Ascites

Last updated: September 26, 2022

Summarytoggle arrow icon

Ascites is the abnormal accumulation of fluid within the peritoneal cavity and is a common complication of portal hypertension (e.g., due to liver cirrhosis, acute liver failure) and/or hypoalbuminemia (e.g., due to nephrotic syndrome). Other conditions resulting in ascites include chronic heart failure, inflammation of abdominal viscera (e.g., pancreatitis), and malignancies. Clinical features include progressive abdominal distention, shifting dullness, and a positive fluid wave test. Abdominal pain may be present in ascites due to acute inflammation. Diagnostics are aimed at identifying the underlying etiology and determining whether the ascitic fluid is infected. They include imaging (e.g., with abdominal ultrasound or CT abdomen and pelvis), which is used to identify free intraperitoneal fluid and possibly the underlying cause, and diagnostic paracentesis with ascitic fluid analysis. The serum-ascites albumin gradient (SAAG), or the difference between albumin levels in serum and ascitic fluid, is essential to determine the underlying cause. A high SAAG indicates that the ascites is secondary to portal hypertension. An ascitic fluid neutrophil count ≥ 250 cells/mm3 indicates spontaneous bacterial peritonitis (SBP), which should be urgently managed with empiric antibiotic therapy. Management of ascites involves identifying and managing the underlying cause as well as dietary sodium restriction and diuretic therapy. Additionally, tense ascites and refractory ascites require therapeutic paracentesis. Liver transplant is a treatment option for patients with cirrhosis who develop ascites. Transjugular intrahepatic portosystemic shunts (TIPS) and peritoneovenous shunts are advanced treatment options for refractory ascites, which carries a high risk of mortality.

  • The etiology can be determined using the serum-ascites albumin gradient (SAAG) based on Starling's law.
  • SAAG = (albumin levels in serum) - (albumin levels in ascitic fluid)
Etiology Pathophysiology

High SAAG ascites

≥ 1.1 g/dL (obsolete term: transudate)

Low SAAG ascites

< 1.1 g/dL (obsolete term: exudate)

  • Production of protein-rich fluid from tubercles

Remember, exudative ascitic fluid is high in protein, like eggs.

References:[1][2][3]

References:[2]

Chylous ascites

Bloody ascites

Diagnostics are used to confirm the presence of ascites, assess its severity, determine the underlying etiology, and evaluate for complications. [5]

Imaging [6][7]

Abdominal ultrasound with Doppler (initial study of choice)

CT abdomen and pelvis [5]

  • Indications: to work up for the underlying cause as needed; examples include [5][8]
  • Findings

Laboratory studies [6]

The choice of laboratory studies should be guided by the pretest probability of the suspected underlying etiology.

Diagnostic paracentesis

For further information on this procedure, see “Paracentesis.”

Indications

Occult SBP is common in patients with ascites and cirrhosis and delays in diagnosis result in increased mortality. [13]

Ascitic fluid analysis [5][6][11]

Routine studies

Differential diagnoses of ascites based on SAAG and ascitic fluid total protein [5]
Ascites due to portal hypertension Ascites due to other causes
SAAG
  • ≥ 1.1 g/dL
  • < 1.1 g/dL

Ascitic fluid total protein levels

Additional studies (based on the pretest probability of the underlying etiology)

The International Ascites Club classifies the severity classification of ascites as follows: [2]

  • Mild ascites (grade 1): ascites only detectable by ultrasound
  • Moderate ascites (grade 2): moderate abdominal distention
  • Large ascites (grade 3): marked abdominal distention

Approach [5][6][11]

Obtain hepatology consult for patients with new-onset ascites and known or suspected liver disease.

Medical and supportive therapy [6][11][17]

This section details the management of ascites due to cirrhosis. Medical and/or supportive management of other causes of ascites (e.g., heart failure, nephrotic syndrome, peritoneal carcinomatosis, tuberculosis) are outlined in the respective articles for these conditions.

Salt and fluid restriction

  • Dietary sodium restriction: 2 g/day or 88 mEq/d (2 g of sodium = 5 g of salt)
    • Recommended for all patients
    • Advise patients to restrict the amount of salt in home-cooked meals and to avoid precooked and prepackaged food.
    • Consider referral to a nutritionist for counseling.
  • Fluid restriction: 1 L/day (only if serum Na+ < 125 mEq/L)

Diuretics

Combination diuretic therapy is associated with more rapid ascites reduction and a lower risk of potassium imbalance than monotherapy. [8][17]

Diuretics should be used with caution in patients with severe hyponatremia, hepatic encephalopathy, and/or renal function deterioration.

