Ascites

Disease Description (Causes and Symptoms)

• Definition summary: Ascites is a condition in which the fluid component within blood vessels escapes into the abdominal cavity and accumulates there.
• Main causes: Cirrhosis (approximately 85%), malignant tumors (liver or peritoneal metastasis), tuberculous peritonitis, kidney disease (nephrotic syndrome), heart failure, hepatitis/toxic liver injury, and others.
• Key pathophysiology: Portal hypertension and hypoalbuminemia caused by reduced liver function induce fluid movement into the abdominal cavity. Peripheral and splanchnic vasodilation → reduced blood flow to the kidneys → activation of the RAAS/sympathetic nervous system/antidiuretic hormone → sodium and water retention → worsening ascites. In malignant diseases, lymphatic obstruction or malignant exudation may also be causes.
• Main symptoms: Abdominal distension (weight gain), shortness of breath (chest pressure), early satiety and loss of appetite, decreased urine output, generalized and lower-extremity edema, umbilical and inguinal hernias, testicular swelling, and, in severe cases, pleural effusion (hepatic hydrothorax) and peritonitis (fever and abdominal pain).

Treatment Methods

• Lifestyle measures
  • Salt restriction: Salt restriction is generally important (the provided materials recommend limiting salt to 10 g or less per day). In clinical practice, the attending physician may recommend stricter restriction depending on the condition (e.g., 5–6 g of NaCl per day).
  • Fluid restriction: Generally unnecessary, but restriction may be needed in cases of severe hyponatremia.
  • Complete abstinence from alcohol (for cirrhotic ascites), daily recording of weight and abdominal circumference, and caution with NSAIDs (which can cause reduced renal perfusion) and some blood pressure medications (medical advice is required).
• Medication treatment
  • Diuretics: Spironolactone (an aldosterone antagonist) may be used alone or combined with a loop diuretic (e.g., furosemide) to maintain fluid removal and potassium balance. The general principle is to use spironolactone first and add a loop diuretic if necessary. Monitoring of electrolytes and kidney function is essential.
  • Infection prevention and treatment: If infection of the ascitic fluid (spontaneous bacterial peritonitis, SBP) is suspected, perform paracentesis and culture, followed immediately by empirical antibiotic administration.
• Procedures/surgery
  • Therapeutic paracentesis: Performed when acute symptom relief is needed due to shortness of breath, excessive intra-abdominal pressure, or other causes. After large-volume paracentesis (usually removal of >5 L), intravenous albumin administration may be considered to prevent hypoalbuminemia and decreased kidney function (administered in proportion to the amount removed).
  • TIPS (transjugular intrahepatic portosystemic shunt): Considered for recurrent or refractory (not responding to treatment) ascites. Indications are determined based on hepatic encephalopathy, reduced cardiac output, liver function status, and complication criteria.
  • Treatment of the underlying disease: Treatment of viral liver disease, anticancer medication and surgery for cancer, and treatment of heart failure and kidney disease.
• Complications and emergency response
  • If new symptoms (fever, abdominal pain, altered consciousness, or low blood pressure) occur after ascites develops, seek medical attention immediately (possible spontaneous bacterial peritonitis, bleeding, or shock).
• Monitoring
  • Regularly check weight, abdominal circumference, blood pressure, urine output, and electrolyte, kidney function, and liver function tests.

Checklist Before an Outpatient Visit (What to Bring and Example Questions)

• Items to bring (recommended)
  • List of medications and supplements currently being taken (including doses)
  • Recent test results (blood tests and liver function, electrolyte, and kidney function results), and ultrasound/CT/ascites test reports, if available
  • Records of changes in abdominal circumference and weight (if possible, for the past 1–2 weeks), and when changes in urine output or worsening edema began
  • History of recent paracentesis (procedure) and treatment (procedure date, amount removed, and whether albumin was administered)
• Symptoms to tell the doctor about in advance
  • Recent fever, severe abdominal pain, or chills; sudden decrease in urine output; altered consciousness; low blood pressure; or worsening shortness of breath
• Useful information for the consultation
  • History of alcohol and medication use, fluid and salt intake, changes in appetite and weight, and when abdominal distension began and how quickly it progressed

Examples of General Questions to Ask the Doctor

• What are the main side effects of this medication (e.g., spironolactone/furosemide), and what should be monitored?
• Can the ascites disappear completely, and what is the prognosis?
• What should I particularly avoid in terms of lifestyle (diet, alcohol, and exercise)?
• Is albumin administration necessary after large-volume paracentesis, and if so, how is that determined?

Examples of Disease-Specific Questions

• My ascites keeps recurring (refractory ascites). What are the indications for TIPS and its expected benefits and risks?
• I suddenly developed abdominal pain and fever. When should I undergo paracentesis regarding the possibility of SBP (spontaneous bacterial peritonitis), and which empirical antibiotics are used?

Additional information: Treatment and control of the underlying cause of ascites (particularly cirrhosis) have a major effect on the prognosis. If emergency signs such as new pain, fever, altered consciousness, or decreased urine output occur, visit an emergency room or outpatient clinic without delay.