Tasneem et al.

, International Current Pharmaceutical Journal, February 2015, 4(3): 370-377

http://www.icpjonline.com/documents/Vol4Issue3/02.pdf

International Current
Pharmaceutical Journal

REVIEW ARTICLE

OPEN ACCESS

Causes, management and complications of ascites: a review

*Hirra Tasneem, Huda Shahbaz and Bushra Ali Sherazi
Institute of Pharmacy, Lahore College For Women University, Jail Road Lahore, 54000, Pakistan

ABSTRACT
Ascites is the pathological state in which fluid accumulates in the peritoneal cavity. Fluid accumulation may be due to infection and
malignancy or due to other diseases like liver disease, heart failure, and renal disease. The ascitic fluid can be graded into Transudative and Exudative fluid based on the serum ascites albumin gradient (SAAG). The prominent cause of ascites is found to be Liver
Cirrhosis. The most common symptom of Ascites is recent weight gain, increased abdominal girth and dyspnea. The first line
treatment of ascites includes education regarding dietary sodium restriction and oral diuretics. However, other mechanical methods
can also be used if the patient is unresponsive to this approach. But, there are some limitations while using these mechanical
methods. Ascites is also associated with certain complications like spontaneous bacterial perotinitis, hepatorenal syndrome and
dilutional hyponatremia. Ascites itself is not fatal unless it becomes infected. So, early diagnosis and effective treatment should be
ensured in order to avoid further complications. This review focuses on the grades, causes, symptoms, management and complications of Ascites.
Key Words: SAAG, causes, cirrhosis, management, diuretics, paracentesis.

INTRODUCTION
INTRODUCTION
Ascites is derived from a Greek term ASKOS which
refers to a bag or sac. It is the pathological accumulation of
free fluid in the peritoneal cavity. The fluid accumulates
because of conditions directly involving the peritoneum
(infection, malignancy), or due to other diseases remote
from the peritoneum (i.e., liver disease, heart failure,
hypoproteinaemia). Normally there is no fluid in the
peritoneal cavity, however in women a small amount
(almost 20 ml) or less than 1 ounce can sometimes (but not
often) can be present depending on her menstrual cycle
(Ascites-1), but for the confirmation of ascites, it is required
that at least 1500 ml of fluid should be present in peritoneal
cavity and also detectable by clinical examination but
significantly more in obese person (ascites-2) (Muhammed
et al., 2012; Al Knawy, 1997).

GRADING OF
OFASCITES
ASCITES
GRADING
Ascites exists in three grades namely, grade 1 which is mild,
only visible on ultrasound and CT scan, grade 2 which is
determined with flank bulging and shifting dullness and
grade 3 is directly visible, and is confirmed with the fluid
wave/thrill test. Traditionally, ascites was divided into 2
types, transudative and exudative type. This classification
was based on the amount of protein found in the fluid. A
more meaningful system has been developed, on the basis
of amount of albumin in the ascitic fluid in contrast to
serum albumin (albumin measured in the blood). This
system is called the Serum Ascites Albumin Gradient or
SAAG. Ascites due to portal hypertension caused cirrhosis,
congestive heart failure or Budd-Chiari has SAAG value
generally greater than 1.1. Ascites related to other reasons
(malignancy, pancreatitis) has value lower than 1.1.
Another grading system adapted from European Association for the study of the liver is given in table 1 (Moore &
Wong, 2003).
*Corresponding Author:
Hirra Tasneem
Institute of Pharmacy
Lahore College For Women University
Jail Road Lahore, 54000, Pakistan
E-mail: [email protected]
Contact No.: +923334915606

