Ascites - Symptoms, Causes, Complications, Prevention and Treatment

Incidence of ascites

Ascites is the common complication of the cirrhotic patients, from the past ten years cirrhosis of liver with ascites is seen in 50% of the decompensated cirrhotic patients. Approximately 50% of cirrhotic patients will have a 3-year death rate. Intraperitoneal ascites fluid is seen in a very low concentration in males, whereas up to 20 ml is seen in females based on the menstrual cycle. Though ascites is a complication or symptom of other conditions, there are no accurate, trusted values regarding the incidence rates in the normal population. 

Ascites symptoms

Symptoms of ascites are indications that occur in the body; they might range from mild to severe and occur suddenly or gradually. However, there are some common ascites signs and symptoms, which include:

• Abdominal distension 
• Abdominal discomfort
• Swelling in the abdomen
• Feeling fullness with small amounts of food
• Shortness of breath 
• Flank and shifting dullness on physical examination
• Pleural effusion
• Fatigue 
• Bloating
• Indigestion and more

Symptoms of ascitic patients with bacterial peritonitis include:

• Fever 
• Tenderness on the abdomen 
• Confusion

Symptoms of malignant ascites include:

• Weight loss

Symptoms of chylous ascites include:

• Steatorrhea (fatty stools) 
• Diarrhoea (loose or watery stools) 
• Nausea
• Oedema (swelling due to fluid accumulation) 
• Night sweats 
• Lymphadenopathy (enlargement of lymph nodes) 
• Early satiety (unable to take full meals due to early fullness)
• Fever 

Ascites causes

The accumulation of fluid in the abdomen, or ascites, can indicate a few underlying medical disorders, even though it can seriously impair daily life. The exact cause of ascites plays a crucial role in getting proper treatment. The key mechanisms that could cause ascites are as follows:

• Increased portal pressure: Portal hypertension is the condition where the portal vein blood pressure increases. The portal vein is the vessel that carry the blood from the spleen, pancreas, and intestine to the liver. Blood flow becomes harder in the liver when it gets scarred, resulting in a back-up of blood pressure in the portal vein. Finally, this leads to increased fluid pressure in the liver and other organs of the abdomen and forces the fluid from the capillaries into the peritoneal cavity. 
• Sodium and water retention: Albumin is the protein that helps to manage the fluid in the bloodstream; if the liver gets damaged, it cannot produce enough albumin. Thus, it leads to low blood pressure and influences the kidneys to retain water and sodium in an attempt to compensate - these increased levels of sodium and water leak outside from the capillaries into the peritoneal cavity. 

Ascites is caused by the following factors, such as:

• Liver cirrhosis
• Heart failure
• Kidney failure
• Cancers and more 

Some of the main risk factors which contribute to the cause of ascites are explained in the section below.

Ascites risk factors

The main risk factors that contribute to the cause of ascites are explained in the section below. Usually, risk factors are the factors that raise the probability of contracting a specific illness or condition; they are not the same as causes but influence the events positively. Some of the risk factors for ascites include:

• Cirrhosis: Portal hypertension is the fundamental factor that causes ascites in liver cirrhosis patients. Portal hypertension causes splanchnic vasodilation and activates the renin-angiotensin-aldosterone system, resulting in renal sodium retention. 
• Cancers: The peritoneum may create excessive amounts of this fluid due to malignancy. The medical term for this is "malignant ascites". Cancer that has make progress to the lining of the abdominal organs is the cause of malignant ascites. Additionally, it may occur when liver cancer spreads.   
• Tuberculosis: TB causes inflammation of the peritoneum and causes fluid leakage out of the capillaries; in addition to this, it also increases the portal pressure. 
• Heart failure: Obstruction of venous flow is seen in heart failure, resulting in volume inflation and hydrostatic pressure. This condition leads to the filtration of the fluid into the peritoneal cavity. 
• Renal failure: Patients with end-stage renal disease or chronic kidney disease are found to have impaired resorption of peritoneal fluids inferior to the peritoneal lymphatic drainage obstruction. 
• Pancreatic diseases: Ascites caused by pancreatic injuries, pancreatitis or diseases is referred to as pancreatic ascites disease. This condition arises when pancreatic secretions are collected in the peritoneum due to a pancreatic injury. 
• Chronic alcohol use: Ascites is the most common complication of alcoholic liver disease, in which the accumulation of fluid takes place in the peritoneal cavity. The patient presents with abdominal distension and pedal oedema in this condition.   
• Hypercholesterolemia: Increased levels of ascitic cholesterol in peritoneal carcinomatosis are due to the movement of plasma HDL and LDL into the peritoneal cavity, resulting in ascites. 
• Obesity: Obesity is indirectly linked to the ascites, as any health issue that causes liver damage or scarring could develop the ascites. Obesity leads to fat buildup and causes fatty liver disease, which might lead to the development of ascites. 
• IV drug use: According to the studies, around 2% of the cases are due to IV drug usage, as these might develop hepatitis infections, which in turn lead to the development of ascites. 
• Ovarian lesions and ovarian cancer: When ovarian cancer is in its advanced stages, ascites may develop. Previous studies from 2013 found that 90.1% of study population with third stage ovarian cancer and 100% of those with fourth stage ovarian cancer had ascites. 
• Type–2 diabetes: Type 2 Diabetes could damage the blood vessels of the liver and might result in the development of portal hypertension, which causes ascites. 
• Nephrotic syndrome: Ascites in the majority of adult nephrotic syndrome patients can be linked to elevated hepatic sinusoidal pressure, liver disease, or congestive heart failure in addition to hypoalbuminemia. 
• Severe malnutrition: Chronic liver disease (CLD) is often associated with altered nutrient metabolism, nutritional requirements, and decreased dietary intake. These worsen the progression to decompensation and ascites.
  

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