View source for Ascites

{{Short description|Abnormal build-up of fluid in the abdomen}}
{{Infobox medical condition (new)
| name            = Ascites
| synonyms        = Peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum, abdominal dropsy<ref name=PM2017/>
| image           = Hepaticfailure.jpg
| caption         = The [[abdomen]] of a person with [[cirrhosis]] that has resulted in massive ascites and prominent superficial veins
| pronounce       = {{IPAc-en|@|'|s|ai|t|i:|z}}, {{Respell|ə|SY|teez}}<ref>{{cite web |title=Ascites {{!}} Definition of Ascites by Lexico |url=https://www.lexico.com/en/definition/ascites |archive-url=https://web.archive.org/web/20191025150253/https://www.lexico.com/en/definition/ascites |url-status=dead |archive-date=October 25, 2019 |website=Lexico Dictionaries {{!}} English |access-date=26 October 2019 |language=en}}</ref>
| field           = [[Gastroenterology]]
| symptoms        = Increased abdominal size, increased weight, abdominal discomfort, [[shortness of breath]]<ref name=Mer2016/>
| complications   = [[Spontaneous bacterial peritonitis]], [[hepatorenal syndrome]], [[hyponatremia|low blood sodium]]<ref name=Mer2016/><ref name=Ped2015/>
| onset           =
| duration        =
| types           =
| causes          = [[Liver cirrhosis]], [[cancer]], [[heart failure]], [[tuberculosis]], [[pancreatitis]], [[Budd–Chiari syndrome|blockage of the hepatic vein]]<ref name=Ped2015/>
| risks           =
| diagnosis       = [[Physical exam]], [[ultrasound]], [[CT scan]]<ref name=Mer2016/>
| differential    =
| prevention      =
| treatment       = [[Low-salt diet]], medications, [[paracentesis|draining the fluid]]<ref name=Mer2016/>
| medication      = [[Spironolactone]], [[furosemide]]<ref name=Mer2016/>
| prognosis       =
| frequency       = >50% of people with cirrhosis<ref name=Ped2015/>
| deaths          =
}}
<!-- Definition and symptoms -->
'''Ascites''' ({{IPAc-en|ə|ˈ|s|aɪ|t|i|z}};<ref name="Pron2017">{{cite web |author=Staff writer |year=2010 |title=Ascites |url=http://dictionary.reference.com/browse/ascites |access-date=December 14, 2017 |work=Dictionary.com |publisher=[[IAC (company)|IAC]] |location=Oakland, CA}}</ref> {{langx|el|ἀσκός|translit=askos}}, meaning "bag" or "sac"<ref>{{Cite web |date=2024-01-22 |title=Ascites: background |url=https://emedicine.medscape.com/article/170907-overview?form=fpf}}</ref>) is the abnormal build-up of fluid in the [[abdomen]].<ref name=PM2017>{{cite web|title=Ascites|url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022961/|website=National Library of Medicine|access-date=14 December 2017}}</ref> Technically, it is more than 25 ml of fluid in the [[peritoneal cavity]], although volumes greater than one liter may occur.<ref name=Ped2015>{{cite journal|last1=Pedersen|first1=JS|last2=Bendtsen|first2=F|last3=Møller|first3=S|title=Management of cirrhotic ascites.|journal=Therapeutic Advances in Chronic Disease|date=May 2015|volume=6|issue=3|pages=124–37|pmid=25954497|pmc=4416972|doi=10.1177/2040622315580069}}</ref> Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and [[shortness of breath]].<ref name=Mer2016/> Complications can include [[spontaneous bacterial peritonitis]].<ref name=Mer2016>{{cite web|title=Ascites - Hepatic and Biliary Disorders|url=http://www.merckmanuals.com/en-ca/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/ascites|website=Merck Manuals Professional Edition|access-date=14 December 2017|language=en-CA|date=May 2016}}</ref>
