What Is Ascites? Symptoms, Causes & Treatment

What Is Ascites? Symptoms, Causes & Treatment

ASCITES-What Is Ascites? Symptoms, Causes & Treatment


  • A minimum of 1.5 L of fluid is felt to be necessary before ascites is detectable on physical examination.
  • As the most common cause of ascites is portal hypertension, patients should be asked about risk factors for chronic liver disease (alcohol, hepatitis, blood transfusions, intravenous drug use)
  • The presence of spider angiomata, palmers erythema, gynecomastia, muscle wasting, splenomegaly, or abdominal wall collaterals suggests chronic liver disease and directs further studies.
  • Abdominal paracentesis is essential in the evaluation of the patient with ascites.
  • The ascitic fluid should be visually inspected.
  • Usual fluid is yellow-orange and transparent.
  • Turbid fluid suggests the presence of white blood cells (>1000/uL).
  • Milky fluid suggests the presence of triglycerides, as with chylous ascites
  • Bloody fluid may be caused by a traumatic tap, malignancy, or tuberculosis.
  • The serum-ascites albumin gradient (SAAG) has supplanted the transudate-exudate model for categorizing ascites.
  • The serum and ascites albumin should be obtained on the same day.
  • The gradient is calculated by subtracting the ascites albumin from the serum albumin (e.g. 3.5 g/dL – 2.5 g/dL = 1 g/dL).
  • A calculated SAAG > 1.1 g/dL suggests with 97% accuracy that portal hypertension is the cause of the ascites (for which there are multiple etiologies).
  • A calculated SAAG < 1.1 g/dL suggests that the pathophysiology of the ascites is not due to portal hypertension.

Causes of ascites


Portal hypertension (SAAG > 1.1 g/dL)

  1. Hepatic congestion

    1. Congestive heart failure
    2. Constrictive pericarditis
    3. Tricuspid insufficiency
    4. Budd-Chiari syndrome
    5. Veno-occlusive disease
  1. Liver disease

    1. Cirrhosis
    2. Alcoholic hepatitis
    3. Fulminant hepatic failure
    4. Massive hepatic metastases
    5. Hepatic fibrosis
    6. Acute fatty liver of pregnancy
    7. Portal vein occlusion

Hypoalbuminemia (SAAG < 1.1 g/dL)

  1. Nephrotic syndrome
  2. Protein-losing enteropathy
  3. Severe malnutrition with anasarca

Miscellaneous conditions (SAAG < 1.1 g/dL)

  1. Chylous ascites
  2. Pancreatic ascites
  3. Bile ascites
  4. Nephrogenic ascites
  5. Urine ascites
  6. Myxedema (SAAG >1 g/dL)
  7. Ovarian disease


  1. Infections
  2. Bacterial peritonitis
  3. Tuberculous peritonitis
  4. Fungal peritonitis
  5. HIV-associated peritonitis
  6. Malignant conditions
  7. Peritoneal carcinomatosis
  8. Primary mesothelioma
  9. Pseudomyxoma peritonei
  10. Massive hepatic metastases
  11. Hepatocellular carcinoma

Other conditions

  1. Familial Mediterranean fever
  2. Vasculitis Granulomatous peritonitis
  3. Eosinophilic peritonitis SAAG = serum-ascites albumin gradient.

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