PATHOPHYSIOLOGY&
&CAUSES
CAUSESOF
OFASCITES
ASCITES
PATHOPHYSIOLOGY
Ascites generally results from portal hypertension and
low levels of a protein called albumin. Diseases that can
lead to severe liver damage can cause ascites. These
diseases include long-term hepatitis C or B infection and
alcohol abuse over many years. People suffering from
certain cancers in the abdomen may develop ascites.
These cancers include colon, ovaries, uterus, pancreas,
and liver cancer. Other conditions that can lead to this
problem include, clots in the veins of the liver (portal vein
thrombosis), congestive heart failure, pancreatitis,
thickening and discoloring of the sac like covering of the
heart. Kidney dialysis may also be linked with ascites
(Runyon, 2009). Table 2 depicts some of the common
causes of ascites.
Ascites due to liver cirrhosis
Literature showed that Cirrhosis is the commonest cause
of ascites in the Western world (~75%), followed by
peritoneal malignancy (12%), cardiac failure (5%) and
peritoneal tuberculosis (2%) (Runyon, 1993).
Mechanism of ascites in cirrhosis
The mechanism of ascites in cirrhosis is complex but
portal hypertension and renal sodium retention is
common. The history shows that cirrhotic ascites progresses from diuretic responsive (uncomplicated) ascites
to the development of dilutional hyponatraemia, refractory ascites, and finally, hepatorenal syndrome (HRS).
While survival of patients who develop ascites in 1 year is
85%, it declines to 25% once it has progressed to hyponatraemia, refractory ascites or HRS (Planas et al., 2004).
In considering portal hypertension, backflow and
stasis of vasodilatory substances, e.g., nitric oxide, begin to
aggregate. This causes, amongst other results visceral
vasodilation with resultant hypoperfusion of the renal
system. Thus by this way renin angiotensin- aldosterone
system (RAAS) is activated leading to aggressive fluid
retention. In short, renin is secreted from the renal
juxtaglomerular apparatus (JGA) around the proximal
nephrons in reaction to changes in vascular pressures,
changes in serum sodium, and from activation of the

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Table 1: Grading of ascites (Fullwood & Purushothaman, 2014).

Grade

Detection Technique

Abdominal Distension

1
2

Ultrasound
Inspection, palpation
and percussion
Inspection, palpation
and percussion

Absent (<500 ml of fluid)

Moderately distended

Grossly or markedly
distended

sympathetic nervous system. In turn, it will change

angiotensinogen (made in the liver) to angiotensin-I
which is further converted to angiotensin-II by angiotensin converting enzyme (ACE) in the lungs. Angiotensi-II
has various important functions that drive fluid accession
and retention, including stimulation of the thirst drive,
release of aldosterone from the zona glomerulosa of the
adrenal cortex, and the secretion of vasopressin from the
posterior pituitary. Pathophysiology of ascites is clearly
shown in figure 1 (Teirstein et al., 2005; Garcia-Tsao, 2011;
Henriksen and Mller, 2005; Llach et al., 1988).
The development of ascites, in cirrhotic patients,
marks the transition from compensated to decompensated
cirrhosis Accumulation of ascitic fluid in cirrhosis results
from different factors broadly defined in terms of cytokine
and hormonal dysregulation and associated volume
overload in the context of portal hypertension (Gins et al.,
1987).
The presence of ascites leads to the progression of
cirrhosis. It is also the most common cause for hospital
admissions and thus increases unpredicted cost; it
increases 1-year mortality and functions as a risk for
orthotopic liver transplantation (OLT). In portal hypertension, the major cause of ascites is Cirrhosis (85%). Other
causes of ascites (non-cirrhotic) can be widely defined as
pre- or post-hepatic in origin (Moore and Thiel, 2013).
Extra-hepatic causes of ascites
Although cirrhosis is the main cause of ascites in majority
of the patients, however almost 15% have a cause other
than liver disease, which can be cancer, cardiac failure,
nephrotic syndrome or tuberculosis. Approximately 5% of
patients with ascites have mixed ascites demonstrated by
2 or more underlying causes of ascites formation. Such
patients have cirrhosis plus 1 other cause i.e., peritoneal
carcinomatosis or peritoneal tuberculosis. Many patients
with inexplicable ascites are finally found to have 2 or
even 3 causes for ascites formation (e.g., heart failure,
diabetic nephropathy, and cirrhosis due to non-alcoholic
steatohepatitis). In this setting, the aggregate of predisposing factors can lead to sodium and water retention when
every individual factor might not be severe enough to
cause surplus fluid (Runyon et al., 1992).
Ascites may be due to multiple reasons other than
the liver diseases or portal hypertension, thus can be ruled
out by the laboratory testing and imaging. As in case of
chronic pancreatitis with associated pseudocyst and
internal fistulae formation, major fluid can directly enter
into the peritoneal cavity and appearing as abdominal
distention with pain. In general, raised ascitic fluid
amylase level, found on diagnostic paracentesis, is a firm
diagnostic for this category. The physician might be
troubled with the diagnosis in a patient with a compelling
history of steatorrhea, alcohol use and chronic pancreatitis.
Particularly, the serum-ascites albumin gradient (SAAG)
is a helpful tool for differentiating ascites-associated
disease processes caused by portal hypertension (e.g.
cirrhosis), from the many other nonportal hypertensive

Table 2: Possible causes of ascites (Marthadu, 2014).

