Ultrasonography detects
ascites easily even in trace amounts. 80% of the cases are caused by hepatic disease, in the remaining 20%
cancer,
inflammation, pancreatic, renal, or
cardiac disease can be found. The underlying disease should be investigated by few inexpensive laboratory test from serum, urine and
ascites and by abdominal sonography. Hepatic
ascites is caused by
portal hypertension and disturbances of humoral factors.
Sodium retention, peripheral, vasodilation, hyperdynamic circulation and progressive renal vasoconstriction lead to a stepwise deterioration of patients condition. Treatment with
diuretics (
furosemide,
torsemide, or
xipamide and
spironolactone) and
sodium-restriction (< 60 mval per day) control 85-90% of the cases with hepatic
ascites. If this regimen fails, non-compliance, spontaneous bacterial
peritonitis,
hyponatremia or additional complications such as
renal failure,
Budd-Chiari syndrome or
tumor should be considered. Ten to 15% of the patients develop refractory
ascites and finally
hepatorenal syndrome and have a poor prognosis. Early
liver transplantation should be considered. Large volume paracentesis with
albumin substitution is a therapeutic option in these patients. The transjugular intrahepatic portosystemic
stent-shunt (
TIPS) may be superior for patients with concurrent
esophageal varices or
hepatorenal syndrome. If
TIPS is considered the patient should be referred to an experienced center. The
peritoneo-venous shunt is restricted to rare indications. In the future, new drugs such as antagonists of
endothelins or of the
antidiuretic hormone may offer new therapeutic options.