Ascites

What is ascites?

Ascites (ay-SITE-eez) is when too much fluid builds up in your abdomen (belly). This condition often happens in people who have cirrhosis (scarring) of the liver.

A sheet of tissue called the peritoneum covers the abdominal organs, including the stomach, bowels, liver and kidneys. The peritoneum has two layers. Ascites happens when fluid builds up between the two layers.

What are risk factors for ascites?

Having a condition that causes cirrhosis puts you at greater risk for developing ascites. These conditions include:

• Non-alcohol associated fatty liver disease.
• Hepatitis B.
• Hepatitis C.
• Alcohol use disorder.
• Autoimmune hepatitis.
• Genetic liver diseases like hemochromatosis, Wilson disease and alpha-1-antitrypsin deficiency.

Other conditions that can lead to ascites include:

• Congestive heart failure.
• Kidney failure.
• Cancers of the organs in the abdomen and pelvis.
• Infections.

How common is ascites?

Fluid buildup rarely occurs in otherwise healthy people. It develops as a result of other diseases, most often cirrhosis. Ascites is the most common complication of cirrhosis. About half of people with decompensated cirrhosis will develop ascites. Cirrhosis accounts for about 80% of the cases of ascites.

What causes ascites?

Cirrhosis is the most common cause of ascites. Other conditions that can cause it include heart failure, kidney failure, infection or cancer.

How does cirrhosis cause ascites?

When you have cirrhosis, your liver doesn’t function as it should. The decrease in liver function combines with portal hypertension to cause ascites symptoms. Portal hypertension is high pressure in the portal vein that delivers blood to your liver. The high pressure causes fluid to leak out of your veins into your belly and collect there.

What are the symptoms of ascites?

The main symptoms of ascites are a large belly and rapid weight gain.

Other symptoms include:

• Swelling in your ankles.
• Shortness of breath.
• Digestive issues, such as bloating, abdominal pain, loss of appetite, indigestion and constipation.
• Back pain.
• Difficulty sitting.
• Fatigue.

How is ascites diagnosed?

Your healthcare provider performs a physical exam and asks you about your symptoms and medical history. You will likely need blood tests or imaging tests as well.

What tests might I need?

After the initial exam, your provider will recommend other tests to confirm a diagnosis:

• Ultrasound or CT scan: These imaging scans show your abdominal area in more detail.
• Paracentesis: You’ll get a local anesthetic before this procedure. Your provider inserts a needle into your abdomen to remove fluid. The fluid is analyzed for signs of cancer, infection, portal hypertension and other conditions.

How is ascites treated?

Limiting sodium in your diet is crucial for treating ascites. For people with ascites, recommended sodium intake is less than 2,000 to 4,000 milligrams a day.

A dietitian can help create a healthy eating plan for you. You may also need to take diuretics (water pills). These water pills help fluid and sodium leave your body.

Will I need surgery for ascites?

Sometimes, diuretics and a low-sodium diet aren’t enough to improve the ascites. You may need other treatments, including:

• Paracentesis: Your provider inserts a needle into your abdomen to remove the fluid. This procedure can remove a large amount of excess fluid.
• Transjugular intrahepatic portosystemic shunt (TIPS): This procedure is performed to treat fluid build-up in the abdomen. A wire mesh (stent) is inserted into a vein in your liver. When inflated, the stent forms a channel (shunt) to bypass the liver. TIPS may be appropriate if your ascites aren't responding to other therapies, if you need several paracenteses per month and you're not a candidate for a liver transplant.
• Liver transplant: In cases of severe cirrhosis, when the liver is failing, a liver transplant may be necessary.

What other treatments are available?

If you have cancer, chemotherapy or hormone therapy can help shrink the tumor. The treatments can stop the fluid buildup.

Can ascites be cured?

Treatments for ascites can help improve symptoms and reduce complications. In some patients, ascites may resolve with diuretic therapy or with TIPS or liver transplant. In the case of alcohol-associated hepatitis, ascites may resolve with improvements in liver function. Follow your healthcare provider’s recommendations to stay as healthy as possible.