Source
Hepatic Source

Extra-Hepatic
Source

Mixed Source

Cause
Cirrhosis
Alcoholic Hepatitis
Budd-Chiari Syndrome
Sinusoidal Obstruction Syndrome
Heart Failure
Nephrotic Syndrome
Pancreatitis
Myxedema
Cancer related (peritoneal metastases,
massive liver metastases, etc.)
Ascites that results from combination of 2 or
more causes

causes of ascites. A SAAG value 1.1 g/dL strongly

reinforce (97% sensitivity) in the diagnosis of portal
hypertension as a cause (Becker et al., 2006).
Malignant Ascites
Malignant ascites, which is found in 10% of cases, is
commonly because of peritoneal metastasis in neoplastic
disease, but it is more common with ovary, breast, gastric,
pancreatic, bronchus or colon cancer. Almost in 20% of
cases with malignant ascites tumor is of unknown origin
and mostly protein content is high in malignant ascites
(Becker et al., 2006).
Pathogenesis of Ascites
Besides its well-known demonstration, the pathogenesis
of ascites remains unclear and continues to evolve. A
hybrid theory currently predominates, which up rise from
the overflow and underfill theories of the past
generation. A brief adumbrate of these views suggests
that the continuous injury to the liver as a combination of
both exogenous factors, like viral or non-alcoholic
steatohepatitis (NASH) or chronic alcohol injury; in the
setting of an appropriate genetic disposition; and
continued micro-processes of inflammation, collagen
deposition/regeneration and necrosis, all conspiring to
transubstantiate the liver from a low-resistance to a highresistance system, like a spectrum of fibrosis with vascular
smooth muscle dysfunction. These collective processes
can lead to increased pressure in the portal vein, leading
to portal hypertension (Moore and Thiel, 2013). Sequence
of events for the hypothesis of ascites formation can be
seen in table 3.
Usually, in rest condition when the peritoneal cavity
is relaxed, it has a pressure of about 5-10 mmHg, which
has almost 25-50 mL of serous fluid. The serous fluid
normally provides a low resistance film over which bowel
can move past each other and further hydrates the serosal
surfaces maintaining suppleness and haleness. The
maximal absorption of fluid out of the peritoneum is
approximately 850 mL/d in the most effective circumstances. Peritoneal dialysis works under the theory of
selective filteration, and it can be observed effective
filtration is altered by modifications in the properties of

Table 3: Sequence of events for the hypothesis of ascites

formation (GarciaTsao, 2011).
Event
Primary event
Secondary event

Underfill/ peripheral arterial

vasodilatation theory
Vascular
Renal

Overfill
theory
Renal
Vascular

371

Figure 2: Assessment of shifting dullness (Fullwood and

Purushothaman, 2014).

SIGNSAND
ANDSYMPTOMS
SYMPTOMSOF
OFASCITES
ASCITES
SIGNS

Figure 1: Pathophysiology of ascites (Fullwood and Purushothaman, 2014).

the peritoneal surface area or lymphatic system, either

due to fibrotic or infectious, or by some inflammation or
mechanical processes. Hence, continued impairment of
physiological system can lead to profound ascitic fluid
retention (Moore and Thiel, 2013).

DETECTIONOF
OFASCITES
ASCITES
DETECTION
Identification of mild ascites is difficult, but abdominal
distension is the clear indication of severe ascites. Patients
suffering from ascites generally complaints about
pressure and abdominal heaviness, as well as shortness of
breath, because of the diaphragm mechanical impingement occur. Physical examination of the abdomen is a
useful parameter for determining ascites, as there is
visible flank bulging and shifting dullness in the
reclining patient, or fluid wave or fluid thrill in the
massive ascites (Runyon, 2009). Assessment of shifting
dullness is also shown in figure 2.
The appearance of a full, bulging abdomen should
lead to percussion of the flanks. One should test for
shifting, if the amount of flank dullness is higher than
usual. Around 1,500 mL of fluid must be present before
flank dullness is detected. The patient has less chance of
having ascites (10%), if flank dullness is not detected. The
fluid wave and puddle sign are not helpful. Ascites due to
alcoholic cardiomyopathy can replicate that due to
alcoholic cirrhosis. Jugular venous distension is shown in
the former but not in the latter. The physical examination
for detecting ascites in the obese patient is difficult. An
abdominal ultrasound may be needed to determine with
surety if fluid is present (Cattau et al., 1982).
Fluid due to portal hypertension can be promptly
differentiated from fluid due to other causes. Also, in
view of the high incidence of ascitic fluid infection at the
time of admission to the hospital, an admission vigilance
tap may detect unpredictable infection (Runyon et al.,
1992; Pinzello et al., 1983).

