Ascites

Ascites is term for an accumulation of fluid in the peritoneal cavity (space between the tissues lining the abdomen and abdominal organs). The condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy

Causes The Serum-ascites albumin gradient (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites Causes of high SAAG ("transudate") are:
[3]

Cirrhosis - 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%)

The two most important factors in the production of ascites due to chronic liver disease are:

Low levels of albumin in the blood that cause a change in the pressure necessary to prevent fluid exchange (osmotic pressure). This change in pressure allows fluid to seep out of the blood vessels. An increase in the pressure within the branches of the portal vein that run through liver (portal hypertension). Portal hypertension is caused by the scarring that occurs in cirrhosis. Blood that cannot flow through the liver because of the increased pressure leaks into the abdomen and causes ascites.

Heart failure - 3% Hepatic Venous occlusion: Budd-Chiari syndrome or veno-occlusive disease Constrictive pericarditis Kwashiorkor

Causes of low SAAG ("exudate") are: Cancer (primary peritoneal carcinomatosis and metastasis) - 10% Infection: Tuberculosis - 2% or Spontaneous bacterial peritonitis Pancreatitis - 1% Serositis Nephrotic syndrome or Protein losing enteropathy

Hereditary angioedema

[5]

Ovarian cancer, endometrial cancer Pancreatitis Pancreatic cancer Protein-losing enteropathy Kidney dialysis may also be associated with ascites

Other Rare causes: Meigs syndrome Vasculitis Hypothyroidism Renal Dialysis Peritoneum Mesothelioma

Types Types of ascites Cirrhosis, which is responsible for 80% of all instances of ascities , triggers a series of diseaseproducing changes that weaken the kidney's ability to excrete sodium in the urine. Pancreatic ascites develops when a cyst that has thick, fibrous walls (pseudocyst) bursts and permits pancreatic juices to enter the abdominal cavity. Chylous ascites has a milky appearance caused by lymph that has leaked into the abdominal cavity.. Cancer causes 10% of all instances of ascites . It is most commonly a consequence of disease that originates in the peritoneum (peritoneal carcinomatosis) or of cancer that spreads (metastasizes) from another part of the body. Endocrine and renal ascites are rare disorders. Endocrine ascites, sometimes a symptom of an endocrine system disorder, also affects women who are taking fertility drugs. Renal ascites develops when blood levels of albumin dip below normal. Albumin is the major protein in blood plasma. It functions to keep fluid inside the blood vessels
.

Signs and Symptoms Mild ascites is hard to notice, but severe ascites leads to abdominal distension. Patients with ascites generally will complain of progressive abdominal heaviness and pressure as well as shortness of breath due to mechanical impingement on the diaphragm. in portal hypertension (perhaps due to cirrhosis or fibrosis of the liver) patients may also complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy. Those with ascites due tocancer (peritoneal carcinomatosis) may complain of chronic fatigue or weight loss Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance.\

A person with ascites usually has severe liver disease. Ascites due to liver disease is caused by high pressure in the blood vessels of the liver (portal hypertension) and low albumin levels.

Differential Diagnosis Chrinic liver disease Right sided heart failure Nephrotic syndrome Hypo protienemia Portal hyoer tension

Examination
Ascites is detected on physical examination of the abdomen by visible bulging of the flanks in the reclining patient ("flank bulging"), "shifting dullness" (difference in percussion note in the flanks that shifts when the patient is turned on the side) In massive ascites with a "fluid thrill" or "fluid wave" (tapping or pushing on one side will generate a wavelike effect through the fluid that can be felt in the opposite side of the abdomen).

Investigations

24-hour urine collection Creatinine and electrolytes Kidney function tests Liver enzyme, bilirubin, coagulation, and serum protein tests Urinalysis

Paracentesis or abdominal tap may be performed. This procedure involves using a thin needle to pull fluid from the abdomen. The fluid is tested in various ways to determine the cause of ascites.