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Evaluation of adults with ascites

INTRODUCTION

Accumulation of fluid within the peritoneal cavity results in ascites. In the United States, ascites is most often due to portal hypertension resulting from cirrhosis. Other common causes include malignancy and heart failure. Successful treatment of ascites depends upon an accurate diagnosis of its cause (table 1 and table 2 and table 3 and algorithm 1) [1].

This topic will review the evaluation of adults with ascites. Performance of paracentesis, specific causes of ascites, the initial therapy of ascites in patients with cirrhosis, and the treatment of refractory ascites are discussed in detail separately. (See "Diagnostic and therapeutic abdominal paracentesis" and "Malignancy-related ascites" and "Chylous, bloody, and pancreatic ascites" and "Tuberculous peritonitis" and "Ascites in adults with cirrhosis: Initial therapy" and "Ascites in adults with cirrhosis: Diuretic-resistant ascites".)

In 2013, the American Association for the Study of Liver Diseases (AASLD) updated its guideline on the management of adult patients with ascites due to cirrhosis (table 4) [2,3]. The discussion that follows is generally consistent with that guideline.

ETIOLOGY

There are numerous causes of ascites, but the most common cause of ascites in the United States is cirrhosis, which accounts for approximately 80 percent of cases (table 1) [4]. Up to 19 percent of patients with cirrhosis will have hemorrhagic ascites, which may develop spontaneously (72 percent probably due to bloody lymph and 13 percent due to hepatocellular carcinoma) or following paracentesis [5]. Other common causes of ascites include malignancy-related ascites and ascites due to heart failure.

Ascites can be classified based on the underlying pathophysiology [6]:

                    