The most prevalent symptoms are increased abdominal

girth (the patient notices tightness of the belt or garments
around the waist) and latter weight gain. As fluid
continues to amass, it leads to elevation of the diaphragm
that result in shortness of breath. Fluid aggregation may
also be related with a feeling of satiety and generalized
abdominal pain. Ascites can be distinguished from
obesity, as the onset of symptoms in ascites is fast, while
obesity develops from a period of months to years (Simel
et al., 1988).
Depending on the underlying etiology, other signs
and symptoms may also be present. For example, patients
having ascites as a result of portal hypertension (may be
due to fibrosis or cirrhosis of liver) may complain of
gynecomastia, hematemesis, leg swelling, bruising or due
to encephalopathy mental changes can also occur. Patients
complaint of weight loss or chronic fatigue, when the
cause of ascites is cancer (peritoneal carcinomatosis).
Heart failure may also be a cause of ascites causing
exercise intolerance, shortness of breath and wheezing in
patients (Warrell et al., 2003).

DIAGNOSISOF
OFASCITES
ASCITES
DIAGNOSIS
Tests of liver enzymes, coagulation, basic metabolic
profile and routine complete blood count (CBC) should be
performed for the diagnosis of ascites. Most of the experts
suggest that if the ascites is newly developed or if the
patient is hospitalized, then paracentesis should be
performed as a diagnostic tool. The fluid is then analyzed
for its gross appearance, albumin, protein level, and cell
counts (red and white) (Warrell et al., 2003).
On the basis of physical examination and history, the
assumption is made on the diagnosis of newly onset
ascites. Ultrasound and successful abdominal paracentesis
then confirms this diagnosis. Physical examination, past
record and ascitic fluid analysis determines the cause of
ascites formation. Generally, some other tests may also be
needed. Moreover, the liver is routinely imaged commonly with ultrasound to in order to make diagnosis for
hepatocellular carcinoma, portal vein thrombosis and
hepatic vein thrombosis. The most economical and speedy
method for diagnosis of etiology of ascites is abdominal
paracentesis with adequate ascitic fluid examination
(Runyon, 1994; Runyon et al., 2002).
Various Turkish, South African and local studies divulge that the major co-morbid of ascitic patients were
fever, abdominal pain, night sweats, weight loss, abdominal swelling, clubbing and palmer erythema
(Muhammed et al., 2012)

372

Table 4: Treatment options for patients with ascites and cirrhosis (Runyon, 2009).
First Line
Cessation of alcohol use, when present
Sodium restricted diet and diet education
Dual dluretics, usually spironolactone and
furosemide, orally with single daily dosing
Discontinue non-steroidal anti-inflammatory
drugs
Evaluation for liver transplatation

Second Line

Third Line

Discontinue beta blockers, angiotensin converting Peritoneovenous shunt

enzyme inhibitors and angiotensin receptor
blockers
Consider adding midodrine especially in the
profoundly hypotensive patient
Serial therapeutic paracentesis
Evaluation for liver transplantation
Transjuglar intrahepatic portosystemic stentshunt (TIPS)

