Ascites is a pathologic collection of fluid in the peritoneal cavity. The most common cause is cirrhosis, which accounts for approximately 75% of cases, followed by congestive heart failure and malignant ascites.[1]
Summary
Clinical features
Patients present with abdominal distension; fluid may be detected on physical examination with shifting dullness. Ultrasound, computed tomography scan, or magnetic resonance imaging can confirm the diagnosis. In the majority of patients, history and examination will provide important clues as to the etiology of ascites (e.g., signs of chronic liver disease or cardiac failure). Causes include diseases that lead to portal hypertension, hypoalbuminemia, and neoplasms.
Cirrhosis
In 2017, cirrhosis caused more than 1.32 million deaths globally.[2] Deaths due to cirrhosis constituted 2.4% of total deaths globally in 2017 compared with 1.9% in 1990.[2] Chronic liver disease and cirrhosis account for approximately 2 million deaths annually worldwide.[3]
In cirrhosis, development of hepatic fibrosis from chronic, recurrent hepatocyte injury leads to disruption in the intrahepatic circulation. This causes increased hepatic resistance to portal flow, resulting in the development of portal hypertension, and subsequent collateral vein formation and shunting of blood to the systemic circulation.[4]
Ascites forms due to both renal dysfunction and the abnormalities in the portal and splanchnic circulation.[4] [5] The chronic hepatic injury results in the release of nitric oxide, promoting splanchnic arterial vasodilation. This vasodilation causes activation of the renin angiotensin system, sympathetic nervous system, and antidiuretic hormone (ADH), to mitigate low circulatory volume. Release of ADH leads to retention of both sodium and water, resulting in the formation of ascites.[6] Dilutional hyponatremia, arising from impaired renal excretion of free water, is a marker of more advanced liver disease.[1] [7]
Other causes
Other causes of portal hypertension that may be associated with ascites include congestive heart failure, constrictive pericarditis, alcohol-related liver disease, fulminant hepatitis, subacute hepatitis, massive liver metastasis, and Budd-Chiari syndrome.
Conditions causing hypoalbuminemia such as nephrotic syndrome and protein-losing enteropathy may result in ascites. Peritoneal diseases including infectious peritonitis and malignancies can also cause ascites.
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Citations
Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Aug;74(2):1014-48.[Abstract][Full Text]
Aithal GP, Palaniyappan N, China L, et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021 Jan;70(1):9-29.[Abstract][Full Text]
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53(3):397-417[Full Text]
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