Ascites Clinical Presentation

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

• Chronic viral hepatitis or jaundice

• Intravenous drug 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.

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

• 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.

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

• Familial Mediterranean fever

• Vasculitis

• Granulomatous peritonitis

• Eosinophilic peritonitis

The most common complication of ascites is the development of spontaneous bacterial peritonitis (ascitic fluid with PMN count of >250 μ L). Note the following:

• Performing repeated physical examinations and paying particular attention to abdominal tenderness may be the best way to become aware of the possible development of this complication. In a study of 133 hospitalized patients with ascites, abdominal pain and abdominal tenderness were more common in patients with spontaneous bacterial peritonitis (P< 0.01), but no other physical sign or laboratory test could separate spontaneous bacterial peritonitis cases from other cases. ^[4]

• Any patient with ascites and fever should have a paracentesis with bedside blood culture inoculation and cell count. Patients with a protein level of less than 1 g/dL in ascitic fluid are at high risk for the development of spontaneous bacterial peritonitis. Prophylactic antibiotic therapy with a quinolone is often recommended.

Complications of paracentesis include infection, electrolyte imbalances, bleeding, and bowel perforation. Bowel perforation should be considered in any patient with recent paracentesis who develops a new onset of fever and/or abdominal pain. All patients with long-standing ascites are at risk of developing umbilical hernias. Large-volume paracentesis often results in large intravascular fluid shifts. This can be avoided by administering albumin replacement if more than 5 L is removed.

Acute kidney injury in the setting of ascites and cirrhosis is a medical emergency, requiring prompt diagnosis and multimodal management. ^[5]