Ascites is the pathological accumulation of fluid within the peritoneal cavity secondary to portal hypertension, hypoalbuminaemia and sodium retention. In patients with chronic liver disease it marks the transition from compensated to decompensated cirrhosis. The severity ranges from mild, detected only by imaging, to gross, producing marked physical and metabolic disturbances.
Metabolic disturbances
Hyponatraemia, muscle cramps and hypervolaemic dilutional anaemia reflect advanced renal sodium retention and impaired free-water clearance.
Progressive abdominal distension
Painless increase in girth is usually the first complaint; patients note tight clothing, difficulty bending forward, and a sensation of heaviness in the flanks.
Shifting dullness and fluid thrill
On percussion, dullness moves toward the dependent side when the patient turns; a fluid thrill may be elicited in tense ascites.
Weight gain and ankle oedema
Rapid daily increments (≥0.5 kg) reflect active sodium-water retention; gravitational oedema often precedes detectable peritoneal fluid.
Early satiety and nausea
Elevation of the diaphragm and compression of the stomach reduce gastric capacity, leading to post-prandial fullness, eructation and occasional vomiting.
Dyspnoea and orthopnoea
Basal atelectasis and elevation of the diaphragm decrease functional residual capacity, producing exertional dyspnoea and inability to lie flat.
Umbilical hernia and striae
Increased intra-abdominal pressure stretches the linea alba, leading to eversion of the umbilicus and occasionally painful incarceration.
Spontaneous bacterial peritonitis (SBP) warning
New-onset fever, abdominal pain, rebound tenderness or altered mental status indicate infection of ascitic fluid and require immediate diagnostic paracentesis.
| Symptom / Sign | Typical Presentation |
|---|---|
| Abdominal distension | Progressive, painless, flank bulging |
| Shifting dullness | Percussion dullness moves with posture |
| Weight gain / oedema | ≥0.5 kg/day, ankle swelling |
| Early satiety | Post-prandial fullness, nausea |
| Dyspnoea | Exertional, orthopnoea from raised diaphragm |
| Umbilical hernia | Everted umbilicus, incarceration risk |
| SBP warning | Fever, pain, rebound tenderness |
| Metabolic | Hyponatraemia, muscle cramps |