MANAGEMENTOF
OFASCITES
ASCITES
MANAGEMENT
Ascites is generally treated while an underlying cause is
known, in order to prevent complications, relieve
symptoms, and prevent further advancement. In those
patients having mild ascites, therapy is usually given as
an outpatient. The major aim of the therapy should be
weight loss of not higher than 1.0 kg/day for patients
having both ascites and peripheral edema and not greater
than 0.5 kg/day for patients having ascites alone. In
patients with severe ascites causing a tense abdomen,
hospital admission is generally imperative for paracentesis (Gins et al., 1987). Treatment options for patients
with cirrhosis and ascites are depicted in table 4.
First-line treatment
The basic treatment guideline for the patients with ascites
and cirrhosis is education with respect to dietary sodium
(which should not be more than 2000 mg per day [88
mmol per day]) and oral diuretics. When alacrity of
weight loss is less than desired, urinary sodium excretion
measurement is a useful parameter to follow (Runyon,
1994; Runyon et al., 2002).
Ascites can be speedily mobilized with severe sodium restriction, but it is not suggested as it is less palatable
and may further worsen the malnutrition that is usually
present in these patients as weight change and fluid loss
are directly linked with the balance of sodium in patients
with ascites caused by portal hypertension. Sodium
restriction is responsible for weight loss, not fluid
restriction, as sodium is followed by fluid passively.
Random specimens are less informative in determining
the rate of sodium excretion, as compared to twenty-fourhour collections of urine; however, full-day collections are
cumbersome. Men suffering from cirrhosis should excrete
creatinine not less than 15 mg/kg of body weight per day,
and women should excrete not less than 10 mg/ kg per
day. Less creatinine indicates insufficient collection. In
afebrile patients with cirrhosis without diarrhea, the
overall sodium excretion (non-urinary) is less than 10
mmol per day. One of the aims of treatment is to enhance
excretion of sodium in urine; so that it exceeds 78 mmol
per day (if intake is 88 mmol per day then non-urinary
excretion should be 10 mmol per day). Only 10% to 15% of
patients who are suffering from spontaneous natriuresis
exceeding 78 mmol per day can be acknowledged for
sodium restriction in diet alone (i.e., without diuretics)
(Garg et al., 2011; Eisenmenger et al., 1949).
Fluid restriction is not necessary in treating most patients with ascites and cirrhosis. The chronic
hyponatremia usually present in cirrhotic ascites patients
is sometimes morbid unless it is immediately corrected at
the time of liver transplantation in the operating room. A
study of 997 patients with ascites and cirrhosis showed
that the sodium level in serum is not greater than 120

mmol/L in only 1.2% of patients and not higher than 125

mmol/L in only 5.7%. In this setting, a try to rapidly
correct hyponatremia with hypertonic saline can cause
severe complications as compared to hyponatremia itself
(Eisenmenger et al., 1950; Abbasoglu et al., 1998).
Salt restriction
The initial treatments in high SAAG ("transudate") are Salt
restriction, which allows diuresis (production of urine) as
the patient now has more fluid than salt concentration.
Salt restriction is fruitful in about 15% of patients (Gatta et
al., 1991).
Use of diuretics
As dietary salt restriction is the basic approach in the
treatment, and aldosterone is the hormone that tends to
increase salt retention, so a medicine that counterbalances
aldosterone should be used. Spironolactone is the drug of
choice as it blocks the aldosterone receptor in the
collecting tubule. This choice has been affirmed in a
randomized controlled trial. Dose of diuretics for ascites
should be once daily (Fogel et al., 1981).
Diuretic Regimen: Oral Spironolactone and furosemide are
given as a single morning doses in the normal diuretic
regimen, starting with 100 mg of the spironolactone and
40 mg of furosemide. Formerly, single-agent spironolactone was recommended, but hyperkalemia and the long
half-life of spironolactone have limited its use as a single
agent only in patients with minimal fluid overload. In a
randomized control trial the use of furosemide as a single
agent has been demonstrated to be less efficacious than
spironolactone. Another randomized trial showed that
only spironolactone should be used, while furosemide can
be added only when patients are refractory. The time to
mobilization of moderate ascites is shortened when initial
treatment is given in combination, as demonstrated in
another randomized trial. However another randomized
trial indicates that initial combination treatment shortens
the time to mobilization of moderate ascites. Most patients
need combination treatment eventually. A study was
performed which is said to be the largest involving a total
of 3860 patients with both ascites and cirrhosis, in which
combination therapy was given from the beginning. For
maintaining normokalemia and achieving rapid natriuresis, the preferred approach was to initiate the therapy
with both drugs. Amiloride (10-40 mg per day) can be
used in place of spironolactone in patients with tender
gynecomastia. Nonetheless, amiloride is more expensive
and has been shown to be less effective than an active
metabolite of spironolactone in a randomized controlled
trial. For the treatment of ascites metolazone, triamterene
and hydrochlorothiazide have also been used. While
using the combination of spironolactone and furosemide,

373

Table 5: Complications, symptoms and proposed treatment of ascites (Fullwood and Purushothaman, 2014).
Complications

Symptoms

Spontaneous
bacterial peritonitis
Dilutional
hyponatraemia
Hepatorenal
Syndrome
Pleural effusion

Abdominal pain, fever. May be asymptomatic.