<!-- Cause and diagnosis -->
In the [[developed world]], the most common cause is [[liver cirrhosis]].<ref name=Ped2015/> Other causes include [[cancer]], [[heart failure]], [[tuberculosis]], [[pancreatitis]], and [[Budd–Chiari syndrome|blockage of the hepatic vein]].<ref name=Ped2015/> In cirrhosis, the underlying mechanism involves [[portal hypertension|high blood pressure in the portal system]] and dysfunction of [[blood vessels]].<ref name=Ped2015/> Diagnosis is typically based on an examination together with [[ultrasound]] or a [[CT scan]].<ref name=Mer2016/> Testing the fluid can help in determining the underlying cause.<ref name=Mer2016/>
<!-- Treatment -->
Treatment often involves a [[low-salt diet]], medication such as [[diuretic]]s, and [[paracentesis|draining the fluid]].<ref name=Mer2016/> A [[transjugular intrahepatic portosystemic shunt]] (TIPS) may be placed but is associated with complications.<ref name=Mer2016/> Attempts to treat the underlying cause, such as by a [[liver transplant]], may be considered.<ref name=Ped2015/> Of those with cirrhosis, more than half develop ascites in the ten years following diagnosis.<ref name=Ped2015/> Of those in this group who develop ascites, half will die within three years.<ref name=Ped2015/>
==Etymology==
The [[Latin]] ascites, originally from [[Greek language|Greek]] (askites [ασκίτης]), meant "bag-like dropsy," from askós (ἀσκός), a leather bag or sheepskin (“wineskin”) used for carrying wine, water or oil.<ref>{{cite journal |last1=Wong |first1=Florence |last2=Blendis |first2=Laurence |title=Historical Aspects of Ascites and the Hepatorenal Syndrome |journal=Clinical Liver Disease |date=29 October 2021 |volume=18 |issue=Suppl 1 |pages=14–27 |doi=10.1002/cld.1090 |pmid=34745581 |pmc=8555459 }}</ref>
==Signs and symptoms==
Mild ascites is hard to notice, but severe ascites leads to [[abdominal distension]]. People with ascites generally will complain of progressive abdominal heaviness and pressure as well as [[shortness of breath]] due to mechanical impingement on the [[diaphragm (anatomy)|diaphragm]].<ref>{{cite web | url= https://www.hopkinsmedicine.org/health/conditions-and-diseases/ascites | title= Ascites | website= Johns Hopkins Medicine |access-date= 1 July 2021}}</ref>
Ascites is detected with [[physical examination]] of the abdomen by visible bulging of the flanks in the reclining person ("flank bulging"), "[[shifting dullness]]" (difference in percussion note in the flanks that shifts when the person is turned on the side), or in massive ascites, with a "fluid thrill" or "[[Fluid wave test|fluid wave]]" (tapping or pushing on one side will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen).
Other signs of ascites may be present due to its underlying cause. For instance, in [[portal hypertension]] (perhaps due to cirrhosis or fibrosis of the liver) people may also complain of leg swelling, bruising, [[gynecomastia]], [[hematemesis]], or mental changes due to [[encephalopathy]]. Those with ascites due to [[cancer]] (peritoneal carcinomatosis) may complain of chronic fatigue or weight loss. Those with ascites due to [[heart failure]] may also complain of shortness of breath as well as wheezing and exercise intolerance.
