From the Guidelines
Ascites can be caused by several conditions beyond liver disease, including heart failure, malignancy, tuberculosis, pancreatic disease, and nephrotic syndrome, as stated in the most recent and highest quality study by the American Association for the Study of Liver Diseases in 2021 1. The main non-hepatic causes of ascites include:
- Heart failure, where poor cardiac function leads to increased pressure in blood vessels and fluid leakage
- Malignancy, such as ovarian, pancreatic, and gastrointestinal cancers, which can produce fluid or block lymphatic drainage
- Tuberculosis peritonitis, an infection of the abdominal lining
- Pancreatic disease, including pancreatitis
- Nephrotic syndrome, a kidney disease that causes protein loss and decreased oncotic pressure These conditions disrupt the balance of forces that normally prevent fluid accumulation, either by increasing hydrostatic pressure, decreasing oncotic pressure, or through inflammatory processes that increase vessel permeability. According to the study by the American Association for the Study of Liver Diseases in 2021 1, the initial evaluation of ascites should include history, physical examination, abdominal doppler ultrasound, laboratory assessment of liver and renal function, serum and urine electrolytes, and a diagnostic paracentesis for analysis of the ascitic fluid. It is essential to note that the serum albumin ascites gradient is calculated by subtracting the ascitic fluid albumin from the serum albumin in simultaneously obtained samples, as mentioned in the study by the American Association for the Study of Liver Diseases in 2021 1. Other studies, such as the one published in the Journal of Hepatology in 2010 1 and 2018 1, also support the idea that ascites can be caused by conditions beyond liver disease, including heart failure, malignancy, tuberculosis, and pancreatic disease. However, the most recent and highest quality study by the American Association for the Study of Liver Diseases in 2021 1 provides the most up-to-date and comprehensive guidance on the diagnosis and management of ascites.
From the Research
Causes of Ascites
The causes of ascites can be diverse and not limited to liver disease. Some of the key causes aside from liver disease include:
- Heart failure: This is a significant cause of ascites, as it leads to fluid buildup in the body, including the abdominal cavity 2.
- Tuberculosis: This infection can cause ascites, particularly in regions where tuberculosis is prevalent 2.
- Hepatosplenic schistosomiasis: This is a parasitic infection that can lead to liver and spleen damage, resulting in ascites 2.
- Chronic kidney disease: Kidney dysfunction can lead to fluid retention and ascites 2.
- Malignancy: Cancer can cause ascites, either by directly involving the peritoneum or by causing liver dysfunction 3.
- Portal vein thrombosis: This condition can lead to increased pressure in the portal vein, causing ascites 3.
- Infection: Certain infections, such as spontaneous bacterial peritonitis, can cause ascites 2.
Clinical Profiles of Ascites
The clinical profile of ascites can vary depending on the underlying cause. For example:
- Patients with heart failure may present with shortness of breath, fatigue, and swelling in the legs 2.
- Patients with tuberculosis may present with fever, weight loss, and abdominal pain 2.
- Patients with hepatosplenic schistosomiasis may present with abdominal pain, diarrhea, and fatigue 2.
- Patients with chronic kidney disease may present with swelling, fatigue, and shortness of breath 2.
Diagnosis and Treatment
Diagnosing the underlying cause of ascites is crucial for effective treatment. Treatment options may include:
- Diuretics and sodium restriction for patients with liver disease 4, 5.
- Therapeutic paracentesis for patients with refractory ascites 3, 6.
- Transjugular intrahepatic portasystemic stent-shunt (TIPS) for patients with refractory ascites and preserved liver function 4, 3.
- Liver transplantation for patients with end-stage liver disease 4, 3.