Umbilical hernia

Treatments

Antibiotic administration. Large volume paracentesis

should be withheld until infection is treated effectively.
Increased peripheral oedema and re-accumulation of
Fluid restriction may be instigated if sodium is
ascites.
<130mmol/L, but should be used with caution
Reduced renal function, raised creatnine in the absence Administration of the vasoconstrictor terlipressin in
of infection, shock or use of nephrotoxic drugs.
combination with albumin. Liver transplantation.
Shortness of breath increased respiratory rate, reduced Chest drains are contraindicated for this cause of pleural
air entry.
effusion. First-line treatment includes diuretic administration and reduced sodium diet.
Swelling of the area around the umbilicus. May be
May require surgical intervention depending on the
associated with abdominal pain or discomfort.
severity of the hernia.

hyponatremia can rapidly develop if hydrochlorothiazide

is added; so it should either be avoided or used with
extreme caution. In the largest, multicenter, randomized
controlled trial performed in patients suffering from
ascites, dietary sodium restriction and a dual diuretic
regimen with spironolactone and furosemide has been
shown to be useful in more than 90% of patients in
accomplishing a reduction in the volume of ascites to
satisfactory levels (Angeloni et al., 2003).
Diuretics and albumin: A non-blinded randomized
controlled trial in patients suffering from new onset
ascites showed that 25 g infusions of albumin weekly, if
given for 1 year preceded by infusions every 2 weeks
enhanced survival related to diuretics alone (Wong et al.,
2012).
Treatment based on the cause of Ascites
Treatment of ascitic patients depends on the cause of fluid
accumulation. The SAAG can be helpful in identifying as
well as in ruling regarding treatment. Patients with low
SAAG (<1.1 g/dL) ascites normally do not have portal
hypertension and, with the omission of nephrotic
syndrome, that do not answer to salt restriction and
diuretics. In contrast, patients with a higher SAAG (1.1
g/dL) have portal hypertension and usually are amenable
to these measures. Liver injury due to alcohol intake is
one of the most volatile causes of liver disease that leads
to high SAAG ascites. Stopping alcohol intake is one of
the useful steps to treat the underlying cause in this
clinical setting. With self-restraint and time ascites may
become more responsive to medical therapy (Runyon,
2002; Angeloni et al., 2003).
Mechanical Methods
If a patient is resistance to or shows poor response to
diuretic therapy, then ultrafiltration or aquapheresis may
be needed to achieve adequate control of fluid retention
and congestion. The adoption of aforesaid mechanical
methods of fluid removal can produce significant clinical
benefits in patients with diuretic resistance and may
restore responsiveness to conventional doses of diuretics.
Water restriction may be needed if hyponatremia
(<130 mmol per liter) develops (Hunt et al., 2005; Gins et
al., 2004).
Therapeutic Paracentesis
In patients having severe (tense) ascites, therapeutic
paracentesis may be required. Albumin may sometimes
be given intravenously in the amount equal to the
proportion of ascites removed, as this method may

decline serum albumin levels in blood (Salerno et al.,

1987).
Site for Paracentesis: In the past, the midline was usually
selected as the site for paracentesis. Nonetheless, the
abdominal wall in the left lower fourth (quadrant), 2
fingerbreadths cephalad and 2 fingerbreadths medial to
the anterior superior iliac spine, which has been delineated to be narrow and with a greater pool of fluid as
compare to the midline. If the fluid is not easy to localize
by examination because of obesity, ultrasonography can
be helpful (Sakai et al., 2002).
Complications of Mechanical Methods: Even though older
published series indicated a relatively high disease rate,
and even death rate, when trocars were used for paracentesis, while in the recent studies no deaths or infections
caused by paracentesis has been documented as the
complication of paracenetsis in patients with ascites.
Although 71% of the patients show abnormal prothrombin time, however, in only 1% of the patients,
complications were detected. Although more serious
complications (hemoperitoneum or bowel entry by the
paracentesis needle) occur, they are sufficiently bizarre
(1/1,000 paracenteses) that they should not monish
performance of this procedure. It is the common practice
of some physicians to administer routinely blood
products to cirrhotic patients with coagulopathy before
performing paracentesis. This practice is not evidencesupported. The costs and risks of preventative transfusions surpass the benefit (Runyon, 1986; Webster et al.,
1996).
Contraindications for performing Paracentesis: There are few
contraindications
while
performing
paracentesis.
Coagulopathy should prevent paracentesis exclusively
when there is clinically noticeable fibrinolysis or clinically
obvious distributed intravascular coagulation. These
situations occur in less than 1 per 1,000 procedures. There
is no evidence-supported shut-off of coagulation parameters beyond which paracentesis should be prevented
(Runyon, 1986).
Use of Shunts
In small number of patients suffering from advanced
cirrhosis and have recurrent ascites, shunts may be used.
Commonly used shunts are peritoneovenous shunt,
portacaval shunt, and the transjugular intrahepatic
portosystemic shunt (TIPS). Nevertheless, none of these
shunts has been shown to extend life assurance, and are
considered to be the link to liver transplantation. A metaanalysis of randomized controlled trials by the interna-

