Ascites: when the stomach fills with fluid

Ascites is fluid collecting inside the abdomen. Families usually notice it before any report does — the stomach starts looking swollen, old clothes stop fitting, and the weight climbs by a few kilos in a couple of weeks even though the person is eating less than before.

Why it happens in liver disease

When the liver becomes scarred, blood cannot pass through it easily and pressure builds up in the veins behind it. At the same time the damaged liver makes less albumin, the protein that holds fluid inside the blood vessels. Fluid leaks out and settles in the abdomen.

In someone with cirrhosis, the arrival of ascites is a turning point. It means the liver has moved from coping to not coping. It needs proper treatment, not a water tablet bought from the chemist.

What you may notice

• The stomach growing over weeks, sometimes tight like a drum
• Weight going up quickly — two or three kilos in a week
• Swelling of both ankles and feet
• Feeling full after only a few bites
• Breathlessness, worse on lying flat

It is not always the liver

Fluid in the abdomen can also come from the heart, the kidneys, tuberculosis of the abdomen, or a cancer. In India, abdominal TB is common enough that it must always be ruled out. Treating the wrong cause wastes months.

The test that settles it is an ascitic tap — a thin needle draws off a sample of the fluid. It takes a few minutes in the OPD, it is not an operation, and it is not something to be frightened of. The fluid is checked for infection, and a calculation called SAAG tells us whether pressure in the liver is the cause.

Salt is the main treatment, not water

Most people arrive expecting to be told to stop drinking water. That is usually wrong. Water is restricted only when the sodium level in the blood has fallen. What actually controls ascites is salt.

• Cook without added salt, and take the salt shaker off the table
• Pickle, papad, chutney and namkeen are the biggest offenders
• Packaged food counts too — biscuits, bread, sauces, instant noodles, chips
• Baking soda and ajinomoto are salt in another form
• Food from outside is almost always too salty, however simple it looks

Water tablets (diuretics) are added on top of this, and the dose is set against your weight and your kidney reports. Doses changed at home, raised or stopped, are one of the commonest reasons people end up admitted.

Keep a simple diary

• Weigh yourself every morning, after passing urine, in the same clothes
• Write the weight down with the date
• Measure around the stomach once a week
• Bring the diary to every visit

That one sheet of paper tells us more about whether the treatment is working than most tests do.

Go to a hospital the same day if there is

• Fever, or pain across the whole abdomen — the fluid can become infected, and that is an emergency
• Confusion, unusual sleepiness, or odd behaviour
• Vomiting of blood, or black stools
• Urine output dropping sharply
• Breathlessness at rest

Infection of the ascitic fluid is very treatable when it is caught early, and dangerous when it is not. Do not wait for the next appointment.