Ascites

Overview

Ascites occurs when excess fluid builds up in your belly area, called the abdomen. The fluid collects in the peritoneal cavity, which is the space around your abdominal organs. This buildup can make your belly look swollen or feel tight. As more fluid accumulates, you might feel discomfort or pain.

Ascites most often happens when someone has serious liver disease, such as cirrhosis. It also can be linked to other conditions, including heart failure, certain cancers and pancreatic disease. The best treatment for ascites depends on what causes the fluid to build up.

Healthcare professionals often classify ascites based on the cause of the fluid buildup. Ascites also may be described by how much fluid is present and how the condition behaves over time.

Based on the amount of fluid, ascites is commonly grouped into these grades:

• Grade 1, mild ascites. A small amount of fluid that may not be noticeable on a physical exam and is sometimes found only on imaging tests.
• Grade 2, moderate ascites. Fluid buildup that causes visible swelling of the abdomen.
• Grade 3, large or tense ascites. A large amount of fluid that makes the abdomen very swollen and causes discomfort.

Ascites also can be described by how it responds to treatment. In many people, fluid buildup can be managed with medicines and dietary changes. In others, ascites continues to worsen or returns despite treatment, and frequent removal is needed by physically draining the fluid. This is called refractory ascites and usually means the underlying disease is more serious.

Symptoms

Mild ascites may not cause any symptoms and can be easy to miss. As more fluid builds up and the ascites progresses to moderate or severe, your belly can look swollen or feel heavy or tight. You also might notice weight gain or a larger waistline, even without changes in eating habits.

Early ascites can feel like bloating, but the swelling usually lasts and may get worse over time. While bloating often comes and goes, ascites typically does not get better without treatment.

Ascites can make it harder to breathe, especially if a lot of fluid builds up. As your belly fills with fluid, it pushes up on the diaphragm, the muscle that helps your lungs expand. Ascites is different from pleural effusion, which is when fluid collects around the lungs and can make breathing harder.

Symptoms of ascites can develop over days or even months, depending on the cause. Some people have a swollen belly without pain. Others feel pressure, fullness or discomfort. If enough fluid collects, symptoms may include:

• Shortness of breath or feeling winded.
• Feeling full after small meals.
• Belly pain, especially when large amounts of fluid collect.
• Swelling in the legs or ankles, called edema.
• Rapid weight gain.
• Fever or confusion, which can be signs of infection.

Causes

Ascites can happen for different reasons, but it most often occurs because of portal hypertension caused by cirrhosis. This condition is a late stage of chronic liver disease, when scarring changes the liver's structure.

Cirrhosis can develop from many causes, including long-term alcohol use, viral hepatitis and fatty liver disease, also called metabolic dysfunction-associated steatotic liver disease (MASLD). As the scarring gets worse, blood cannot flow through the liver as easily. This increases pressure in the portal vein system, which carries blood to the liver.

This higher pressure, along with changes that cause the body to keep more salt and water, can make fluid build up in the belly. In people with cirrhosis, developing ascites typically means the liver disease has reached an advanced stage.

Liver disease is not the only reason someone might get ascites. Some other possible causes include:

• Cancer, sometimes called malignant ascites. This can include ovarian, breast, colon, and liver cancers, among others.
• Heart failure.
• Infections of the lining of the abdomen, such as tuberculosis.
• Low blood protein levels from conditions such as nephrotic syndrome, protein-losing enteropathy or severe malnutrition.
• Pancreatic disease, such as pancreatitis or injury to the pancreas, which can lead to fluid buildup in the abdomen.

These conditions can cause ascites in different ways. For example, cancer may affect the lining of the abdomen or block typical fluid absorption. Low blood protein levels also can make it easier for fluid to collect in the abdomen.

Sometimes, more than one condition can cause ascites. Because treatment depends on the cause, your care team will try to find out what is making the fluid build up.