Empiric antibiotic therapy [6][11]

Antibiotic therapy for patients with cirrhosis and ascites is recommended in the following situations:

Monitoring [6][17]

  • Monitor weight, blood pressure, nutritional status, serum electrolytes, and renal function.
  • Goals of diuretic therapy
    • Patients without peripheral edema: weight loss of up to 0.5 kg/day
    • Patients with significant peripheral edema
      • Maximum recommended weight reduction: 1 kg/day
      • Once edema has resolved, daily weight loss should not exceed 0.5 kg/day
  • Discontinue or adjust the dosage of diuretics if adverse effects develop (e.g., hyponatremia, hyperkalemia, renal dysfunction).

Therapeutic paracentesis [6][17][18]

Therapeutic paracentesis may be performed for symptom relief. Paracentesis is also a diagnostic procedure (see “Diagnostic paracentesis”).

Clotting factors (e.g., fresh frozen plasma) and/or platelets are not routinely recommended before paracentesis in patients with INR > 1.5 or platelets < 50 cells/mm3, as procedure-related hemorrhage is uncommon. [6][17]

Consider performing paracentesis under ultrasound guidance to reduce the risk of serious complications and improve success rates. See “FAST” for basic principles of abdominal ultrasound. [19]

Management of refractory ascites [6][17][22]

Ascites is considered refractory if it does not respond to treatment or recurs after therapeutic paracentesis despite dietary sodium restriction and high-dose diuretic therapy. The following recommendations apply to refractory ascites in patients with cirrhosis.

Half of all patients with cirrhosis who develop refractory ascites die within a year. Do not delay referral for surgical management. [6]

We list the most important complications. The selection is not exhaustive.