==Causes==
Causes of high [[serum-ascites albumin gradient]] (SAAG or transudate) are:<ref name="OTM" />
* [[Cirrhosis]] – 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%)
* [[Heart failure]] – 3%
* Hepatic venous occlusion: [[Budd–Chiari syndrome]] or [[veno-occlusive disease]]
* [[Constrictive pericarditis]]
* [[Kwashiorkor]] (childhood protein-energy malnutrition)
Causes of low SAAG ("exudate") are
* [[Cancer]] (metastasis and [[primary peritoneal carcinoma]]tosis) – 10%
* Infection: [[Tuberculosis]] – 2% or [[spontaneous bacterial peritonitis]]
* [[Pancreatitis]] – 1%
* [[Serositis]]
* [[Nephrotic syndrome]]<ref>Kumar & Clark's Clinical Medicine e.8 Chapter 7: Liver, biliary tract and pancreatic disease Pg. 335</ref>
* Hereditary [[angioedema]]<ref name="pmid9636820">{{cite journal |vauthors=Branco-Ferreira M, Pedro E, Barbosa MA, Carlos AG |title=Ascites in hereditary angioedema |journal=Allergy |volume=53 |issue=5 |pages=543–5 |year=1998 |pmid=9636820 |doi=10.1111/j.1398-9995.1998.tb04098.x|s2cid=35762764 }}</ref>
==Diagnosis==
[[File:Auscities.PNG|thumb|Ascites in a person with abdominal cancer as seen on ultrasound]] [[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites]]
Routine [[complete blood count]] (CBC), basic metabolic profile, [[liver enzymes]], and [[coagulation]] should be performed. Most experts recommend diagnostic [[paracentesis]] if the ascites is new or if the person with ascites is being admitted to the hospital. The fluid is then reviewed for its gross appearance, protein level, [[human serum albumin|albumin]], and cell counts (red and white). Additional tests will be performed if indicated such as [[microbiological culture]], [[Gram stain]], and [[cytopathology]].<ref name=OTM>Warrell DA, Cox TN, Firth JD, Benz ED. ''Oxford textbook of medicine''. Oxford: Oxford University Press, 2003. {{ISBN|0-19-262922-0}}.</ref>
The [[serum-ascites albumin gradient]] (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites.<ref>{{cite journal | pmid = 1616215 | volume=117 | issue=3 | title=The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites |date=August 1992 |vauthors=Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG | journal=Ann. Intern. Med. | pages=215–20 | doi=10.7326/0003-4819-117-3-215| s2cid=24317271 }}</ref> A high gradient (>&nbsp;1.1&nbsp;g/dL) indicates the ascites is due to portal hypertension. A low gradient (<&nbsp;1.1&nbsp;g/dL) indicates ascites of non-portal hypertensive as a cause.<ref name="Ascites">{{cite web | url= https://www.lecturio.com/concepts/ascites/ | title= Ascites | website= The Lecturio Medical Concept Library |access-date= 1 July 2021}}</ref>
[[Medical ultrasonography|Ultrasound]] investigation is often done before attempts to remove fluid from the abdomen. This may reveal the size and shape of the abdominal organs, and Doppler studies may show the direction of flow in the portal vein, as well as detecting [[Budd–Chiari syndrome]] (thrombosis of the hepatic vein) and [[portal vein thrombosis]]. The sonographer also can estimate the amount of ascitic fluid, and difficult-to-drain ascites may be drained under ultrasound guidance. An abdominal [[X-ray computed tomography|CT scan]] is more accurate than a sonogram to reveal abdominal organ structure and morphology.<ref name="Ascites"/>
===Classification===
Uncomplicated ascites is characterized by receding or nonrecurring ascites post-[[paracentesis]], and is treatable with diet control and diuretic treatment. Refractory ascites is characterized as ascites that recurs or does not recede post-paracentesis, despite diet control and diuretic treatment.<ref>{{Cite journal |last1=Siqueira |first1=Fabiolla |last2=Kelly |first2=Traci |last3=Saab |first3=Sammy |date=2009-09-01 |title=Refractory Ascites: Pathogenesis, Clinical Impact, and Management |journal=Gastroenterology and Hepatology |volume=5 |issue=9 |pages=647–656 |issn=1554-7914 |pmc=2886420 |pmid=37967427}}</ref>
