Can ascites occur without liver dysfunction?

From the Guidelines

Yes, you can have ascites without liver impairment, as evidenced by the 2021 practice guidance by the American Association for the Study of Liver Diseases 1. Ascites refers to abnormal fluid accumulation in the abdominal cavity and can result from conditions unrelated to liver function. These include:

• Heart failure, where poor cardiac output leads to fluid backup
• Kidney disease, particularly nephrotic syndrome
• Certain cancers that spread to the peritoneum
• Pancreatic disorders
• Severe malnutrition causing low protein levels
• Tuberculosis affecting the abdomen The mechanism behind non-hepatic ascites typically involves either increased hydrostatic pressure (as in heart failure), decreased oncotic pressure from low protein levels, or inflammation of the peritoneal lining. According to the serum albumin ascites gradient (SAAG) interpretation, a SAAG < 1.1 g/dL excludes portal hypertension, suggesting that ascites can occur without liver impairment 1. While ascites without liver impairment is possible, any unexplained fluid accumulation in the abdomen warrants thorough medical evaluation to determine the underlying cause, as treatment approaches differ significantly depending on the source of the problem, as outlined in the initial diagnosis and management of ascites guidance 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 1. In evaluating the etiology of ascites, the serum albumin ascites gradient is calculated by subtracting the ascitic fluid albumin from the serum albumin in simultaneously obtained samples, which can help differentiate between liver-related and non-liver related causes of ascites 1.

From the Research

Ascites and Liver Impairment

• Ascites is often associated with liver failure and portal hypertension, as stated in 2 and 3.
• However, ascites can also occur due to other causes such as cancer, heart failure, and visceral artery rupture, as mentioned in 4.
• The presence of ascites is a marker of hepatic decompensation and is associated with a poor prognosis, as noted in 5.
• It is essential to properly evaluate patients presenting with ascites to differentiate potential etiologies and tailor accurate treatment plans, as emphasized in 4.

Causes of Ascites

• Cirrhosis is the most common cause of ascites, as stated in 3 and 5.
• Other causes of ascites include:
  • Cancer
  • Heart failure
  • Visceral artery rupture, as mentioned in 4
• The diagnostic evaluation of ascites involves an assessment of its cause by determining the serum-ascites albumin gradient and the exclusion of complications, as noted in 2.

Management of Ascites

• Sodium restriction and diuretics remain the cornerstone of ascites management, as stated in 2 and 3.
• Other treatment options include:
  • Repeated large volume paracentesis
  • Transjugular intrahepatic portosystemic shunts, as mentioned in 2 and 3
  • Plasma volume expansion, as noted in 3
• Early paracentesis is associated with decreased in-hospital mortality and should be considered as a key inpatient quality measure among hospitalized adults with cirrhosis, as emphasized in 6.