 2008 Feb. 28(1):43-58. [Medline].

  8. Ginès P, Wong F, Watson H, et al, for the HypoCAT Study Investigators. Effects of satavaptan, a selective vasopressin V(2) receptor antagonist, on ascites and serum sodium in cirrhosis with hyponatremia: a randomized trial. Hepatology. 2008 Jul. 48(1):204-13. [Medline].

  9. Bellot P, Welker MW, Soriano G, von Schaewen M, Appenrodt B, Wiest R, et al. Automated low flow pump system for the treatment of refractory ascites: a multi-center safety and efficacy study. J Hepatol. 2013 May. 58(5):922-7. [Medline].

  10. Sola-Vera J, Minana J, Ricart E, et al. Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites. Hepatology. 2003 May. 37(5):1147-53. [Medline]. [Full Text].

  11. Lata J, Marecek Z, Fejfar T, Zdenek P, et al. The efficacy of terlipressin in comparison with albumin in the prevention of circulatory changes after the paracentesis of tense ascites--a randomized multicentric study. Hepatogastroenterology. 2007 Oct-Nov. 54(79):1930-3. [Medline].

  12. Singh V, Kumar R, Nain CK, Singh B, Sharma AK. Terlipressin versus albumin in paracentesis-induced circulatory dysfunction in cirrhosis: a randomized study. J Gastroenterol Hepatol. 2006 Jan. 21(1 pt 2):303-7. [Medline].

  13. Mercadante S, Intravaia G, Ferrera P, Villari P, David F. Peritoneal catheter for continuous drainage of ascites in advanced cancer patients. Support Care Cancer. 2008 Aug. 16(8):975-8. [Medline].

  14. Courtney A, Nemcek AA Jr, Rosenberg S, et al. Prospective evaluation of the PleurX catheter when used to treat recurrent ascites associated with malignancy. J Vasc Interv Radiol. 2008 Dec. 19(12):1723-31. [Medline].

  15. Sorrentino P, Castaldo G, Tarantino L, Bracigliano A, Perrella A, Perrella O, et al. Preservation of Nutritional-status in Patients with Refractory Ascites due to Hepatic Cirrhosis who are Undergoing Repeated Paracentesis. J Gastroenterol Hepatol. 2011 Dec 6. [Medline].

  16. Guo TT, Yang Y, Song Y, Ren Y, Liu ZX, Cheng G. Effects of midodrine for patients with ascites due to cirrhosis: systematic review with meta-analysis. J Dig Dis. 2015 Dec 2. [Medline].

  17. Seike M, Maetani I, Sakai Y. Treatment of malignant ascites in patients with advanced cancer: peritoneovenous shunt versus paracentesis. J Gastroenterol Hepatol. 2007 Dec. 22(12):2161-6. [Medline].

  18. Wallerstedt S, Olsson R, Simren M, et al. Abdominal tenderness in ascites patients indicates spontaneous bacterial peritonitis. Eur J Intern Med. 2007 Jan. 18(1):44-7. [Medline].

  19. Tapper EB, Bonder A, Cardenas A. Preventing and treating acute kidney injury among hospitalized patients with cirrhosis and ascites: a narrative review. Am J Med. 2015 Dec 24. [Medline].

 
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This computed tomography scan demonstrates free intraperitoneal fluid due to urinary ascites.
Peritoneovenous shunt.
Massive ascites.
 
 
 
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