From the Guidelines
Non-portal hypertension causes of ascites include malignancy, heart failure, nephrotic syndrome, tuberculosis peritonitis, pancreatic ascites, and hypoalbuminemia, which require treatment of the underlying cause rather than diuretics. The most common non-portal hypertension causes are malignancy (particularly peritoneal carcinomatosis, ovarian cancer, and gastrointestinal cancers), heart failure (especially right-sided heart failure), nephrotic syndrome, tuberculosis peritonitis, pancreatic ascites, and hypoalbuminemia from various causes such as protein-losing enteropathy or malnutrition 1. Other causes include chylous ascites from lymphatic obstruction, Budd-Chiari syndrome, myxedema from hypothyroidism, and peritoneal dialysis-related complications.
Key Points to Consider
- Diagnostic evaluation should include ascitic fluid analysis with serum-ascites albumin gradient (SAAG) calculation, which is typically <1.1 g/dL in non-portal hypertension ascites 2.
- Cytology, cell count, culture, and specific tests like adenosine deaminase for tuberculosis or amylase for pancreatic ascites may be needed.
- Management focuses on treating the underlying cause rather than using diuretics, which are less effective in these conditions 3.
- For malignant ascites, paracentesis, peritoneovenous shunts, or intraperitoneal chemotherapy might be considered, while heart failure requires cardiac support with medications like ACE inhibitors, beta-blockers, and careful diuretic use 4.
Underlying Causes and Treatment
- Malignancy: paracentesis, peritoneovenous shunts, or intraperitoneal chemotherapy might be considered.
- Heart failure: cardiac support with medications like ACE inhibitors, beta-blockers, and careful diuretic use.
- Nephrotic syndrome, tuberculosis peritonitis, pancreatic ascites, and hypoalbuminemia: treatment of the underlying cause. It is essential to note that the treatment of non-portal hypertension ascites depends on the underlying cause, and diuretics are less effective in these conditions 5.
From the Research
Non-Portal Hypertension Causes of Ascites
The causes of ascites can be classified into portal hypertension-related and non-related, with the serum-ascites albumin gradient allowing for diagnosis with an accuracy of > or = 97% 6. Non-portal hypertension causes of ascites include:
- Cardiac failure
- Tuberculosis
- Malignancy-related ascites
- Other less common causes
Diagnosis and Evaluation
To determine the cause of ascites, a careful evaluation of the patient should be performed, including:
- Clinical history
- Physical examination
- Diagnostic paracentesis
- Laboratory investigations, such as cell count and albumin, along with simultaneous determination of serum albumin to determine the serum-ascites albumin gradient 6, 7
Management and Treatment
While the management of ascites often involves sodium restriction and diuretics, many patients may require additional therapy, including repeated large volume paracentesis and transjugular intrahepatic portosystemic shunts 7. The treatment of non-portal hypertension causes of ascites, such as cardiac failure and malignancy-related ascites, should be targeted at the underlying cause.
Non-Cirrhotic Portal Hypertension
Non-cirrhotic portal hypertension (NCPH) is a heterogeneous group of conditions that can cause portal hypertension in the absence of cirrhosis 8, 9. The management of NCPH consists of the treatment of associated diseases and of portal hypertension, with TIPS placement and liver transplantation being considerable options in patients with refractory variceal bleeding/ascites and with progressive liver failure 8.