Ascites: Fluid in the Abdomen — Causes, Treatment and When It Means Transplant

Why fluid collects in the abdomen

In cirrhosis, scar tissue makes the liver stiff, so blood backs up in the portal vein that carries blood from the gut to the liver. This raised pressure (portal hypertension) pushes fluid out of the blood vessels. At the same time the body senses that the circulation is 'under-filled' and the kidneys hold on to salt and water. The failing liver also makes less albumin, the protein that keeps fluid inside blood vessels. Together these push fluid steadily into the abdomen.

The diagnostic tap and what SAAG means

Anyone with new ascites, and anyone with ascites who is admitted to hospital, should have a diagnostic paracentesis: a thin needle is passed into the lower abdomen under local anaesthetic, usually with ultrasound guidance, and a small amount of fluid is drawn off. It takes a few minutes and is safe even when clotting tests are abnormal.

The key number is the SAAG — serum-ascites albumin gradient. The laboratory measures albumin in the blood and in the fluid and subtracts one from the other. In plain words: if there is much more albumin in the blood than in the fluid (a SAAG of 1.1 g/dL or more), the fluid is being pushed out by high pressure in the portal vein, which almost always means cirrhosis or a heart cause. If the gap is small, the fluid is more likely to come from inflamed or diseased lining of the abdomen — cancer, tuberculosis or pancreatitis.

• Cell count: a raised neutrophil count (250 cells/mm³ or more) means the fluid is infected — spontaneous bacterial peritonitis — even if the patient looks well.
• Culture: fluid is put into blood-culture bottles at the bedside to identify the germ.
• Total protein, cytology, ADA: help point towards cancer or tuberculosis when the picture is unclear.

First-line treatment: salt, diuretics and the cause

1. 1

   Treat the underlying liver disease

   Stopping alcohol completely, treating hepatitis B or C, and controlling diabetes and weight can shrink ascites considerably. In alcohol-related cirrhosis, abstinence alone sometimes makes diuretics unnecessary over months. See alcohol-related liver disease.

2. 2

   No added salt

   The target is roughly 2 g of sodium a day (about 5 g of salt). In an Indian kitchen that practically means cooking with very little salt, no extra salt at the table, and avoiding pickles, papad, chanachur and namkeen, packaged snacks, instant noodles, sauces, processed cheese and restaurant food. Very strict, tasteless diets are not better — they reduce appetite and cause malnutrition.

3. 3

   Diuretics (water tablets)

   Spironolactone is the main medicine, usually combined with furosemide. Doses are increased gradually while weight, urine output, sodium, potassium and creatinine are checked. A sensible target is losing about half to one kilogram a day — faster loss risks kidney injury.

4. 4

   Avoid harmful medicines

   Painkillers such as diclofenac, ibuprofen and other NSAIDs can tip the kidneys into failure in cirrhosis and make diuretics stop working. Paracetamol in modest doses is generally the safer choice — check with your doctor.

Large-volume tapping with albumin

When the abdomen is tense and uncomfortable, or breathing is difficult, a large-volume paracentesis removes several litres in one session through a thin drain. It gives quick relief. When more than about 5 litres are removed, intravenous albumin is given (commonly around 8 g for each litre drained) to protect the circulation and kidneys. Draining large volumes without albumin can cause a drop in blood pressure and kidney injury.

Tapping treats the fluid, not the cause. The fluid will return unless salt and diuretics are working, and needing a tap every week or two is itself important information about how the liver is doing.

Refractory ascites and TIPS

Ascites is called refractory when it cannot be controlled despite a proper salt limit and the maximum diuretic doses, or when the diuretics cannot be continued because of kidney injury, very low sodium or other side effects. It usually comes back quickly after each tap.

TIPS (transjugular intrahepatic portosystemic shunt) is a metal stent placed through a vein in the neck that creates a channel inside the liver, lowering portal pressure. In carefully selected patients it reduces or stops the need for tapping. It is not suitable for everyone: it can worsen confusion (hepatic encephalopathy) and strain the heart, and it is generally avoided when liver function is very poor. For some patients a surgical option is discussed — see portal hypertension surgery.

Infection of the fluid and other warning signs

Spontaneous bacterial peritonitis (SBP) is an infection of the ascitic fluid without any hole in the bowel. Symptoms can be surprisingly mild — sometimes only confusion or a rise in creatinine. It is treated with intravenous antibiotics, and albumin is often added to protect the kidneys. After one episode, long-term preventive antibiotics are usually advised, because it tends to recur.

Why ascites is a transplant signal

The first appearance of ascites marks the change from compensated to decompensated cirrhosis. Survival falls noticeably from that point, and it falls further once ascites becomes refractory, SBP occurs or the kidneys are affected. Widely published data suggest that roughly half of patients with refractory ascites do not survive beyond about a year without a transplant, although individual outlook varies a lot.

That is why international guidelines advise that anyone with cirrhosis and ascites be considered for liver transplant evaluation — early, while they are still strong enough for surgery. A successful liver transplant removes the cause of the ascites altogether. In India most transplants are living donor liver transplants, so a family member can often be assessed as a donor without waiting for a deceased-donor organ.

Dr Bappaditya Har and the transplant team at Narayana RN Tagore Hospital, Mukundapur, Kolkata assess patients with difficult ascites together with hepatologists. Families from outside Kolkata can send reports on WhatsApp (+91 70420 39420) for an initial review.