A common complaint in patients with liver problems is a sensation of fullness or bloating within the abdomen. This sensation results from increased water retention within the membranous lining of the abdominal tissue known as ascites, according to "Harrison's Principles of Internal Medicine." Ascites increases the intra-abdominal pressure and distends the abdomen. A study published in Mayo Clinic Proceedings describes ascites as an accumulation of fluid within the peritoneal cavity due to portal hypertension. Portal hypertension is a result of liver diseases, most commonly cirrhosis.
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According to "Clinical Hepatology: Principles and Practice of Hepatobiliary Diseases" by Dr. Henryk Dancygier, approximately 25 percent of cirrhosis patients develop ascites within 10 years. Prognostically, the development of ascites is important to predicting the patient's survival and healing outcome. Ascites is associated with an 80 percent mortality rate. Death has been shown to occur less than five years after the first appearance of the peritoneal fluid accumulation.
The conditions that cause ascites vary widely, with liver problems being the most common. Of all ascites instances, the liver disease known as cirrhosis makes up more than 80 percent of cases, according to "Harrison's Principles of Internal Medicine." Other liver causes include "mixed ascites," fulminant hepatic failure, alcoholic hepatitis, viral hepatitis, massive hepatic metastases, nonalcoholic steatohepatitis and hepatic fibrosis.
Researchers Lewis Roberts and Dr. Patrick Kamath of the Mayo Clinic published an article about the relationship between the renin-angiotensin-aldosterone system and ascites in cirrhosis patients. Cirrhosis leads to dysfunctions in the renin-angiotensin-aldosterone system, resulting in the sodium imbalance and water retention that cause ascites. Cirrhosis also produces sinusoidal portal hypertension, which further increases the ascites by promoting localization of fluid in the peritoneal cavity.
Signs and Symptoms
Drs. Maxine Papadakis and Stephen McPhee provide a list of the signs and symptoms of ascites in "2007 Current Consult Medicine." Some of the most common signs listed are consistent redness of the palms, enlarging of the breasts in men, increasing abdominal girth and cutaneous spider angiomas--red splotches on the surface of the skin due to dilated blood vessels that appear in spider-like or flower-like patterns. Common symptoms include abdominal pain, swollen ankles, lower back pain, shortness of breath, the sensation of skin stretching across the stomach and a tender liver.
According to Roberts and Kamath, the goal of ascites treatment is to achieve a negative sodium balance to decrease the amount of fluid trapped within the abdomen interstitium. Dancygier promotes a treatment regimen that starts with bed rest and a sodium-restricted diet. Next, an aldosterone antagonist called spironolactone is combined to the patient management to reduce the trapped fluid. Then, if the measures aren't adequate, a loop diuretic such as furosemide or torsemide is added. In persistent ascites, large-volume paracentesis is applied to manually remove the fluid by large-bore needle. Liver transplant is suggested if previous measures are ineffective.
REFERENCES & RESOURCES
- "Harrison's Principles of Internal Medicine" 17th Ed.; Anthony Fauci, M.D., et al., eds.; 2008
- "2007 Current Consult Medicine"; Maxine Papadakis, M.D. and Stephen McPhee, M.D.; 2007
- "Clinical Hepatology: Principles and Practice of Hepatobiliary Diseases"; Henryk Dancygier, M.D.; 2010
- "Mayo Clinic Proceedings"; Ascites and Hepatorenal Syndrome: Pathophysiology and Management; Lewis Roberts, Ph.D. and Patrick Kamath, M.D.; September 1996
- Merck Manual: Ascites
- Mayo Clinic: Cirrhosis