Ascites (Fluid in the Abdomen): Causes, Symptoms, Tests and Treatment

Have you noticed that your abdomen is gradually becoming larger, your clothes feel tighter around the waist, or you are gaining weight despite eating less?

Sometimes, abdominal swelling is not caused by ordinary weight gain or gas. It may be due to the accumulation of fluid inside the abdominal cavity, a condition known as ascites.

Ascites is commonly associated with advanced liver disease and cirrhosis, but it can also occur due to heart disease, abdominal tuberculosis, certain cancers and pancreatic disorders.

Some patients develop only mild abdominal swelling, while others experience marked distension, leg swelling, difficulty eating or breathlessness.

The important point is that ascites is a medical sign, not a disease by itself. Finding the underlying cause is essential for appropriate treatment.

If you or a family member has been diagnosed with ascites in Faridabad, timely evaluation by a gastroenterologist or liver specialist can help identify the cause and assess the risk of complications.

What is ascites?

Ascites is the abnormal accumulation of fluid in the space between the abdominal organs and the inner lining of the abdomen, called the peritoneal cavity.

Under normal circumstances, only a small amount of fluid is present in this space.

When fluid accumulates excessively, the abdomen may become swollen or distended.

In people with cirrhosis, ascites commonly develops because of increased pressure in the portal venous system, changes in circulation and the kidneys retaining excess sodium and water.

However, not every patient with ascites has cirrhosis. Other causes must be considered before deciding on treatment.

What are the symptoms of ascites?

Symptoms depend on how much fluid has accumulated and the underlying medical condition.

Common symptoms include:

• Increasing abdominal size or waist circumference.
• Unexplained or rapid weight gain.
• A feeling of heaviness or tightness in the abdomen.
• Abdominal discomfort or pressure.
• Early fullness after eating small meals.
• Reduced appetite.
• Swelling of the feet, ankles or legs.
• Difficulty bending forward or moving comfortably.
• Breathlessness, particularly when lying down, if fluid accumulation is substantial.
• Development or worsening of an umbilical hernia in some patients.

Some patients have only a small amount of fluid and may not notice any symptoms. Ascites may first be detected during an ultrasound examination performed for another reason.

Important: New or rapidly increasing abdominal swelling should not automatically be attributed to fatty liver, gas or weight gain. It needs medical evaluation.

What causes fluid accumulation in the abdomen?

Several medical conditions can cause ascites. The underlying mechanism is important because treatment differs considerably between them.

1. Liver cirrhosis and portal hypertension

Cirrhosis is one of the most important causes of ascites.

In cirrhosis, healthy liver tissue is progressively replaced by scar tissue. This interferes with normal blood flow through the liver and can lead to increased pressure in the portal vein, known as portal hypertension.

Several changes then contribute to fluid accumulation:

• Increased pressure within the portal circulation.
• Changes in blood vessel function and circulation.
• Activation of hormonal systems that make the kidneys retain sodium and water.
• Reduced effective circulating blood volume.
• Low blood albumin in some patients.

The combined effect can lead to fluid accumulation inside the abdominal cavity.

Ascites is an important complication of decompensated cirrhosis and deserves specialist assessment.

2. Chronic hepatitis B and hepatitis C

Long-standing hepatitis B or hepatitis C infection can cause chronic liver inflammation.

Over time, untreated or inadequately controlled infection may lead to fibrosis and cirrhosis. Ascites may develop when advanced liver disease causes portal hypertension and impaired circulation.

Appropriate antiviral treatment and liver monitoring can reduce the risk of disease progression.

Read more about hepatitis B and C treatment in Faridabad.

3. Metabolic dysfunction-associated steatotic liver disease (MASLD)

Fatty liver disease associated with metabolic risk factors can progress in some individuals to inflammation, fibrosis and cirrhosis.

People with obesity, type 2 diabetes, high triglycerides and other metabolic risk factors may be more likely to develop progressive liver disease.

Ascites is not a usual feature of uncomplicated fatty liver. If abdominal fluid develops, advanced liver disease or another cause needs to be investigated.

4. Abdominal tuberculosis

Abdominal or peritoneal tuberculosis is an important consideration in India.

Tuberculosis can affect the lining of the abdomen and cause fluid accumulation.

Possible symptoms include:

• Persistent abdominal swelling.
• Abdominal discomfort or pain.
• Fever, sometimes more noticeable in the evening.
• Reduced appetite.
• Unexplained weight loss.
• Fatigue.

The diagnosis may require analysis of ascitic fluid, imaging and, in selected cases, tissue sampling.

