Ascites is defined as an abnormal accumulation fluid in the abdominal /peritoneal cavity. There are a variety of diseases that can cause accumulation of fluid, the reasons that the ascites occurs may be different for each disease, but a common cause is Liver cirrhosis after 40 years. In this article, I will discuss this topic.



Sign & Symptoms:

  • Abnormal abdominal distension & increased abdominal size.
  • Increased weight.
  • Shortness of breath
  • The skin over the abdomen is starched & shiny.
  • Indigestion & heartburn due to gastro-oesophagal reflux .
  • Nausea & Vomiting
  • Dyspnoea & Orthopnoea can be seen due to an elevation of the diaphragm.
  • Loss of appetite
  • Back pain can be seen.
  • Umbilicus may be everted or flat.
  • Hernia
  • On physical examination of abdomen visible bulging of the flanks in the reclining patient (“flank bulging”), “shifting dullness” (difference in percussion note in the flanks that shifts when the patient is turned if minimum 1000ml fluid is available) or in massive ascites with a “fluid thrill” or “fluid wave” (on tapping or pushing will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen).

Causes: It can because of

  • Liver Cirrhosis
  • Congestive Heart failure
  • Nephrotic syndrome
  • Disorders of the pancreas
  • Infection by bacteria & fungal like Tuberculosis, HIV, E. coli etc
  • Beriberi
  • Hepatitis
  • Inferior vena caval obsrtuction
  • Malignancy
  • Ovarian disease
  • Hereditary angioedema etc


  • Routine complete blood count, basic metabolic profile, LFT, liver enzymes, and coagulation should be performed.
  • Clinic Diagnosis
  • USG & CT scan
  • Aspiration of fluid & culture protein level, albumin, and cell counts. If indicated, microbiological culture, Gram stain and cytopathology should be performed. 
  • SAAG [Serum ascites albumin gradient], it is the difference between serum albumin & ascitic fluid albumin. SAAG = blood serum albumin – ascites albumin. A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive as a cause. 



Ascites, Draining the fluid

           SAAG >1.1 g/dL

This is usually caused by conditions leading to portal hypertension. These are

  • Hepatic congestion
  • Congestive heart failure
  • Constrictive pericarditis
  • Liver disease or cirrhosis
  • Alcoholic hepatitis
  • Vascular occlusion
  • Myxedema
  • Malnutrition
  • Fulminant hepatic failure
  • Massive hepatic metastases

    SAAG < 1.1 g/dL

    • Hypoalbuminemia
    • Bile ascites
    • Pancreatis
    • Bowel obstruction
    • Nephrogenic ascites
    • Urine ascites
    • Systemic lupus erythematosus
    • Ovarian disease
    • Peritoneal Disease
      • Infections  – Bacterial, tuberculous, fungal, HIV associated peritonitis
      • Malignancy
      • Other rare conditions
        • Vasculitis
        • Eosinophilic peritonitis
  • Chest X-ray & abdomen x-ray.

Treatment: Treatment will be depending upon cause.  

  • A low-sodium diet and bed rest
  • Removal of ascitic fluid (therapeutic paracentesis)
  • For infectious peritonitis, antibiotics treatment needed.
  • Diuretics
  • Sometimes surgery to reroute blood flow (portosystemic shunting) or liver transplantation


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