Ascites
Ascites, the accumulation of fluid in the abdomen, can be a life-threatening condition
by Geoff Drushel
Garth hadn’t been feeling well for some time. At 38, he was feeling run down, and his lower legs hurt all the time. He had been diagnosed with adult-onset diabetes a year or so before, and so he attributed his fatigue, the swelling in his legs and other ailments as just part of the disease. Then his stomach began to swell, like he had eaten too much rich food that wouldn’t digest. It continued that way for several days, but then finally, much to his relief, dissipated. Three months later, however, it was back, and this time it was worse. Garth felt like he was going to pop.
The swelling in Garth’s abdomen was increasingly uncomfortable, and it wouldn’t go away. His skin stretched tightly across his stomach area, his naval lay flat – hardly there at all – and his flanks bulged. Working was difficult to say the least, and despite his rather large appearance and continued weight gain, he had little to no appetite. Breathing at times was difficult. Fed up, both with his condition and the constant pleas of his wife to see a doctor, Garth grudgingly made an appointment.
The diagnosis
Immediately upon seeing the doctor, Garth was referred to a gastroenterologist who took one look at him and said, “You’ve got ascites.” Finally, a diagnosis, he thought. It’s only ascites. Then it hit him. What in the world is ascites? Garth had never heard of this condition; all he knew was that it was painful. He wanted to know what could be done.
The doctor told Garth that he would need a paracentesis, a procedure whereby a needle is inserted into the peritoneum, or lining of the gut, to drain off the ascitic fluid that has accumulated. Fine, he thought. They’ll drain off the fluid, and everything will return to normal. What Garth didn’t know was that the ascites he was experiencing was a common symptom of a much larger problem – one which had not yet been diagnosed. Garth also didn’t know that the fluid that had been drained from him would soon return and that he would be back in the hospital again for a repeat performance, one of many to come.
But what was causing this massive fluid buildup? Why suddenly, having not yet reached 40, was Garth experiencing these symptoms? The doctors seemed to think at first that the abnormal accumulation of fluid in Garth’s abdomen (ascites) had been caused by cirrhosis of the liver, which had been brought about by Garth’s admittedly heavy drinking. And it was natural for the doctors to assume that Garth’s past alcohol consumption was behind it all, since cirrhosis is responsible for 80 percent of all instances of ascites (cancer accounts for another 10 percent and the other incidents are brought about by several other causes, including heart failure, tuberculosis, pancreatic disease and hemodialysis).
While talking to his boss one day about some of the problems he was experiencing, Garth’s boss asked a very straightforward question that had never occurred to Garth or the doctors treating him at the time. “Have you been tested for hepatitis C?” she asked. Well, he thought, surely they would have tested for things like that considering all of the blood they had drawn. But Garth asked the doctors anyway and learned to his surprise that, no, they had not tested him for hepatitis C. It simply had not occurred to them either, and even though they seemed dismissive of the request, they ordered the test along with some others they hoped would lead them to the cause of this most bothersome affliction. “Bingo!” the doctor announced proudly at Garth’s next appointment. “You’ve got hep C.”Now, not only was Garth suffering from this terrible fluid buildup, he had hepatitis C as well, a disease he knew as little about as he did ascites. “What’s next,” he thought. If only he had known.
By the time a hepatitis C patient develops ascites, as was the case with Garth, the damage to the liver, in the form of scarring known as fibrosis, has progressed to the point where cirrhosis is beginning to occur. The flow of blood through the liver is significantly impeded as a result. The blood begins to back up in the portal vein like a clogged pipe (a condition known as portal hypertension). At the same time, low levels of albumin (the glue that holds blood together) in the blood change the pressure inside the blood vessels, prompting osmosis to occur. Blood fluids simply begin to ooze out of the higher-pressure vessels and into the lower-pressure abdomen. Ascites is the result.
As long as the patient is “compensated,” the ascites will not be present, but as the liver decompensates and these various mechanisms previously described begin to occur, the fluid builds up. So for Garth and many others with this condition, the prognosis is not very good. While it can be treated with diuretics, including spironolactone (Aldactone) and furosemide (Lasix) and periodic paracenteses to rid the body of the fluid, the condition often remains persistent and the possibility of complications arising from it, most notably an infection of the fluid known as spontaneous bacterial peritonitis, increases.
“Unfortunately, treatment of ascites will not improve the functioning of the liver, nor will it improve one’s prognosis,” says Melissa Palmer, M.D., a hepatologist and author who practices in Long Island, N.Y. “The development of ascites is a serious complication of cirrhosis that requires prompt evaluation and treatment. It indicates that a person no longer has compensated cirrhosis. Rather, he or she is considered to have decompensated cirrhosis, which means that the body can no longer ‘compensate’ for the extensive scarring (cirrhosis) that has occurred in the liver.