How can I prevent ascites?

The best way to prevent ascites is to live a healthy lifestyle. Limit alcohol and salt, don’t smoke and exercise regularly.

How can I control ascites?

If you have ascites, these steps can help you control the condition:

• Weight checks: Weigh yourself daily. Call your healthcare provider if you gain more than 10 pounds, or more than two pounds per day for three consecutive days.
• Limit alcohol: It’s best to avoid beverages that contain alcohol to reduce your ascites risk.
• Limit NSAID use: Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Motrin® and Advil®) and aspirin, affect your kidneys. They can cause your body to retain excess water and salt.
• Low-salt diet: Stick to a low-sodium diet, consuming no more than 2,000 to 4,000 milligrams per day.

How do I know if I’m at risk for ascites?

If you have cirrhosis, fatty liver disease, hepatitis B or hepatitis C, you may be at higher risk for ascites. Consuming a lot of alcohol can also put you at risk for health conditions such as ascites.

What’s the outlook for people with ascites?

Ascites is a sign that your liver is not working as it should. The survival rate five years after an ascites diagnosis is around 30% to 40%. Your healthcare provider may refer you to a liver specialist to discuss a possible liver transplant.

What are complications of ascites?

Ascites can lead to:

• Abdominal problems: The fluid buildup may lead to pain, discomfort and difficulty breathing. These symptoms can interfere with your ability to eat, walk and do daily activities.
• Infection: The fluids can become infected, called spontaneous bacterial peritonitis. You may have fever and stomach pain. Call your healthcare provider if you have these symptoms. You’ll need IV antibiotics and long-term antibiotic treatment to keep the infection from coming back.
• Hepatic hydrothorax, or fluid in the lungs: Abdominal fluid fills the lung, usually on the right side. You may experience shortness of breath, cough, chest discomfort and hypoxemia (lack of oxygen in the blood). You may need thoracentesis to remove the fluid.
• Ascites-related hernias: The increase in abdominal pressure can lead to hernias, specifically umbilical and inguinal hernias. Your healthcare provider will discuss your treatment options.
• Kidney failure: If cirrhosis worsens, it may lead to kidney failure (hepatorenal syndrome).

Is ascites life-threatening?

Ascites is a sign of liver damage. If left untreated, it can lead to life-threatening complications. But with proper treatment and diet changes, you can manage ascites. Your healthcare provider may also talk to you about getting a liver transplant if the damage is severe.

Can ascites come back?

The fluid can continue to build up. You may need to have it drained again. If the fluid builds up quickly, your healthcare provider might suggest treatment with diuretics, transjugular intrahepatic portosystemic shunt (TIPS), or liver transplant.

If I have ascites, how can I best take care of myself?

People with ascites should work with a dietitian to plan a sodium-restricted diet. Check food labels, and avoid high-sodium foods.

You can use several salt substitutes. However, avoid substitutes with potassium, since the medicine you may be taking for ascites can also increase potassium. A dietitian can help you plan a healthy diet and provide recommendations for salt alternatives.

In addition, you should:

• Take your diuretics as prescribed.
• Record your weight every day.
• Stop drinking alcohol, which can cause further liver damage.
• Treat hepatitis B or C if necessary.

What should I ask my doctor?

If you have ascites, ask your healthcare provider:

• Will I need surgery?
• What treatments are available?
• Should I consider a liver transplant?
• What diet should I follow to stay healthy?
• What medications are available?
• Will the ascites return?

When should I go to the ER?

If you have ascites, go to the emergency room right away if you have:

• Fever.
• Stomach pain.

A note from Cleveland Clinic

Ascites is a sign of liver damage. People who have cirrhosis may develop ascites. With the right treatments and diet changes, you can manage ascites and feel your best. Restricting your salt intake is one of the most effective treatments for ascites. Ask your provider about working with a dietitian to plan a salt-restricted diet and other treatment options for ascites that doesn’t respond to diuretics.