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Literature review current through: Jun 2014. | This topic last updated: May 13, 2014.
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References
Top
  1. Runyon BA. Management of adult patients with ascites caused by cirrhosis. Hepatology 1998; 27:264.
  2. http://www.aasld.org/practiceguidelines/Documents/ascitesupdate2013.pdf (Accessed on April 23, 2013).
  3. Runyon BA, AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology 2013; 57:1651.
  4. Runyon BA. Care of patients with ascites. N Engl J Med 1994; 330:337.
  5. Urrunaga NH, Singal AG, Cuthbert JA, Rockey DC. Hemorrhagic ascites. Clinical presentation and outcomes in patients with cirrhosis. J Hepatol 2013; 58:1113.
  6. Norton J. Greenberger. Ascites & spontaneous bacterial peritonitis. In: Current diagnosis & treatment: Gastroenterology, hepatology, & endoscopy, Second Edition, Norton J. Greenberger. (Ed), McGraw-Hill, New York 2012. p.515.
  7. Miedema EB, Bissada NK, Finkbeiner AE, Casali RE. Chylous ascites complicating retroperitoneal lymphadenectomy for testis tumors: management with peritoneovenous shunting. J Urol 1978; 120:377.
  8. Müller-Schoop JW, Wang SP, Munzinger J, et al. Chlamydia trachomatis as possible cause of peritonitis and perihepatitis in young women. Br Med J 1978; 1:1022.
  9. Ackerman Z. Ascites in Nephrotic syndrome. Incidence, patients' characteristics, and complications. J Clin Gastroenterol 1996; 22:31.
  10. Wilkins KW Jr, Hoffman GS. Massive ascites in systemic lupus erythematosus. J Rheumatol 1985; 12:571.
  11. Mauer K, Manzione NC. Usefulness of serum-ascites albumin difference in separating transudative from exudative ascites. Another look. Dig Dis Sci 1988; 33:1208.
  12. Ryu JH, Doerr CH, Fisher SD, et al. Chylothorax in lymphangioleiomyomatosis. Chest 2003; 123:623.
  13. Dees A, Kluchert SA, van Vliet AC. Pseudo-renal failure associated with internal leakage of urine. Neth J Med 1990; 37:197.
  14. Cappell MS, Shetty V. A multicenter, case-controlled study of the clinical presentation and etiology of ascites and of the safety and clinical efficacy of diagnostic abdominal paracentesis in HIV seropositive patients. Am J Gastroenterol 1994; 89:2172.
  15. Saab S, Rickman LS, Lyche KD. Ascites and the acquired immunodeficiency syndrome. Report of 54 cases. Medicine (Baltimore) 1996; 75:131.
  16. Jamidar PA, Campbell DR, Fishback JL, Klotz SA. Peritoneal coccidioidomycosis associated with human immunodeficiency virus infection. Gastroenterology 1992; 102:1054.
  17. Fábregues F, Balasch J, Ginès P, et al. Ascites and liver test abnormalities during severe ovarian hyperstimulation syndrome. Am J Gastroenterol 1999; 94:994.
  18. Gregora MG, McNamara T. Ascites--an unusual association with pelvic inflammatory disease. Aust N Z J Obstet Gynaecol 1997; 37:477.
  19. Ross JA, Hacket E, Lawton F, Jurkovic D. Massive ascites due to abdominal pregnancy. Hum Reprod 1997; 12:390.
  20. el-Newihi HM, Antaki JP, Rajan S, Reynolds TB. Large bloody ascites in association with pelvic endometriosis: case report and literature review. Am J Gastroenterol 1995; 90:632.
  21. Paspatis GA, Kissamitaki V, Kyriakakis E, et al. Ascites associated with the initial presentation of Crohn's disease. Am J Gastroenterol 1999; 94:1974.
  22. Bourantas KL, Christou LG, Dalekos GN, et al. A 54-year-old stockbreeder with ascites. Lancet 1997; 349:994.
  23. Kapoor OP, Nathwani BN, Joshi VR. Amoebic peritonitis. A study of 73 cases. J Trop Med Hyg 1972; 75:11.
  24. Peterkin IR, Lewandowski BJ. Salmonella enteritis: a cause for ascites. Am J Gastroenterol 1993; 88:1274.
  25. Parikh VA, Edlund JW. Ascites associated with antibiotic-associated pseudomembranous colitis. South Med J 1997; 90:460.
  26. Hui JY, Woo PC, Kan PS, Tang AP. A woman with ascites and abdominal masses. Lancet 2000; 355:546.
  27. Alegre A, Martínez-Chamorro C, Fernández-Rañada JM. Massive myelomatous ascites responsive to VAD chemotherapy and autologous stem cell transplantation. Bone Marrow Transplant 1999; 24:343.