“People with any form of decompensated cirrhosis, whether from ascites, esophageal varices, portal gastropathy and/or encephalopathy, should be evaluated for liver transplantation,” Dr. Palmer says. “The chances of a person’s living one year drops from greater than 90 percent to less than 50 percent once ascites has developed. Therefore, once ascites has developed, liver transplantation should always be considered.”
Ascites can be successfully treated so that it goes away. However, most patients will have the tendency to develop ascites again once it has occurred, and treatment of ascites will not improve the functioning of the liver, nor will it improve one’s prognosis, according to Dr. Palmer. “But treatment of ascites is important,” she adds. “First, it improves the quality of life of the cirrhotic patient. And second, spontaneous bacterial peritonitis (SBP), a life-threatening infection of the ascitic fluid, will not occur if ascites is not present.”
What’s on tap?
For those with ascites that cannot be controlled through diuretics, some other options exist, although there are increased risks with these procedures. For most, including Garth, it means getting drained of the fluid, or “tapped” in clinical parlance, until such time as the patient improves, receives a transplanted liver or dies.
John Hoef, a physician’s assistant at St. Luke’s Center for Liver Disease in Houston’s sprawling medical center, has been performing paracenteses on patients for the past 12 years. Hoef says he probably does five to 10 “taps” a week and has done hundreds over the years. Garth is one of his patients. He has had more than 40 such procedures performed on him over a four-year period. Hoef says Garth is an unusual case in that he has been treating him for so long. Most patients, he says, either get a transplant within a few years or, sadly, die while waiting for a liver, as is the case with about 25 percent of all those on the liver transplant list.
A typical paracentesis takes about 30 to 45 minutes to perform, Hoef says, and removes around 4 to 6 liters of fluid on average, although it varies case by case. “Everyone is a little different, but I always tell patients not to obsess about the fluid because it’s just going to come back anyway,” he says. “We do it mainly for comfort. If a patient gets the typical back pain and is short of breath and can’t eat and can’t sleep, then we do the procedure to relieve all that. Some people need it once a week, some twice a week, but most people need it every couple of weeks. Some can go longer.”
Hoef says he has drained as much as 13 liters from a patient, but, he adds, that’s not typical. Garth says he has had as much as 10.5 liters drained from him, which amounts to about 22 pounds of fluid filling more than five large, 2-liter bottles. He currently averages about 5 or 6 liters each time he is tapped, which he does monthly at the medical center.
The procedure
After swabbing the lower abdomen with betadine, an antiseptic, a local anesthetic (typically lidocaine) is injected in the area to numb it, according to Hoef. Then, a larger needle is inserted with a catheter attached. The needle is slipped out, with the catheter left intact, and the other end of the catheter is inserted into one of the vacuum-sealed bottles. The fluid rapidly begins to drain from the abdomen into the bottle. When the bottle is full, the catheter is closed off temporarily while another bottle is prepared, and the procedure continues until the fluid is mostly drained. Once this occurs, the needle is removed, the area is cleaned again and a bandage is placed over the small incision where the catheter/needle was inserted. A few minutes of recovery, and the patient is free to go, although some dizziness and a general loss of energy may impede the patient’s ability to leave right away or to operate a motor vehicle.
In some hospitals or clinics, the process can take longer depending on the facility’s protocol. Some provide the patient with pain relief (typically Valium or Demerol), which can take longer to recover from, and many require that the patient stay for an albumin drip to replace that lost from the procedure. This also requires a longer recovery period since it can take a couple of hours to slowly drip the proper amount of albumin into the body through an IV.
While the procedure generally is done in an outpatient setting, there are, of course, risks, including accidental perforation of the bowel requiring immediate hospitalization. But most medical personnel agree that the alternative of leaving the ascites there is a much larger and much more serious risk. “It’s a risk because some patients with ascites get spontaneous bacterial peritonitis with a high mortality,” says Dr. Bennet Cecil, a hepatologist with a large practice in Kentucky. “And some may get hepatorenal syndrome, where the kidneys shut down causing death.” Either way, he says, it’s a good idea to rid the body of ascites.
For Garth and many in his position, it’s simply a matter of getting used to the uncomfortable procedure and used to the fact that the condition likely will persist unless the liver is able through treatment to repair itself or, in the alternative, a transplant is performed. “I know I can control it to a certain degree, but I don’t think I’ll ever get rid of it totally unless I get a transplant, which I can’t say I’m looking forward to,” Garth says. “For me, it’s just part of life – something I have to deal with whether I like it or not. For the record, I don’t.”
http://www.liverhealthtoday.org/viewarticle.cfm?aid=168
by Geoff Drushel
Garth hadn’t been feeling well for some time. At 38, he was feeling run down, and his lower legs hurt all the time. He had been diagnosed with adult-onset diabetes a year or so before, and so he attributed his fatigue, the swelling in his legs and other ailments as just part of the disease. Then his stomach began to swell, like he had eaten too much rich food that wouldn’t digest. It continued that way for several days, but then finally, much to his relief, dissipated. Three months later, however, it was back, and this time it was worse. Garth felt like he was going to pop.
The swelling in Garth’s abdomen was increasingly uncomfortable, and it wouldn’t go away. His skin stretched tightly across his stomach area, his naval lay flat – hardly there at all – and his flanks bulged. Working was difficult to say the least, and despite his rather large appearance and continued weight gain, he had little to no appetite. Breathing at times was difficult. Fed up, both with his condition and the constant pleas of his wife to see a doctor, Garth grudgingly made an appointment.
The diagnosis
Immediately upon seeing the doctor, Garth was referred to a gastroenterologist who took one look at him and said, “You’ve got ascites.” Finally, a diagnosis, he thought. It’s only ascites. Then it hit him. What in the world is ascites? Garth had never heard of this condition; all he knew was that it was painful. He wanted to know what could be done.
The doctor told Garth that he would need a paracentesis, a procedure whereby a needle is inserted into the peritoneum, or lining of the gut, to drain off the ascitic fluid that has accumulated. Fine, he thought. They’ll drain off the fluid, and everything will return to normal. What Garth didn’t know was that the ascites he was experiencing was a common symptom of a much larger problem – one which had not yet been diagnosed. Garth also didn’t know that the fluid that had been drained from him would soon return and that he would be back in the hospital again for a repeat performance, one of many to come.
But what was causing this massive fluid buildup? Why suddenly, having not yet reached 40, was Garth experiencing these symptoms? The doctors seemed to think at first that the abnormal accumulation of fluid in Garth’s abdomen (ascites) had been caused by cirrhosis of the liver, which had been brought about by Garth’s admittedly heavy drinking. And it was natural for the doctors to assume that Garth’s past alcohol consumption was behind it all, since cirrhosis is responsible for 80 percent of all instances of ascites (cancer accounts for another 10 percent and the other incidents are brought about by several other causes, including heart failure, tuberculosis, pancreatic disease and hemodialysis).
While talking to his boss one day about some of the problems he was experiencing, Garth’s boss asked a very straightforward question that had never occurred to Garth or the doctors treating him at the time. “Have you been tested for hepatitis C?” she asked. Well, he thought, surely they would have tested for things like that considering all of the blood they had drawn. But Garth asked the doctors anyway and learned to his surprise that, no, they had not tested him for hepatitis C. It simply had not occurred to them either, and even though they seemed dismissive of the request, they ordered the test along with some others they hoped would lead them to the cause of this most bothersome affliction. “Bingo!” the doctor announced proudly at Garth’s next appointment. “You’ve got hep C.”Now, not only was Garth suffering from this terrible fluid buildup, he had hepatitis C as well, a disease he knew as little about as he did ascites. “What’s next,” he thought. If only he had known.
By the time a hepatitis C patient develops ascites, as was the case with Garth, the damage to the liver, in the form of scarring known as fibrosis, has progressed to the point where cirrhosis is beginning to occur. The flow of blood through the liver is significantly impeded as a result. The blood begins to back up in the portal vein like a clogged pipe (a condition known as portal hypertension). At the same time, low levels of albumin (the glue that holds blood together) in the blood change the pressure inside the blood vessels, prompting osmosis to occur. Blood fluids simply begin to ooze out of the higher-pressure vessels and into the lower-pressure abdomen. Ascites is the result.
As long as the patient is “compensated,” the ascites will not be present, but as the liver decompensates and these various mechanisms previously described begin to occur, the fluid builds up. So for Garth and many others with this condition, the prognosis is not very good. While it can be treated with diuretics, including spironolactone (Aldactone) and furosemide (Lasix) and periodic paracenteses to rid the body of the fluid, the condition often remains persistent and the possibility of complications arising from it, most notably an infection of the fluid known as spontaneous bacterial peritonitis, increases.
“Unfortunately, treatment of ascites will not improve the functioning of the liver, nor will it improve one’s prognosis,” says Melissa Palmer, M.D., a hepatologist and author who practices in Long Island, N.Y. “The development of ascites is a serious complication of cirrhosis that requires prompt evaluation and treatment. It indicates that a person no longer has compensated cirrhosis. Rather, he or she is considered to have decompensated cirrhosis, which means that the body can no longer ‘compensate’ for the extensive scarring (cirrhosis) that has occurred in the liver.
“People with any form of decompensated cirrhosis, whether from ascites, esophageal varices, portal gastropathy and/or encephalopathy, should be evaluated for liver transplantation,” Dr. Palmer says. “The chances of a person’s living one year drops from greater than 90 percent to less than 50 percent once ascites has developed. Therefore, once ascites has developed, liver transplantation should always be considered.”
Ascites can be successfully treated so that it goes away. However, most patients will have the tendency to develop ascites again once it has occurred, and treatment of ascites will not improve the functioning of the liver, nor will it improve one’s prognosis, according to Dr. Palmer. “But treatment of ascites is important,” she adds. “First, it improves the quality of life of the cirrhotic patient. And second, spontaneous bacterial peritonitis (SBP), a life-threatening infection of the ascitic fluid, will not occur if ascites is not present.”
What’s on tap?
For those with ascites that cannot be controlled through diuretics, some other options exist, although there are increased risks with these procedures. For most, including Garth, it means getting drained of the fluid, or “tapped” in clinical parlance, until such time as the patient improves, receives a transplanted liver or dies.
John Hoef, a physician’s assistant at St. Luke’s Center for Liver Disease in Houston’s sprawling medical center, has been performing paracenteses on patients for the past 12 years. Hoef says he probably does five to 10 “taps” a week and has done hundreds over the years. Garth is one of his patients. He has had more than 40 such procedures performed on him over a four-year period. Hoef says Garth is an unusual case in that he has been treating him for so long. Most patients, he says, either get a transplant within a few years or, sadly, die while waiting for a liver, as is the case with about 25 percent of all those on the liver transplant list.
A typical paracentesis takes about 30 to 45 minutes to perform, Hoef says, and removes around 4 to 6 liters of fluid on average, although it varies case by case. “Everyone is a little different, but I always tell patients not to obsess about the fluid because it’s just going to come back anyway,” he says. “We do it mainly for comfort. If a patient gets the typical back pain and is short of breath and can’t eat and can’t sleep, then we do the procedure to relieve all that. Some people need it once a week, some twice a week, but most people need it every couple of weeks. Some can go longer.”
Hoef says he has drained as much as 13 liters from a patient, but, he adds, that’s not typical. Garth says he has had as much as 10.5 liters drained from him, which amounts to about 22 pounds of fluid filling more than five large, 2-liter bottles. He currently averages about 5 or 6 liters each time he is tapped, which he does monthly at the medical center.
The procedure
After swabbing the lower abdomen with betadine, an antiseptic, a local anesthetic (typically lidocaine) is injected in the area to numb it, according to Hoef. Then, a larger needle is inserted with a catheter attached. The needle is slipped out, with the catheter left intact, and the other end of the catheter is inserted into one of the vacuum-sealed bottles. The fluid rapidly begins to drain from the abdomen into the bottle. When the bottle is full, the catheter is closed off temporarily while another bottle is prepared, and the procedure continues until the fluid is mostly drained. Once this occurs, the needle is removed, the area is cleaned again and a bandage is placed over the small incision where the catheter/needle was inserted. A few minutes of recovery, and the patient is free to go, although some dizziness and a general loss of energy may impede the patient’s ability to leave right away or to operate a motor vehicle.
In some hospitals or clinics, the process can take longer depending on the facility’s protocol. Some provide the patient with pain relief (typically Valium or Demerol), which can take longer to recover from, and many require that the patient stay for an albumin drip to replace that lost from the procedure. This also requires a longer recovery period since it can take a couple of hours to slowly drip the proper amount of albumin into the body through an IV.
While the procedure generally is done in an outpatient setting, there are, of course, risks, including accidental perforation of the bowel requiring immediate hospitalization. But most medical personnel agree that the alternative of leaving the ascites there is a much larger and much more serious risk. “It’s a risk because some patients with ascites get spontaneous bacterial peritonitis with a high mortality,” says Dr. Bennet Cecil, a hepatologist with a large practice in Kentucky. “And some may get hepatorenal syndrome, where the kidneys shut down causing death.” Either way, he says, it’s a good idea to rid the body of ascites.
For Garth and many in his position, it’s simply a matter of getting used to the uncomfortable procedure and used to the fact that the condition likely will persist unless the liver is able through treatment to repair itself or, in the alternative, a transplant is performed. “I know I can control it to a certain degree, but I don’t think I’ll ever get rid of it totally unless I get a transplant, which I can’t say I’m looking forward to,” Garth says. “For me, it’s just part of life – something I have to deal with whether I like it or not. For the record, I don’t.”
http://www.liverhealthtoday.org/viewarticle.cfm?aid=168