Uncomplicated ascites is more common, responsive to treatment, and exists in three grades:<ref>{{cite journal |last=Moore |first=K. P. |author2=Wong, F. |author3=Gines, P. |author4=Bernardi, M. |author5=Ochs, A. |author6=Salerno, F. |author7=Angeli, P. |author8=Porayko, M. |author9=Moreau, R. |author10=Garcia-Tsao, G. |author11=Jimenez, W. |author12=Planas, R. |author13=Arroyo, V|display-authors=3 |title=The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club |journal=Hepatology |year=2003 |volume=38 |issue=1 |pages=258–66 |pmid=12830009 |doi=10.1053/jhep.2003.50315|doi-access=free }}</ref>
* Grade 1: mild, only visible on ultrasound and CT
* Grade 2: detectable with flank bulging and shifting dullness
* Grade 3: directly visible, confirmed with the [[fluid wave test]]
Refractory ascites is less common, difficult to treat, and exists in two subtypes: i) diuretic intractable ascites makes up the majority of refractory ascites cases, where diuretic treatment is difficult due to diuretic-induced complications such as elevated creatinine and [[hypokalemia]]; ii) diuretic resistant ascites does not respond to diuretic treatment.<ref>{{Cite journal |last1=Moore |first1=K. P. |last2=Aithal |first2=G. P. |date=2006-10-01 |title=Guidelines on the management of ascites in cirrhosis |url=https://gut.bmj.com/content/55/suppl_6/vi1 |journal=Gut |language=en |volume=55 |issue=suppl 6 |pages=vi1–vi12 |doi=10.1136/gut.2006.099580 |issn=0017-5749 |pmc=1860002 |pmid=16966752}}</ref><ref>{{Citation |last1=Kwo |first1=Paul Y. |title=Clinical Features of Liver Disease |date=2011-01-01 |url=https://www.sciencedirect.com/science/article/pii/B978044306803400006X |work=Practical Hepatic Pathology: A Diagnostic Approach |pages=63–72 |editor-last=Saxena |editor-first=Romil |access-date=2023-11-18 |place=Saint Louis |publisher=W.B. Saunders |doi=10.1016/b978-0-443-06803-4.00006-x |isbn=978-0-443-06803-4 |last2=Strahotin |first2=Cristina Simona}}</ref>
==Pathophysiology==
Ascitic fluid can accumulate as a [[transudate]] or an [[exudate]]. Amounts of up to 35 liters are possible.
Roughly, transudates are a result of increased pressure in the [[hepatic portal vein]] (>8&nbsp;mmHg, usually around 20&nbsp;mmHg<ref>{{cite journal |last1=Castell |first1=Donald O. |title=Ascites in cirrhosis: Relative importance of portal hypertension and hypoalbuminemia |journal=The American Journal of Digestive Diseases |date=September 1967 |volume=12 |issue=9 |pages=916–922 |doi=10.1007/BF02236449 |pmid=6039572 |s2cid=28150018 }}</ref> (e.g., due to cirrhosis), while exudates are actively secreted fluid due to [[inflammation]] or malignancy. As a result, exudates are high in protein and [[lactate dehydrogenase]] and have a low [[pH]] (<7.30), a low [[glucose]] level, and more [[white blood cell]]s. Transudates have low protein (<30&nbsp;g/L), low LDH, high pH, normal glucose, and fewer than 1 white cell per 1000&nbsp;mm<sup>3</sup>. Clinically, the most useful measure is the difference between ascitic and [[serum albumin]] concentrations. A difference of less than 1&nbsp;g/dl (10&nbsp;g/L) implies an exudate.<ref name=OTM/>
Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed.
Regardless of the cause, sequestration of fluid within the abdomen leads to additional [[Water retention (medicine)|fluid retention]] by the kidneys due to stimulatory effect on blood pressure hormones, notably [[aldosterone]]. The [[sympathetic nervous system]] is also activated, and [[renin]] production is increased due to decreased perfusion of the kidney. Extreme disruption of the renal blood flow can lead to [[hepatorenal syndrome]]. Other complications of ascites include [[spontaneous bacterial peritonitis]] (SBP), due to decreased antibacterial factors in the ascitic fluid such as [[Complement system|complement]].