  28. Shimoni A, Shvidel L, Shtalrid M, et al. Prolymphocytic transformation of B-chronic lymphocytic leukemia presenting as malignant ascites and pleural effusion. Am J Hematol 1998; 59:316.
  29. Runyon BA, Hoefs JC. Peritoneal lymphomatosis with ascites. A characterization. Arch Intern Med 1986; 146:887.
  30. Bonnet P, Smadja C, Szekely AM, et al. Intractable ascites in systemic mastocytosis treated by portal diversion. Dig Dis Sci 1987; 32:209.
  31. Myers TJ, Kyle RA, Jacobson DR. Familial amyloid with a transthyretin leucine 33 mutation presenting with ascites. Am J Hematol 1998; 59:249.
  32. Oren I, Goldman A, Haddad N, et al. Ascites and pleural effusion secondary to extramedullary hematopoiesis. Am J Med Sci 1999; 318:286.
  33. Abarca M, Andrade RJ, García-Arjona A, et al. Portal hypertension and refractory ascites associated with multicentric Castleman's disease. Dig Dis Sci 2000; 45:697.
  34. de Kerguenec C, Hillaire S, Molinié V, et al. Hepatic manifestations of hemophagocytic syndrome: a study of 30 cases. Am J Gastroenterol 2001; 96:852.
  35. Loeb JM, Hauger PH, Carney JD, Cooper AD. Refractory ascites due to POEMS syndrome. Gastroenterology 1989; 96:247.
  36. Iwai M, Kashiwadani M, Okuno T, et al. Cholestatic liver disease in a 20-yr-old woman with histiocytosis X. Am J Gastroenterol 1988; 83:164.
  37. Imparato AM. Gaucher's Disease With Ascites: Response to Portacaval Shunt. Ann Surg 1960; 151:431.
  38. West GA, Berger MS, Geyer JR. Childhood optic pathway tumors associated with ascites following ventriculoperitoneal shunt placement. Pediatr Neurosurg 1994; 21:254.
  39. Isenberg JI, Gilbert SB, Pitcher JL. Ascites with peritoneal involvement in Whipple's disease. Report of a case. Gastroenterology 1971; 60:305.
  40. Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215.
  41. Press OW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med 1982; 96:358.
  42. Steinemann DC, Dindo D, Clavien PA, Nocito A. Atraumatic chylous ascites: systematic review on symptoms and causes. J Am Coll Surg 2011; 212:899.
  43. Browse NL, Wilson NM, Russo F, et al. Aetiology and treatment of chylous ascites. Br J Surg 1992; 79:1145.
  44. Aalami OO, Allen DB, Organ CH Jr. Chylous ascites: a collective review. Surgery 2000; 128:761.
  45. Cattau EL Jr, Benjamin SB, Knuff TE, Castell DO. The accuracy of the physical examination in the diagnosis of suspected ascites. JAMA 1982; 247:1164.
  46. Cárdenas A, Chopra S. Chylous ascites. Am J Gastroenterol 2002; 97:1896.
  47. 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; 38:258.
  48. Stanley MM, Ochi S, Lee KK, et al. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites. N Engl J Med 1989; 321:1632.
  49. Berzigotti A, Ashkenazi E, Reverter E, et al. Non-invasive diagnostic and prognostic evaluation of liver cirrhosis and portal hypertension. Dis Markers 2011; 31:129.
  50. Aagaard J, Jensen LI, Sørensen TI, et al. Recanalized umbilical vein in portal hypertension. AJR Am J Roentgenol 1982; 139:1107.
  51. Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009; 49:2087.
  52. Chinnock B, Hendey GW. Can clear ascitic fluid appearance rule out spontaneous bacterial peritonitis? Am J Emerg Med 2007; 25:934.
  53. Runyon BA, Akriviadis EA, Keyser AJ. The opacity of portal hypertension-related ascites correlates with the fluid's triglyceride concentration. Am J Clin Pathol 1991; 96:142.
  54. Rector WG Jr. Spontaneous chylous ascites of cirrhosis. J Clin Gastroenterol 1984; 6:369.
  55. DeSitter L, Rector WG Jr. The significance of bloody ascites in patients with cirrhosis. Am J Gastroenterol 1984; 79:136.
  56. Akriviadis EA. Hemoperitoneum in patients with ascites. Am J Gastroenterol 1997; 92:567.
  57. Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology 1988; 8:1104.
  58. Kung CT, Liu BM, Ng SH, et al. Transcatheter arterial embolization in the emergency department for hemodynamic instability due to ruptured hepatocellular carcinoma: analysis of 167 cases. AJR Am J Roentgenol 2008; 191:W231.
