Aetiology

The causes of ascites can be grouped into those with a serum-ascites albumin gradient (SAAG) <11 g/L or a gradient >11g/L as per the table below:

SAAG > 11g/L SAAG <11g/L
Indicates portal hypertension

Cirrhosis
Alcoholic hepatitis
Cardiac ascites
Mixed ascites
Massive liver metastases
Fulminant hepatic failure
Budd-Chiari syndrome
Portal vein thrombosis
Veno-occlusive disease
Myxoedema
Fatty liver of pregnancy
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Bowel obstruction
Biliary ascites
Postoperative lymphatic leak
Serositis in connective tissue diseases

Clinical features

Management

Management
  • reducing dietary sodium
  • fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
  • aldosterone antagonists: e.g. spironolactone
  • drainage if tense ascites (therapeutic abdominal paracentesis)
    • large-volume paracentesis for the treatment of ascites requires albumin 'cover'. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
    • paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate
  • prophylactic antibiotics to reduce the risk of spontaneous bacterial peritonitis. NICE recommend: 'Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved'
  • a transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some patients