==Treatment==
[[File:Diagram showing fluid (ascites) being drained from the abdomen CRUK 122.svg|thumb|Diagram showing ascites being drained]]
Ascites is generally treated while an underlying cause is sought, in order to relieve symptoms and to prevent complications and progression. In people with mild ascites, therapy is usually as an outpatient. The goal is weight loss of no more than 1.0&nbsp;kg/day for people with both ascites and [[peripheral edema]] and no more than 0.5&nbsp;kg/day for people with ascites alone.<ref name="pmid4910836">{{cite journal |vauthors=Shear L, Ching S, Gabuzda GJ |title=Compartmentalization of ascites and edema in patients with hepatic cirrhosis |journal=N. Engl. J. Med. |volume=282 |issue=25 |pages=1391–6 |year=1970 |pmid=4910836 |doi=10.1056/NEJM197006182822502}}</ref> In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for [[paracentesis]].<ref name="pmid3297907">{{cite journal |vauthors=Ginés P, Arroyo V, Quintero E |title=Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study |journal=Gastroenterology |volume=93 |issue=2 |pages=234–41 |year=1987 |pmid=3297907 |doi=10.1016/0016-5085(87)91007-9|display-authors=etal|doi-access=free }}</ref><ref name="pmid3655306">{{cite journal |vauthors=Salerno F, Badalamenti S, Incerti P |title=Repeated paracentesis and i.v. albumin infusion to treat 'tense' ascites in cirrhotic patients. A safe alternative therapy |journal=J. Hepatol. |volume=5 |issue=1 |pages=102–8 |year=1987 |pmid=3655306|doi=10.1016/S0168-8278(87)80067-3|display-authors=etal}}</ref>
=== High serum-ascites albumin gradient (transudative) ascites ===
====Diet====
Salt restriction is the initial treatment, which allows [[:wikt:diuresis|diuresis]] (production of urine) since the person now has more fluid than salt concentration. Salt restriction is effective in about 15% of these people.<ref name="pmid1860680">{{cite journal |vauthors=Gatta A, Angeli P, Caregaro L, Menon F, Sacerdoti D, Merkel C |title=A pathophysiological interpretation of unresponsiveness to spironolactone in a stepped-care approach to the diuretic treatment of ascites in nonazotemic cirrhotic patients |journal=Hepatology |volume=14 |issue=2 |pages=231–6 |year=1991 |pmid=1860680 |doi=10.1002/hep.1840140205|s2cid=24614489 |doi-access=free }}</ref> Water restriction is needed if [[hyponatremia|serum sodium levels drop below 130&nbsp;mmol&nbsp;L<sup>−1</sup>]].<ref name="pmid15084697"/>
====Diuretics====
Because salt restriction is the basic concept in treatment, and [[aldosterone]] is one of the hormones that increase salt retention, a medication that counteracts aldosterone should be sought. [[Spironolactone]] (or other distal-tubule diuretics, such as [[triamterene]] and [[amiloride]]) is the drug of choice, because it blocks the aldosterone receptor in the collecting tubule. This choice has been confirmed in a [[randomized controlled trial]].<ref name="pmid7035545">{{cite journal |vauthors=Fogel MR, Sawhney VK, Neal EA, Miller RG, Knauer CM, Gregory PB |title=Diuresis in the ascitic patient: a randomized controlled trial of three regimens |journal=[[Journal of Clinical Gastroenterology]] |volume=3 |issue=Suppl 1 |pages=73–80 |year=1981 |pmid=7035545 |doi=10.1097/00004836-198100031-00016}}</ref> Diuretics for ascites should be taken once a day.<ref name="pmid8277955">{{cite journal |author=Runyon BA |title=Care of patients with ascites |journal=[[New England Journal of Medicine]] |volume=330 |issue=5 |pages=337–42 |year=1994 |pmid=8277955|doi=10.1056/NEJM199402033300508}}</ref> Generally, the starting dose is oral spironolactone 100&nbsp;mg/day (max 400&nbsp;mg/day).
