What is ascites?
The increased pressure of portal hypertension causes fluid to seep out and pool in the abdominal cavity. This is called ascites.
People with liver disease may experience different amounts of fluid buildup – a little buildup of fluid may not cause any symptoms but as the amount of fluid increases it can cause waist size to expand and weight gain. When large amounts of fluid gather in the belly it can lead to swelling and pain and be very uncomfortable. The belly becomes hard from the fluid buildup, may resemble a pregnancy belly and the belly button can become pushed out. Some people with ascites may develop swollen legs and ankles, called edema. Ascites can become infected for no reason which is called spontaneous bacterial peritonitis. This infection needs to be treated early with the right antibiotics. If left untreated the infection can be fatal. This infection can also greatly impact the function of your kidney. Someone with spontaneous bacterial peritonitis will usually feel even more uncomfortable and experience tenderness in their abdomen and may develop a fever.
How is ascites treated?
Ascites is treated with a low-sodium diet, medications called diuretics, removing the fluid, or surgery to reroute blood flow. Reducing sodium, or salt, is a first line therapy for ascites. If you have ascites, be sure to learn more from a nutritionist who specializes in the liver about your unique needs. Medications called diuretics may be prescribed which make the kidneys excrete more sodium and water into your urine, causing you to pee more frequently. Sometimes, diuretics are not enough, and the fluid will continue to build up. When this happens, someone may have a procedure called therapeutic paracentesis. During paracentesis, a doctor, usually an interventional radiologist, uses ultrasound to guide a needle into the abdomen and drain the fluid out of the body. The fluid will build back up and the procedure will need to be repeated. If someone continues to have fluid build-up or other treatments do not work, a doctor may consider a TIPS procedure (transjuglar intrahepatic portosystemic shunt). During a TIPS procedure, a new pathway is made to connect the portal vein, or one of its branches, with a vein in general circulation, bypassing the liver. While this shunt placement can improve ascites, it can also cause a worsening in hepatic encephalopathy or in liver function.
What is ascites?
One common problem caused by high pressure in the veins of the liver is ascites. Fluid leaks out into the belly and begins to fill it up. This can make the abdomen (belly) enlarge like a balloon filled with water. The legs can get swollen too. This can be very uncomfortable.
How do you treat ascites?
Avoid further liver damage Stop all alcohol consumption
- Low salt (sodium) diet The buildup of fluid is the result of too much salt (sodium) intake. Most of the salt in a person’s diet comes from processed foods, even for people who do not use a salt shaker. For this reason, it is important to reduce your salt intake by carefully reviewing how much sodium is in your food and drink. We usually aim for less than 2000mg of sodium per day. Often you will be asked to work with a nutritionist. Please note: even though fluid is building up, this is not a problem with water or fluid intake! It’s the salt/sodium that causes the fluid to build up in the belly. The key is to limit your salt intake, not your fluid intake.
- Diuretic medications (“Water Pills”) These medications help the body get rid of the extra salt and fluid through the kidneys. Common medications include spironolactone (Aldactone®), and furosemide (Lasix®). One treatment plan begins with 100 mg of spironolactone and 40 mg of furosemide every morning. Weight (fluid) loss is often slow. If there is no weight loss in the first 2 weeks, the dose is gradually increased. Response to treatment varies and finding out which treatment plan works best for you takes time, as the doctor adjusts the dose of medications over a period of weeks or months.
- Paracentesis (Tap) Paracentesis is draining fluid out of the abdomen with a needle. This is done using local anesthetic (lidocaine). Taps provide relief of ascites symptoms, but the fluid eventually returns. You must follow strict sodium restriction and diuretic therapy in order to slow down the build-up of fluid. Frequent taps can increase the risk of infection, and cause an imbalance of nutrients (potassium and sodium) levels in the blood. It can also worsen kidney function.
- Monitor progress During treatment, it is important that both you and your doctor monitor your weight and blood tests. This is especially true if you are taking diuretics (which may cause reduced kidney function and changes in your blood levels of sodium and potassium). The best way you can help the doctors manage your fluid problem is by recording your weight and dose of water pills (diuretics) every day. Use the log available to record your weight and diuretic dose daily:
Transjugular intrahepatic portosystemic shunt, or TIPS procedure
TIPS is the placement of a shunt (internal tunnel) within the liver to improve blood flow. A TIPS procedure is performed through the veins and does not require surgery. TIPS can help control bleeding from varices if other simple measures fail. In some cases, it can also help to decrease fluid buildup (ascites). About 30 out of 100 (30%) of patients develop mental confusion after TIPS, and in some cases the shunt must be closed back down. Rarely, jaundice and liver failure develops after a TIPS procedure.
Liver transplant
Developing ascites as a complication of cirrhosis of the liver is a concerning sign. Liver transplant is the best treatment if you are an appropriate candidate, but unfortunately, not all people qualify for this procedure. Talk to your doctor about liver transplant if you have decompensated cirrhosis. Special risks and considerations in ascites • Spontaneous bacterial peritonitis This condition occurs when ascites becomes infected, and it can be life threatening. Symptoms include fever and abdominal pain but you may not have these symptoms in the early stages. If you have an infection of ascites, you will need to be admitted for IV (intravenous) antibiotics. After the first episode of peritonitis is treated, you will take an antibiotic pill to prevent future episodes of peritonitis. Sometimes we recommend antibiotics to prevent peritonitis even in people who have never had it.