Ascites is the accumulation of fluid in the peritoneal space. It is a common problem in cirrhosis(due to portal hypertension) and when there is malignant spread into the peritoneum(which is common in ovarian and gastrointestinal cancers). It can cause significant swelling and discomfort and peritoneal drainage often brings relief.
Epidemiology and pathogenesis
Ascites is a common problem in patients with palliative illnesses.
The majority of Most patients with end-stage liver disease from cirrhosis develop ascites.
About 10% of cancer patients develop ascites, with the most common malignant causes including:
Ovarian cancer
Breast cancer
Lung cancer
Gastric cancer
Pancreas cancer
Cancer of unknown primary(accounts for around 20% of case of malignant ascites)
Clinical features
Symptoms
As ascites develops, the abdomen becomes increasingly swollen. This can cause tightness and discomfort and eventually the resultant mass effect of the fluid causes poor appetite, early satiety and nausea(through compression the gastrointestinal tract) and dyspnoea(through upwards pressure on the diaphragm and lungs).
Signs
On abdominal examination:
On inspection, abdominal distension is obvious with significant ascites
On percussion, dullness at the flanks that moves when the patient rolls on his side tends to become apparent once at least a litre of fluid has accumulated(shifting dullness)
On general inspection there may be signs of the underlying cause of the ascites. In cirrhosis, for example, a hepatic flap, jaundice and spider naevi are often present. In malignancy on the other hand, the patient may appeared frail and cachectic.
Point of care ultrasound is very useful in confirming ascites. The cheapest and most basic of hand-held ultrasounds can be used to immediately confirm or exclude the presence of a significant volume of ascites.
Image: A bedside ultrasound showing some ascites with superficial bowel loops
2D and M-mode point of care images showing ascites to a depth of 5.2cm
Point of care ultrasound(original Signos Handheld device) showing ascites in a man with cirrhosisPoin
Bedside ultrasound showing locules of ascites in a woman with primary peritoneal cancer. Her ascites was quite thick and required suction to drain.
Investigations
Ascites can be confirmed radiologically via a formal ultrasound or CT imaging, although this usually isn't necessary in the palliative care context in a patient who has had recurrent ascites previously diagnosed.
A CT scan of a patient with gastric cancer who presented with acute abdominal pain. His imaging above shows liver metastases, ascites and free gas anteriorly.
Where the cause of the ascites isn't known, a diagnostic tap is helpful to confirm the aetiology and fluid can be sent for:
Albumin
Cytology
Cell count and differential
Gram stain and culture
Ascites with a high amount of albumin is an exudate which is what would be expected in malignant infiltration. When the albumin level is low this is a transudate consistent with portal hypertension(e.g. from cirrhosis). However most patients already have a low serum albumin which means that what is considered a high or low albumin in the peritoneal fluid is relative to the absolute serum albumin level. Thus to determine if the fluid looks like an exudate or a transudate, the serum-ascites albumin gradient(SAAG) should be calculated as follows:
Serum-ascites albumin gradient = Serum albumin - ascites albumin
Epidemiology and pathogenesis
Clinical features