40% of people will respond to spironolactone.<ref name="pmid1860680"/> For nonresponders, a [[loop diuretic]] may also be added and generally, [[furosemide]] is added at a dose of 40&nbsp;mg/day (max 160&nbsp;mg/day), or alternatively ([[bumetanide]] or [[torasemide]]). The ratio of 100:40 reduces risks of potassium imbalance.<ref name="pmid8277955"/> Serum [[potassium]] level and renal function should be monitored closely while the patient is on these medications.<ref name="pmid15084697">{{cite journal |vauthors=Ginès P, Cárdenas A, Arroyo V, Rodés J |title=Management of cirrhosis and ascites |journal=New England Journal of Medicine |volume=350 |issue=16 |pages=1646–54 |year=2004 |pmid=15084697 |doi=10.1056/NEJMra035021}}</ref>
Monitoring diuresis: Diuresis can be monitored by weighing the person daily. The goal is weight loss of no more than 1.0&nbsp;kg/day for people with both ascites and [[peripheral edema]] and no more than 0.5&nbsp;kg/day for people with ascites alone.<ref name="pmid4910836"/>
If daily weights cannot be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs.<ref name="pmid8277955"/> A random urine sodium-to-potassium ratio of > 1 is 90% [[sensitivity (tests)|sensitivity]] in predicting negative balance (> 78-mmol/day sodium excretion).<ref name="Runyon1996">{{cite journal |vauthors=Runyon BA, Heck M |title=Utility of 24-hour urine sodium collection and urine Na/K ratios in the management of patients with cirrhosis and ascites |journal=Hepatology |volume=24 |pages=571A |year=1996 }}</ref>
Diuretic resistance: Diuretic resistance can be predicted by giving 80&nbsp;mg intravenous furosemide after 3 days without diuretics and on an 80 mEq sodium/day diet. The urinary sodium excretion over 8 hours <&nbsp;50&nbsp;mEq/8 hours predicts resistance.<ref name="pmid11124817">{{cite journal |vauthors=Spahr L, Villeneuve JP, Tran HK, Pomier-Layrargues G |title=Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites |journal=Hepatology |volume=33 |issue=1 |pages=28–31 |year=2001 |pmid=11124817 |doi=10.1053/jhep.2001.20646|doi-access=free }}</ref>
If the person exhibits a resistance or poor response to diuretic therapy, [[ultrafiltration]] or [[aquapheresis]] may be needed to achieve adequate control of fluid retention and congestion. The use of such mechanical methods of fluid removal can produce meaningful clinical benefits in people with diuretic resistance and may restore responsiveness to conventional doses of diuretics.<ref name="pmid16160202">{{cite journal |vauthors=[[Sharon Ann Hunt|Hunt SA]], Abraham WT, Chin MH |title=ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation (journal)|Circulation]] |volume=112 |issue=12 |pages=154–235 |year=2005 |pmid=16160202 |doi=10.1161/CIRCULATIONAHA.105.167586|display-authors=etal|doi-access=free }}</ref><ref name="pmid16500560">{{cite journal |vauthors=Adams KF, Lindenfeld J, Arnold JM, Baker DW, Barnard DH, Baughman KL, Boehmer JP, Deedwania P, Dunbar SB, Elkayam U, Gheorghiade M, Howlett JG, Konstam MA, Kronenberg MW, Massie BM, Mehra MR, Miller AB, Moser DK, Patterson JH, Rodeheffer RJ, Sackner-Bernstein J, Silver MA, Starling RC, Stevenson LW, Wagoner LE|display-authors=3 |title=[[Heart Failure Society of America]] (HFSA) 2006 Comprehensive Heart Failure Practice Guideline. |journal=[[Journal of Cardiac Failure]] |volume=12 |pages=e1–e122 |year=2006 |pmid=16500560 |issue=1 |doi=10.1016/j.cardfail.2005.11.005}}</ref>
====Paracentesis====
{{main|Paracentesis}}
In those with severe (tense) ascites, therapeutic [[paracentesis]] may be needed in addition to medical treatments listed above.<ref name="pmid3297907"/><ref name="pmid3655306"/> As this may deplete [[serum albumin]] levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed.
====Surgery====
Ascites that is refractory to medical therapy is considered an indication for [[liver transplantation]]. In the United States, the [[Model for End-Stage Liver Disease|MELD score]]<ref name="pmid2682175">{{cite journal |vauthors=Cosby RL, Yee B, Schrier RW |title=New classification with prognostic value in cirrhotic patients |journal=Mineral and Electrolyte Metabolism |volume=15 |issue=5 |pages=261–6 |year=1989 |pmid=2682175 }}</ref> is used to prioritize people for transplantation.