Ascites due to abdominal tuberculosis requires a different treatment approach from ascites due to cirrhosis.

5. Cancer-related ascites

Certain cancers can cause fluid accumulation in the abdomen.

These may include cancers involving the:

• Ovary.
• Stomach.
• Pancreas.
• Colon.
• Liver.
• Bile ducts.
• Peritoneum.

Cancer-related ascites may occur because of involvement of the peritoneal lining, impaired lymphatic drainage or other changes in abdominal circulation.

The evaluation may include imaging, ascitic fluid analysis and cytology when clinically indicated.

6. Heart failure

In some patients with heart failure, increased pressure in the venous circulation can cause fluid accumulation in the abdomen and legs.

Ascites associated with heart disease may have a different fluid-protein pattern from typical cirrhotic ascites.

Cardiac evaluation may therefore be necessary when the history, examination or fluid analysis suggests a heart-related cause.

7. Pancreatic disease

Pancreatitis or leakage from a pancreatic duct can occasionally lead to pancreatic ascites.

Patients may have a history of pancreatitis, abdominal pain or other pancreatic symptoms.

Ascitic fluid testing, particularly amylase measurement when indicated, can help investigate this possibility.

8. Other causes

Less commonly, ascites may be associated with:

• Portal vein thrombosis.
• Certain kidney disorders.
• Pericardial disease.
• Other conditions affecting abdominal fluid circulation.

This is why identifying the cause is more important than simply removing the fluid.

What are the different grades of ascites?

In patients with cirrhosis, ascites may be classified according to the amount of fluid and its response to treatment.

Grade 1: Mild ascites

A small amount of fluid is present and can generally be detected only through ultrasound.

The abdomen may not appear visibly swollen.

Grade 2: Moderate ascites

There is more noticeable, relatively symmetrical abdominal distension.

Patients may experience increasing abdominal girth, discomfort or early satiety.

Grade 3: Large or tense ascites

A substantial amount of fluid has accumulated, causing marked abdominal distension.

Patients may experience significant discomfort, difficulty moving, reduced appetite or breathlessness.

The grade helps describe the amount of fluid, but treatment decisions also depend on kidney function, blood sodium, symptoms and the overall condition of the liver.

How is ascites diagnosed?

Diagnosis involves identifying the fluid, understanding why it has accumulated and assessing whether complications are present.

1. Clinical examination

The doctor will ask about:

• When the abdominal swelling started.
• Whether it is increasing.
• Previous liver disease or hepatitis.
• Alcohol intake.
• Diabetes and obesity.
• Fever, abdominal pain or weight loss.
• Swelling in the legs.
• Breathlessness.
• Previous abdominal surgery or pancreatitis.
• Medicines and supplements.

Physical examination may help identify abdominal fluid, leg swelling, signs of chronic liver disease or other relevant abnormalities.

2. Abdominal ultrasound

Ultrasound is commonly used to detect fluid accumulation.

It can help assess:

• The amount and distribution of abdominal fluid.
• Liver appearance and texture.
• Spleen size.
• Portal vein and other abdominal blood vessels, particularly when Doppler examination is performed.
• Certain masses or other structural abnormalities.

An ultrasound can confirm the presence of fluid, but it may not establish its underlying cause.

3. Blood investigations

Depending on the clinical situation, blood tests may include:

• Complete blood count.
• Liver function tests.
• Serum albumin.
• Bilirubin.
• Prothrombin time and INR.
• Kidney function tests, including creatinine.
• Blood sodium and potassium.
• Hepatitis B and C testing where appropriate.

These tests help assess liver function, kidney health, electrolyte balance and possible causes of ascites.

4. Diagnostic paracentesis (abdominal fluid test)

One of the most important investigations for new-onset ascites is diagnostic paracentesis.

In this procedure, a doctor uses a sterile needle or catheter to withdraw a small sample of abdominal fluid for laboratory analysis.

When new ascites is accessible for sampling, diagnostic paracentesis is generally recommended to establish the cause and assess for infection.

The fluid may be tested for:

• Cell count and differential.
• Albumin concentration.
• Total protein.
• Culture when infection is suspected.
• Additional investigations such as cytology, amylase or tests for tuberculosis when clinically indicated.

The serum-ascites albumin gradient, or SAAG, is calculated using blood albumin and ascitic fluid albumin measured at approximately the same time.

A SAAG of 1.1 g/dL or higher generally suggests portal hypertension as an important mechanism. It does not, by itself, prove that cirrhosis is the cause.

Additional fluid characteristics and clinical findings help distinguish liver-related ascites from cardiac, malignant, infectious and pancreatic causes.

