Clinical Review ABC of diseases of liver, pancreas, and biliary system

Portal hypertension—2. Ascites, encephalopathy, and other conditions

BMJ 2001; 322 doi: (Published 17 February 2001) Cite this as: BMJ 2001;322:416
  1. J E J Krige,
  2. I J Beckingham


    Ascites is caused by cirrhosis in 75% of cases, malignancy in 10%, and cardiac failure in 5%; other causes account for the remaining 10%. In most patients the history and examination will give valuable clues to the cause of the ascites—for example, signs of chronic liver disease, evidence of cardiac failure, or a pelvic mass. The formation of ascites in cirrhosis is due to a combination of abnormalities in both renal function and portal and splanchnic circulation. The main pathogenic factor is sodium retention. About half of patients with cirrhosis develop ascites during 10 years of observation. The development of ascites is an important event in chronic liver disease as half of cirrhotic patients with ascites die within two years.

    Causes of ascites

    Portal hypertension
    • Cirrhosis of liver

    • Congestive heart failure

    • Constrictive pericarditis

    • Budd-Chiari syndrome

    • Inferior vena cava obstruction

    • Nephrotic syndrome

    • Protein losing enteropathy

    • Peritoneal carcinomatosis

    • Pseudomyxoma

    • Pancreatic ascites

    • Nephrogenic ascites (associated with maintenance haemodialysis)

    • Myxoedema

    • Meigs's syndrome


    Ascites may not be clinically detectable when present in small volumes. In larger volumes, the classic findings of ascites are a distended abdomen with a fluid thrill or shifting dullness. Ascites must be differentiated from abdominal distension due to other causes such as obesity, pregnancy, gaseous distension of bowel, bladder distension, cysts, and tumours. Tense ascites may cause appreciable discomfort, difficulty in breathing, eversion of the umbilicus, herniae, and scrotal oedema. Rapid onset of ascites in patients with cirrhosis may be due to gastrointestinal haemorrhage, infection, portal venous thrombosis, or the development of a hepatocellular carcinoma. Ascites can also develop during a period of heavy alcohol misuse or excessive sodium intake in food or drugs. Ultrasonography is used to confirm the presence of minimal ascites and guide diagnostic paracentesis.

    Tense ascites with umbilical and left inguinal hernias

    Analysis of ascitic fluid

    • Evaluate macroscopic appearance (straw coloured, turbid, bloody, chylous)

    • Cell count …

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