In a minority of people with advanced cirrhosis that have recurrent ascites, shunts may be used. Typical shunts used are the [[portacaval shunt]], the [[peritoneovenous shunt]], and the [[transjugular intrahepatic portosystemic shunt]] (TIPS). However, none of these has been shown to extend life expectancy, and they are considered to be bridges to [[liver transplantation]]. A 2006 [[meta-analysis]] concluded that "TIPS was more effective at removing ascites [than] paracentesis[,] without a significant difference in mortality, gastrointestinal bleeding, infection, and acute renal failure. However, TIPS patients develop hepatic encephalopathy significantly more often."<ref name="pmid17054221">{{cite journal |vauthors=Saab S, Nieto JM, Lewis SK, Runyon BA |title=TIPS versus paracentesis for cirrhotic patients with refractory ascites |journal=Cochrane Database of Systematic Reviews |issue=4 |pages=CD004889 |year=2006 |volume=2010 |pmid=17054221 |doi=10.1002/14651858.CD004889.pub2|pmc=8855742 }}</ref>
Another option for people with refractory or malignant ascites is the automated low-flow ascites pump (Alfapump), an implanted machine, which uses a pump to move ascites from the peritoneal cavity to the bladder for urination.<ref>{{cite journal |last1=Angeli |first1=Paolo |last2=Bernardi |first2=Mauro |last3=Villanueva |first3=Càndid |last4=Francoz |first4=Claire |last5=Mookerjee |first5=Rajeshwar P. |last6=Trebicka |first6=Jonel |last7=Krag |first7=Aleksander |last8=Laleman |first8=Wim |last9=Gines |first9=Pere|display-authors=3 |title=EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis |journal=Journal of Hepatology |date=August 2018 |volume=69 |issue=2 |pages=406–460 |doi=10.1016/j.jhep.2018.03.024 |pmid=29653741 |s2cid=206137363 |doi-access=free }}</ref><ref>{{Cite web|title=NICE Guidelines, UK 2018. (NICEGuidance IPG 631, replacing IPG479|date=14 November 2018 |url=https://www.nice.org.uk/guidance/ipg631|url-status=live|archive-url=https://web.archive.org/web/20211029172624/https://www.nice.org.uk/guidance/ipg631 |archive-date=2021-10-29 }}</ref>
=== Low SAAG ("exudative") ascites ===
Exudative ascites generally does not respond to manipulation of the salt balance or diuretic therapy.<ref>{{cite journal | pmid=19115470 | date=2009 | last1=Senousy | first1=B. E. | last2=Draganov | first2=P. V. | title=Evaluation and management of patients with refractory ascites | journal=World Journal of Gastroenterology | volume=15 | issue=1 | pages=67–80 | doi=10.3748/wjg.15.67 | pmc=2653293 | doi-access=free }}</ref> Repeated paracentesis and treatment of the underlying cause is the mainstay of treatment.
==Society and culture==
It has been suggested that ascites was seen as a punishment especially for [[oath]]-breakers among the [[Proto-Indo-Europeans]].<ref>Oettinger, Norbert. Die Militärischen Eide der Hethiter. Wiesbaden, 1976. {{ISBN|3-447-01711-2}}.</ref> This proposal builds on the [[Hittite military oath]] as well as various [[Veda|Vedic]] hymns ([[Rigveda|RV]] 7.89, [[Atharvaveda|AVS]] 4.16.7). A similar curse dates to the [[Kassites|Kassite]] dynasty (12th century BC).
==References==
{{Reflist}}
==External links==
{{Medical resources
| DiseasesDB      = 943
| ICD10           = {{ICD10|R|18||r|10}}
| ICD9            = {{ICD9|789.5}}
| ICDO            =
| OMIM            =
| MedlinePlus     = 000286
| eMedicineSubj   = ped
| eMedicineTopic  = 2927
| eMedicine_mult  = {{eMedicine2|med|173}}
| MeshID          = D001201
}}
{{Digestive system and abdomen symptoms and signs}}
{{Disorders of volume state}}
{{Nutritional pathology}}
{{Authority control}}
[[Category:Symptoms and signs: Digestive system and abdomen]]
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