Section 10. Liver and Gallbladder Disorders

Chapter 135. Clinical Manifestations of Liver Disease

Topics: Introduction | Jaundice | Cholestasis | Liver Enlargement | Portal Hypertension | Ascites | Liver Encephalopathy | Liver Failure

Ascites

Ascites is the accumulation of protein-containing (ascitic) fluid in the abdominal cavity.

Ascites tends to occur in long-standing (chronic) rather than in short-lived (acute) disorders. It occurs most commonly in cirrhosis (severe scarring of the liver), especially in cirrhosis caused by alcoholism. Other liver disorders in which ascites may occur include alcoholic hepatitis without cirrhosis, chronic hepatitis, and obstruction of the hepatic vein. Ascites can also occur in nonliver diseases, such as cancer, heart failure, kidney failure, inflammation of the pancreas (pancreatitis), and tuberculosis affecting the lining of the abdominal cavity.

In people with liver disease, ascitic fluid leaks from the surface of the liver and intestine. A combination of factors is responsible, including portal hypertension, decreased ability of the blood vessels to retain fluid, fluid retention by the kidneys, and alterations in various hormones and chemicals that regulate bodily fluids.

Symptoms and Diagnosis

Small amounts of fluid in the abdomen usually produce no symptoms, but massive amounts may cause abdominal expansion (distention) and discomfort. Pressure on the stomach from the swollen abdomen may lead to loss of appetite, and pressure on the lungs may lead to shortness of breath. When a doctor taps (percusses) the abdomen, the fluid makes a dull sound. When the abdomen contains large amounts of fluid, the abdomen is taut, and the navel is flat or even pushed out. In some people with ascites, the ankles swell with excess fluid (edema).

If the presence of ascites or its cause is not clear, the doctor may use ultrasound scanning. In addition, a small sample of ascitic fluid can be withdrawn by inserting a needle through the abdominal wall--a procedure called diagnostic paracentesis (see Section 9, Chapter 119). Laboratory analysis of the fluid can help determine the cause.

Treatment

The basic treatment for ascites is bed rest and a salt-restricted diet, usually combined with drugs called diuretics, which make the kidneys excrete more water into the urine. If ascites makes breathing or eating difficult, the fluid may be removed through a needle--a procedure called therapeutic paracentesis. The fluid tends to reaccumulate unless the person also takes a diuretic. Because a large amount of albumin (the major protein in plasma) is usually lost from the blood into the abdominal fluid, albumin may be administered intravenously.

An infection called spontaneous bacterial peritonitis occasionally develops in ascitic fluid for no apparent reason, especially in people with alcoholic cirrhosis. Untreated, this infection can be fatal. Survival depends on early vigorous treatment with antibiotics.