Risk factors

Risk factors for ascites are generally those that increase your likelihood of developing the underlying conditions that cause it. These include:

• Factors that raise the risk of liver disease and cirrhosis.
• Long-term alcohol use. Drinking large amounts of alcohol over time can damage the liver, leading to cirrhosis.
• Chronic viral hepatitis. Long-term infection with hepatitis B or hepatitis C can damage your liver and raise the risk of cirrhosis.
• Obesity. Being obese is linked to a higher risk of metabolic dysfunction-associated steatotic liver disease (MASLD), which can progress to cirrhosis.
• Factors that raise the risk of cancer. Depending on the type of cancer, risk factors can include genetics, smoking, obesity, certain infections and environmental exposures.
• Factors that raise the risk of heart failure. These can include high blood pressure, coronary artery disease, diabetes and obesity.

Having more than one risk factor or underlying condition can further increase the likelihood of developing ascites. Your healthcare team can talk with you about your personal risk based on your health history.

Complications

Ascites can cause complications, especially when a large amount of fluid builds up. Some complications need prompt medical care. Potential complications include:

• Infection of the abdominal fluid, called spontaneous bacterial peritonitis (SBP). Sometimes, the fluid from ascites can get infected. Spontaneous bacterial peritonitis is a serious condition that can lead to fever, belly pain, kidney failure or confusion. It needs urgent treatment with antibiotics.
• Breathing problems. When there is a lot of fluid, it can push up on the diaphragm, the muscle that helps you breathe. This pressure can make breathing harder.
• Hernias. If fluid keeps building up, it can weaken the muscles in your belly. This can cause hernias, such as umbilical or inguinal hernias, which can be painful or uncomfortable.
• Malnutrition and weakness. Ascites can make you feel full quickly, lower your appetite and make it hard to eat enough. Over time, this can lead to poor nutrition.

Because complications can develop quickly, it's important to stay in close contact with your healthcare team and report any new or worsening symptoms.

Prevention

Ascites cannot always be prevented. It most often develops as a complication of serious liver disease or other medical conditions. However, steps to protect your liver and manage underlying health issues may lower the risk of developing ascites or slow its progression.

Here are some ways you can lower your risk:

• Manage liver disease early. Getting treatment for conditions such as viral hepatitis or fatty liver disease can lower your risk of liver-related issues, including ascites.
• Get vaccinated against hepatitis A and B. The hepatitis B vaccine helps prevent chronic liver disease that can lead to cirrhosis and ascites, while the hepatitis A vaccine helps protect overall liver health. There is currently no vaccine for hepatitis C.
• Avoid alcohol if you have liver disease. Alcohol can worsen liver damage and increase the risk of cirrhosis.
• Keep a healthy weight. Being overweight increases the chance of fatty liver disease, which can lead to cirrhosis and ascites over time.
• Manage other medical conditions. Treating conditions such as heart failure may help reduce fluid buildup in the body.
• Reduce salt intake. Eating less salt can help your body avoid holding on to extra fluid. If you are at risk of ascites, following a low-salt diet may help slow down or reduce fluid buildup.

If you already have liver disease or another condition linked to ascites, working closely with your healthcare team can help reduce the risk of complications.

Diagnosis

To diagnose ascites, your healthcare professional will ask about your symptoms and perform a physical exam. The exam may include pressing your abdomen to check for signs of fluid. Larger amounts of fluid are easier to detect during an exam.

Tests and procedures that help diagnose ascites include the following:

Imaging tests

Imaging tests are often used to confirm ascites. An abdominal ultrasound is usually the first test. It can detect even small amounts of fluid and show where fluid has collected. During this test, ascites appears as fluid collecting around the abdominal organs rather than inside them.

In some cases, a CT scan is used to get a closer look at the abdomen and nearby organs. Imaging reports may mention free fluid, which means fluid is present in the abdominal cavity.

On imaging tests, a small amount of fluid in the pelvis can sometimes be a regular finding in women. In men, visible fluid is not expected. A healthcare professional looks at how much fluid is present and whether symptoms are occurring.

Blood tests

Blood tests can help find possible causes of ascites. These tests may check kidney and liver function, look for signs of infection, and measure protein levels in the blood.

Diagnostic paracentesis

Most people with ascites also have a procedure called diagnostic paracentesis. In this procedure, a thin needle removes a small amount of fluid from the abdomen. The fluid is tested for protein content, infection, cancer and other conditions.

Healthcare professionals often use a combination of exam findings, imaging, blood tests and fluid tests to confirm ascites and find its cause. This helps them understand the cause and plan the best treatment for you.

Treatment

How ascites is treated depends on why the fluid is building up and how much there is. The main goals are to ease symptoms, lower the amount of fluid and address the underlying cause.

Medicines

If ascites is related to liver disease, treatment usually begins with medicines and diet changes. Your healthcare professional may prescribe medicines called diuretics. These help your body remove extra salt and water through urine. In addition, eating less salt helps your body hold on to less fluid.

Managing the underlying liver disease also is an important part of treatment. Managing liver disease may help lower fluid buildup over time and reduce the chance that ascites will return.

Treatment for ascites caused by other conditions focuses on managing the underlying issue. For example, cancer-related ascites may be treated with cancer therapies and medicines. Heart-related ascites may improve when heart failure is treated.

Surgery or other procedures

If excess fluid is making you uncomfortable or making it hard to breathe, your care team may need to remove some of the fluid from your belly. This procedure is called therapeutic paracentesis. A thin needle is used to drain the extra fluid, which can help relieve symptoms. The procedure is done by a trained healthcare professional, often with ultrasound guidance to improve safety. After fluid is drained, ascites may return, especially if the underlying cause is still present.

In some cases, albumin may be given after paracentesis of large volumes of fluid to help prevent circulation problems, support fluid balance and protect kidney function.

For people with advanced liver disease, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered. This procedure creates a new pathway for blood to flow through the liver, which can lower pressure and help reduce fluid buildup.

If you have serious liver disease, a liver transplant might be an option. Your care team will look at your overall health to decide if a transplant is an option for you.

Lifestyle and home remedies

Making changes to your daily habits can support medical treatment for ascites.

• Limit salt. Eating too much salt makes your body hold on to extra fluid. Following a low-sodium diet can help lower fluid buildup. Many people with ascites are advised to limit sodium to less than about 2,000 milligrams a day.
• Check your weight regularly. If you take diuretics, your healthcare team may recommend weighing yourself daily while your dose is being adjusted. Let your healthcare team know if you gain weight quickly or notice more swelling.
• Avoid alcohol if you have liver disease. Alcohol can worsen liver damage and increase complications.

Coping and support

Living with ascites can be stressful, especially when symptoms change or make daily life harder. It's natural to feel worried or overwhelmed sometimes. Here are some strategies that may help:

• Learn about your condition. Understanding ascites and its management can help you feel more involved in your care. Ask your healthcare team questions and share concerns.
• Stay connected with your healthcare team. Regular follow-up visits help keep track of symptoms and adjust treatment when needed.
• Reach out for support when you need it. Family, friends or caregivers can help with daily chores, getting to appointments and offering emotional support.
• Consider counseling or support groups. Talking with others, including those who have chronic illnesses, can help you feel less alone.

If ascites is linked to a long-term condition, your healthcare team can help connect you with more resources as needed.

Preparing for an appointment

Often, your first step is to see your primary healthcare professional. You may then be referred to a specialist, such as a liver specialist called a hepatologist, depending on what is causing the ascites.

To help make the most of your appointment, you may want to:

• Write down your symptoms. Include when they began, how often they happen and if they are getting worse.
• Keep track of any changes in your weight or swelling. This helps your healthcare team understand changes in fluid buildup.
• Make a list of all medicines and supplements you take. This includes prescriptions, medicines you can buy without a prescription, vitamins and herbal products.
• Bring key medical information. Note any liver disease, heart disease, cancer or past infections, including hepatitis.
• Consider bringing a family member or friend. Another person can help remember information and offer support.
• Write down any questions you have. This helps make sure your concerns are discussed during your visit.

Your healthcare professional may ask questions such as:

• When did you first notice swelling in your belly or weight gain?
• Have your symptoms changed over time?
• Do you have a history of liver disease, heart disease or cancer?
• What medicines or supplements do you take?
• Do you drink alcohol, or have you in the past?

Getting ready ahead of time can help you feel more confident and make your appointment go more smoothly.