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

  1. Cárdenas A, Gelrud A, Chopra S. Chylous, bloody, and pancreatic ascites. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/chylous-bloody-and-pancreatic-ascites.Last updated: December 15, 2015. Accessed: March 20, 2017.
  2. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  3. Moore KP, Wong F, Gines P, et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology. 2003; 38 (1): p.258-266. doi: 10.1053/jhep.2003.50315 . | Open in Read by QxMD
  4. Cabral FC, Krajewski KM, Kim KW, Ramaiya NH, Jagannathan JP. Peritoneal lymphomatosis: CT and PET/CT findings and how to differentiate between carcinomatosis and sarcomatosis. Cancer Imaging. 2013; 13 : p.162-170. doi: 10.1102/1470-7330.2013.0018 . | Open in Read by QxMD
  5. Lai M. Budd-Chiari syndrome: Epidemiology, clinical manifestations, and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/budd-chiari-syndrome-epidemiology-clinical-manifestations-and-diagnosis?source=see_link§ionName=CLINICAL+MANIFESTATIONS&anchor=H2#H2.Last updated: November 2, 2016. Accessed: February 12, 2017.
  6. Such J, Runyon BA. Pathogenesis of ascites in patients with cirrhosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/pathogenesis-of-ascites-in-patients-with-cirrhosis?source=see_link.Last updated: December 16, 2015. Accessed: February 12, 2017.
  7. Runyon BA. Malignancy-related ascites. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/malignancy-related-ascites?source=see_link§ionName=ETIOLOGY+AND+PATHOGENESIS&anchor=H2#H2.Last updated: December 9, 2016. Accessed: February 12, 2017.
  8. Hernaez R, Hamilton JP. Unexplained ascites.. Clinical liver disease. 2016; 7 (3): p.53-56. doi: 10.1002/cld.537 . | Open in Read by QxMD
  9. Runyon BA. Evaluation of adults with ascites. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/evaluation-of-adults-with-ascites#H25272225.Last updated: April 22, 2015. Accessed: February 12, 2017.
  10. Ascites. http://www.medbullets.com/step2-3-gastrointestinal/21668/ascites. Updated: April 11, 2016. Accessed: February 12, 2017.
  11. Hou W, Sanyal AJ. Ascites: Diagnosis and Management. Med Clin North Am. 2009; 93 (4): p.801-817. doi: 10.1016/j.mcna.2009.03.007 . | Open in Read by QxMD
  12. 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; 74 (2): p.1014-1048. doi: 10.1002/hep.31884 . | Open in Read by QxMD
  13. Rudralingam V, Footitt C, Layton B. Ascites matters. Ultrasound. 2016; 25 (2): p.69-79. doi: 10.1177/1742271x16680653 . | Open in Read by QxMD
  14. Runyon BA. American Association for the Study of Liver Disease (AASLD) Practice Guideline: Management of Adult Patients with Ascites Due to Cirrhosis, Update 2012. undefined. 2012 . doi: 10.1002/hep.00000 . | Open in Read by QxMD
  15. Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. 2015; 64 (4): p.531-7. doi: 10.1136/gutjnl-2014-308874 . | Open in Read by QxMD
  16. Ginès P, Cárdenas A, Arroyo V, Rodés J. Management of Cirrhosis and Ascites. N Engl J Med. 2004; 350 (16): p.1646-1654. doi: 10.1056/nejmra035021 . | Open in Read by QxMD
  17. Aithal GP, Palaniyappan N, China L, et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021; 70 (1): p.9-29. doi: 10.1136/gutjnl-2020-321790 . | Open in Read by QxMD
  18. Liaskou E, Hirschfield GM. Cirrhosis-associated immune dysfunction: Novel insights in impaired adaptive immunity. EBioMedicine. 2019; 50 : p.3-4. doi: 10.1016/j.ebiom.2019.10.056 . | Open in Read by QxMD
  19. Kim JJ, Tsukamoto MM, Mathur AK, et al. Delayed Paracentesis Is Associated With Increased In-Hospital Mortality in Patients With Spontaneous Bacterial Peritonitis. Am J Gastroenterol. 2014; 109 (9): p.1436-1442. doi: 10.1038/ajg.2014.212 . | Open in Read by QxMD
  20. Runyon BA. Patients with deficient ascitic fluid opsonic activity are predisposed to spontaneous bacterial peritonitis. Hepatology. 1988; 8 (3): p.632-635. doi: 10.1002/hep.1840080332 . | Open in Read by QxMD
  21. Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic approach and current management of chylous ascites. Aliment Pharmacol Ther. 2017; 46 (9): p.816-824. doi: 10.1111/apt.14284 . | Open in Read by QxMD
  22. Runyon BA. Amylase Levels in Ascitic Fluid. J Clin Gastroenterol. 1987; 9 (2): p.172-174. doi: 10.1097/00004836-198704000-00012 . | Open in Read by QxMD
  23. Angeli P, Bernardi M, Villanueva C, et al. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018; 69 (2): p.406-460. doi: 10.1016/j.jhep.2018.03.024 . | Open in Read by QxMD
  24. Thomsen TW, Shaffer RW, White B, Setnik GS. Paracentesis. N Engl J Med. 2006; 355 (19): p.e21. doi: 10.1056/nejmvcm062234 . | Open in Read by QxMD
  25. Cho J, Jensen TP, Reierson K, et al. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019; 14 (1). doi: 10.12788/jhm.3095 . | Open in Read by QxMD
  26. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  27. Sola-Vera J. Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites. Hepatology. 2003; 37 (5): p.1147-1153. doi: 10.1053/jhep.2003.50169 . | Open in Read by QxMD
  28. Khungar V, Saab S. Cirrhosis With Refractory Ascites: Serial Large Volume Paracentesis, TIPS, or Transplantation?. Clinical Gastroenterology and Hepatology. 2011; 9 (11): p.931-935. doi: 10.1016/j.cgh.2011.04.028 . | Open in Read by QxMD
  29. Yan L, Xie F, Lu J, et al. The treatment of vasopressin V2-receptor antagonists in cirrhosis patients with ascites: a meta-analysis of randomized controlled trials. BMC Gastroenterol. 2015; 15 (1). doi: 10.1186/s12876-015-0297-z . | Open in Read by QxMD
  30. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.26972. Updated: March 1, 2014. Accessed: March 27, 2017.
  31. Soriano G, Castellote J, Álvarez C, et al. Secondary bacterial peritonitis in cirrhosis: A retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010; 52 (1): p.39-44. doi: 10.1016/j.jhep.2009.10.012 . | Open in Read by QxMD
  32. Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations.. Eur J Gastroenterol Hepatol. 2016; 28 (3): p.e10-8. doi: 10.1097/MEG.0000000000000548 . | Open in Read by QxMD
  33. Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology. 1988; 8 (5): p.1104-9. doi: 10.1002/hep.1840080521 . | Open in Read by QxMD

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer