One of the most common complications of cirrhosis of the liver is Ascites. It can occur in 50% of the people over the ten year period after a diagnosis of Cirrhosis. The development of ascites in a cirrhotic patient must be taken seriously because it has a 50% mortality rate over 2 years after developing. Any patient who develops ascites after a history of cirrhosis of the liver, should consider the option of liver transplantation as a therapeutic approach to avoid the high mortality risk associated with the condition.
What Is Ascites?
Ascites is defined as accumulation of fluid within the peritoneal cavity in our abdomen. It may develop by a certain sequence of events. It may start off by the development of portal hypertension (increased pressure in the portal vein leaving the liver). This causes the release of local vasodilators. These reduce the blood flow in the arteries.
But progressive vasodilation leads to the release to vasoconstrictors and anti natriuretic mechanisms are activated to ensure complete perfusion to the organs. The ultimate effect is sodium and water retention by the body, eventually leading to fluid accumulation in the abdominal region causing ascites.
Causes Of Ascites
Although cirrhosis of the liver appears to be the main cause that leads to ascites, there are many other causes that may lead to this problem. These may be peritoneal or extra-peritoneal and include:
- Malignancy (10%),
- Heart failure (3%),
- Infection like tuberculosis (2%),fungal bacterial or parasitic
- Ovarian cancer
2. Extra peritoneal
- Pancreatitis (1%)
- Budd chiari syndrome
- Chylous ascites
- Nephrotic syndrome
- Protein-losing enteropathy
- Congestive heart failure
Signs And Symptoms Of Ascites
The signs and symptoms of ascites depend on the amount of fluid in the abdominal cavity and the type of ascites that the person is suffering from. If trace amounts of fluid are present, then the condition may only be discovered on a physical examination. If a large amount of fluid is present, one of the following signs may be observed. These include:
- Abdominal distension
- Flank fullness
- Early satiety
- Abdominal pain
- Shortness of breath (dyspnea)
Diagnosis Of Ascites In A Patient With Cirrhosis Of The Liver
Diagnostic paracentesis with ascitic fluid evaluation is the standard method for diagnosis in a non cirrhotic patient. The role of paracentesis in a cirrhotic patient is more questionable. The protocol is to keep monitoring a patient who shows no serious signs of deterioration.
However the onset of unexplained fever, abdominal pain, encephalopathy or hospital admission may be warning signs that may require a paracentesis to diagnose the cause of these symptoms. A gross examination of the ascitic fluid may give many hints about the underlying condition:
- Translucent and yellow fluid: Uncomplicated cirrhotic ascites
- Brown Fluid: the patient may be deeply jaundiced
- Turbidity or cloudiness of the ascites fluid: infection may be present and further diagnostic testing should be performed
- Pink or bloody fluid : mild trauma, with subcutaneous blood contaminating the sample
- Bloody ascites: hepatocellular carcinoma or any malignancy-associated ascites
- Milky-appearing fluid: An elevated triglyceride concentration may produce it. Such fluid is referred to as chylous ascites. It may be related to thoracic duct injury, duct obstruction or lymphoma, but often cirrhosis is the primary cause
Another constituent that can give a hint about the cause, is albumin in the fluid compared with serum. This calculated serum-to-ascites albumin gradient (SAAG) can be used to determine whether the patient has portal hypertension–related ascites.
Treatment For Ascites
Successful treatment for ascites of the liver encompasses the fact that intraperitoneal fluid is minimized without depleting the intravascular volume. Not only can decreasing the quantity of ascitic fluid decrease mortality, it can improve your quality of life by decreasing dyspnea and abdominal discomfort associated with the condition.
General guidelines for management of an ascitic patient would include reducing the alcohol consumption, dietary sodium/salt intake and avoiding NSAIDs. The more aggressive treatment options depend on the type and severity of ascites. Measures such as oral diuretics, therapeutic paracentesis, transjugular intrahepatic portosystemic shunt and orthotopic liver transplantation may help reduce severe ascites in a patient with cirrhosis of the liver.