374

tional Cochrane Collaboration agreed that "TIPS was more

effective at removing ascites as compared with paracentesis, nonetheless, TIPS patients establish hepatic
encephalopathy significantly more often" (Saab et al.,
2006).
Culturing bacteria for infection detection
Bacterial culture should be performed if ascitic fluid
infection is suspected i.e., fever, unexplained encephalopathy or abdominal pain. To identify neutropihils urine
dipstick can also be used which hardly takes 90 seconds to
minutes. Manual cell count can be replaced by automated
cell counting in order to have more accurate and speedy
results (Castellote et al., 2003; Eisenmenger et al., 1950).
It has been concluded from multiple prospective trials that when the polymorphonuclear leukocyte (PMN)
count was more than or equal to 250cells/mm3 in the
ascetic fluid was cultured by previous method, then the
bacterial growth occurs in almost 50% of the cases in
comparison to the ascitic fluid being inoculated into blood
culture bottles at the patients bedside was 80% (Angeloni
et al., 2003).
Usefulness of Baclofen
Baclofen has been shown in a randomized trial, which
included only patients with alcoholic liver disease, to
decrease alcohol craving and alcohol consumption; it can
be given at a dose of 5 mg orally tid for 3 days and then 10
mg tid. Ascites in decompensated hepatitis B cirrhosis and
autoimmune hepatitis can also have a dramatic response
to specific treatment. Liver diseases other than alcoholrelated, hepatitis B and autoimmune hepatitis are less
reversible; by the time ascites is present, these patients
may be perfect served by referring for liver transplantation opinion rather than protracted medical treatment
(Bruce et al., 2009; Addolorato et al., 2007).
Use of vaptans
Vaptans are a relatively new class of drugs (the vasopressin receptor antagonists) and have been studied
predominantly in heart failure but also in the setting of
cirrhosis. The most recent oral agent, satavaptan, was
especially studied to find its efficacy in treating ascites
rather than hyponatremia and was found to be not
clinically useful in the long-term treatment of ascites in
cirrhosis in a study including 1200 patients having
cirrhosis. Satavaptan was also associated with higher
mortality in comparison to placebo. These drugs can raise
thirst (Sterns, 1987; Wong et al., 2003).
Bed rest
Unfortunately, many drugs that have theoretical promise
in managing ascites, e.g., angiotensin-converting enzyme
inhibitors, have been shown to exacerbate hypotension
and have not been clinically helpful. Severe hyponatremia
does ensure fluid restriction in the patient with cirrhosis
and ascites; nonetheless, there is no evidence-supported
specific threshold for initiating fluid restriction and no
data-supported level of restriction. Although it is traditional to recommend bed rest (based on extrapolation
from heart failure), this is illogical and there are no
controlled trials to support this practice. Upright posture
may worsen the plasma renin elevation found in patients
with cirrhosis and ascites. Theoretically, this may increase
sodium cupidity. This theoretical interest would have to
translate into clinically relevant outcomes before bed rest
could be advised (Schrier et al., 2006).