  59. Runyon BA. Ascitic fluid bilirubin concentration as a key to choleperitoneum. J Clin Gastroenterol 1987; 9:543.
  60. Hoefs JC. Serum protein concentration and portal pressure determine the ascitic fluid protein concentration in patients with chronic liver disease. J Lab Clin Med 1983; 102:260.
  61. Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis 1998; 27:669.
  62. Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterology 1988; 95:1351.
  63. Runyon BA, Antillon MR. Ascitic fluid pH and lactate: insensitive and nonspecific tests in detecting ascitic fluid infection. Hepatology 1991; 13:929.
  64. Hoefs JC. Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease. Hepatology 1981; 1:249.
  65. Runyon BA, Hoefs JC. Ascitic fluid chemical analysis before, during and after spontaneous bacterial peritonitis. Hepatology 1985; 5:257.
  66. Runyon BA. Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis. Gastroenterology 1986; 91:1343.
  67. Soriano G, Guarner C, Teixidó M, et al. Selective intestinal decontamination prevents spontaneous bacterial peritonitis. Gastroenterology 1991; 100:477.
  68. Runyon BA, Hoefs JC. Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid. Hepatology 1984; 4:447.
  69. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 1990; 98:127.
  70. Kolle L, Ortiz J, Ricart E, et al. Ascitic fluid culture is not necessary in asymptomatic cirrhotic outpatients undergoing repeated therapeutic paracentesis (abstract). Hepatology 1996; 24:445A.
  71. Jeffries MA, Stern MA, Gunaratnam NT, Fontana RJ. Unsuspected infection is infrequent in asymptomatic outpatients with refractory ascites undergoing therapeutic paracentesis. Am J Gastroenterol 1999; 94:2972.
  72. Runyon BA, Antillon MR, Akriviadis EA, McHutchison JG. Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J Clin Microbiol 1990; 28:2811.
  73. Wilson JA, Suguitan EA, Cassidy WA, et al. Characteristics of ascitic fluid in the alcoholic cirrhotic. Dig Dis Sci 1979; 24:645.
  74. Chinnock B, Fox C, Hendey GW. Gram's stain of peritoneal fluid is rarely helpful in the evaluation of the ascites patient. Ann Emerg Med 2009; 54:78.
  75. Runyon BA. Amylase levels in ascitic fluid. J Clin Gastroenterol 1987; 9:172.
  76. al Karawi MA, Mohamed AE, Yasawy MI, et al. Protean manifestation of gastrointestinal tuberculosis: report on 130 patients. J Clin Gastroenterol 1995; 20:225.
  77. Singh MM, Bhargava AN, Jain KP. Tuberculous peritonitis. An evaluation of pathogenetic mechanisms, diagnostic procedures and therapeutic measures. N Engl J Med 1969; 281:1091.
  78. Hillebrand DJ, Runyon BA, Yasmineh WG, Rynders GP. Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology 1996; 24:1408.
  79. Anand BS, Schneider FE, El-Zaatari FA, et al. Diagnosis of intestinal tuberculosis by polymerase chain reaction on endoscopic biopsy specimens. Am J Gastroenterol 1994; 89:2248.
  80. Cardozo PL. A critical evaluation of 3000 cytologic analyses of pleural fluid, ascitic fluid, and pericardial fluid. Acta Cyto 1966; 10:455.
  81. DiBonito L, Falconieri G, Colautti I, et al. The positive peritoneal effusion. A retrospective study of cytopathologic diagnoses with autopsy confirmation. Acta Cytol 1993; 37:483.
  82. Chetty R, Learmonth GM, Taylor DA. Giant cell hepatocellular carcinoma. Cytopathology 1990; 1:233.
  83. Matsukuma S, Sato K. Peritoneal seeding of hepatocellular carcinoma: clinicopathological characteristics of 17 autopsy cases. Pathol Int 2011; 61:356.
  84. Loewenstein MS, Rittgers RA, Feinerman AE, et al. Carcinoembryonic antigen assay of ascites and detection of malignancy. Ann Intern Med 1978; 88:635.
  85. Sheer TA, Joo E, Runyon BA. Usefulness of serum N-terminal-ProBNP in distinguishing ascites due to cirrhosis from ascites due to heart failure. J Clin Gastroenterol 2010; 44:e23.
  86. Runyon BA. Malignancy-related ascites and ascitic fluid "humoral tests of malignancy". J Clin Gastroenterol 1994; 18:94.