COMPLICATIONS
COMPLICATIONS
However, some patients with cirrhosis and ascites also
have hepatic encephalopathy, gastrointestinal hemorrhage, bacterial infection, hypotension, azotemia, and/or
hepatocellular carcinoma, and may need hospitalization
for determinate diagnosis and management of their liver
disease as well as management of their fluid overload.
Diuretics should be retained in the setting of active
gastrointestinal bleeding, hepatic encephalopathy or renal
dysfunction. Frequently, intensive education is required
to ensure patient understanding that the diet and diuretics
are actually effective and worth the effort. There is no
limit to the daily weight loss of patients who have
significant edema. Once the edema has resolved, 0.5 kg is
probably a sensible daily maximum. In the past, patients
with ascites frequently occupied hospital beds for
prolonged periods of time because of confusion regarding
diagnosis and treatment and because of iatrogenic
problems (Angeloni et al., 2003).
As, the ultimate aim is to have no clinically identifiable fluid in the abdomen; but it is not significant for
getting discharge from the hospital. Patients, who are now
stable, with ascites as their main problem, can be released
from the clinic after it has been found that they are
responding to their medical regimen. Liver transplantation should be considered in the treatment options of
patients with ascites. Once patients become fractious to
routine medical therapy, 50% die within 6 months and 75%
die within 1 year. Referral should not be delayed in
patients with refractory ascites (Angeloni et al., 2003).
In patients with ascites possible associated complications are spontaneous bacterial peritonitis (a lifethreatening infection of the ascites fluid), hepatorenal
syndrome (kidney failure), weight loss and protein
malnutrition, mental confusion, coma (hepatic encephalopathy) or change in the level of alertness, and other
complications related to liver cirrhosis (Mehta and
Rothstein, 2009). Table 5 highlights some of the complications of ascites.
The most frequent decompensating event is the development of ascites in cirrhosis. Splanchnic and
peripheral vasodilatation is the most common etiological
factors causing ascites and leading to a decrease in
effective volume of blood. When talk about the usual
development of ascites, it is firstly a compensated event,
in which patient responds to diuretics, then becoming
resistant to its use, developing hyponatremia and finally
leading to hepatorenal syndrome. Most patients respond
to diuretics. Patients who no longer react should be
managed with repeated large - volume paracenteses.
Transjugular intrahepatic portosystemic shunt (TIPS)
should be considered in those requiring frequent paracenteses. Fluid restriction is suggested in patients with
hyponatraemia. Vasoconstrictors may revert hepatorenal
syndrome and are useful as a bridge to liver transplantation. Ascites itself is not lethal unless it gets infected
(spontaneous bacterial peritonitis). Infection often
increases the hepatorenal syndrome leading to mortality.
Antibiotic preventability is indicated for secondary
prophylaxis of spontaneous bacterial peritonitis and in
high - risk patients (GarciaTsao, 2011).

CONCLUSIONAND
ANDRECOMMENDATIONS
RECOMMENDATIONS
CONCLUSION
Ascites is a lethal disease, which is common all over the
world. Its early detection is required to ensure effective
management without any complications. It may be due to
hepatic or extra-hepatic causes. Treatment depends upon
the cause of the ascites. Dietary sodium restriction and

375

diuretics remains the first line therapy for its management.

Ascites itself is not fatal, unless it becomes infected. So,
awareness regarding this disease should be provided to
the people.
Recommendations:
Dietary salt should be restricted to a noadded salt
diet of 90 mmol salt/day (5.2 g salt/day)
Proper prognosis should be made before starting the
treatment, in order to get optimal therapeutic outcome.
In renal compromised patients, before performing
dialysis certain hygienic parameters should be kept in
mind by the patients like to wash hands (including
fingernails), before touching the catheter. Cleaning
the skin around the catheter daily. Following doctors
instructions regarding the care and storage of medical
supplies.
Treatment must begin promptly after diagnosis in
order to avoid serious and potentially fatal complications.
Laboratory examinations should be performed on
periodic basis to check the disease progression and
therapeutic effectiveness.
Due to compromised liver function unnecessary
medications should be avoided
Therapeutic drug monitoring (TDM) should be
performed for the drugs having narrow margin of
safety
Pharmacist should counsel the patients regarding the
potential side effects of the therapy, proper use and
duration of therapy for the optimal outcome.
Pharmacist should counter check the prescription
before handling to the patient.
Pharmacist should actively participate in patient
awareness programs regarding Ascites.

ACKNOWLEDGEMENT
ACKNOWLEDGEMENT
We would like to show our sincere regards to Prof. Dr.
Maqsood Ahmad, Director of Institute of Pharmacy,
Lahore College For Women University, Lahore, and all
the supervisors who helped us. Even our thanks would
not be enough for their tremendous support and help,
without their encouragement and guidance this review
would not have been possible. Last but not least we wish
to avail ourselves of this opportunity to express a sense of
gratitude and love to our beloved parents and lovely
friends for their manual support, strength and help.

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