5. Testing for infection in ascitic fluid

Patients with cirrhosis and ascites are at risk of an infection called spontaneous bacterial peritonitis (SBP).

The infection can sometimes develop without dramatic symptoms.

A raised ascitic fluid neutrophil count, particularly 250 cells/mm³ or more, is an important diagnostic threshold used in evaluating SBP.

When infection is suspected, fluid culture and other tests help guide treatment.

This is one reason new abdominal pain, fever, confusion or unexplained deterioration in a patient with cirrhosis and ascites must be treated seriously. AASLD

What is the treatment for ascites?

Treatment depends on the cause, the amount of fluid, kidney function, electrolyte levels and the presence of complications.

The objective is not simply to remove fluid. It is also to treat the underlying disease and reduce the chance of recurrence.

1. Treat the underlying cause

If ascites is due to cirrhosis, treatment includes managing the underlying liver disease and complications of portal hypertension.

If it is due to tuberculosis, cancer, heart failure or pancreatic disease, treatment must address that specific condition.

The same treatment cannot be used for every type of ascites.

2. Dietary sodium restriction

In patients with cirrhosis-related ascites, reducing excess sodium intake is an important part of treatment.

A commonly recommended target is approximately 2 grams of sodium per day, adjusted to the patient’s nutritional requirements and clinical condition.

Practical measures may include:

• Avoiding excessive added salt.
• Limiting pickles and papad.
• Reducing packaged namkeen and salty snacks.
• Checking the sodium content of packaged foods.
• Limiting high-sodium sauces and ready-made meals.
• Choosing freshly prepared meals with controlled salt.

Very severe dietary restriction can reduce food intake and worsen malnutrition. Patients with cirrhosis need adequate calories and protein, so dietary changes should be planned carefully.

A dietitian familiar with liver disease can help individualise the plan.

3. Diuretic medicines

Diuretics are medicines that help the kidneys remove excess sodium and water.

In appropriate patients, treatment may involve:

• Spironolactone.
• Furosemide, when required.
• A combination of both medicines in selected cases.

The dose must be individualised.

During treatment, doctors may monitor:

• Body weight.
• Blood pressure.
• Urine output.
• Serum sodium and potassium.
• Kidney function.
• Symptoms and abdominal swelling.

Incorrect use or excessive doses can cause dehydration, low blood pressure, electrolyte abnormalities and kidney injury.

Do not start, stop or increase water tablets on your own.

4. Therapeutic paracentesis (fluid drainage)

When ascites is large or tense, therapeutic paracentesis may be performed to remove abdominal fluid and relieve discomfort.

It may help patients who have:

• Marked abdominal distension.
• Significant abdominal pressure.
• Difficulty eating.
• Breathlessness due to fluid accumulation.
• Ascites that does not respond adequately to medicines.

For large-volume fluid removal, intravenous albumin is generally recommended when more than 5 litres are removed in a session. The AASLD guidance recommends approximately 6–8 grams of albumin for each litre removed in this setting.

The procedure and albumin requirement are determined by the treating team.

5. Treatment of spontaneous bacterial peritonitis

If ascitic fluid testing identifies spontaneous bacterial peritonitis, it requires urgent hospital-based treatment.

Management generally includes appropriate antibiotics and, in selected patients, intravenous albumin.

Some patients at high risk of SBP or with a previous episode may need preventive antibiotics. These are not required by every person with ascites.

Antibiotics should never be started or continued without a clinician’s assessment.

6. TIPS procedure in selected patients

TIPS stands for transjugular intrahepatic portosystemic shunt.

It is an interventional procedure that creates a channel within the liver to reduce pressure in the portal venous system.

It may be considered for carefully selected patients with recurrent or refractory ascites.

However, TIPS is not suitable for everyone. The decision requires assessment of liver function, cardiac status, kidney function and the risk of complications such as hepatic encephalopathy.

7. Liver transplantation assessment

Ascites in cirrhosis may indicate advanced or decompensated liver disease.

Patients with recurrent or refractory ascites should be assessed for the need for liver transplant evaluation, depending on their overall condition.

Transplant assessment should not be delayed solely because a numerical severity score appears relatively low. The clinical picture and complications matter.

The AGA’s October 2025 practice update also recommends considering transplant evaluation in patients with refractory ascites.

What foods should patients with ascites eat?

Nutrition is an important part of managing chronic liver disease.

Patients with cirrhosis may lose muscle and become malnourished even when their abdomen appears large due to fluid accumulation.

General principles include:

• Maintain adequate calorie intake.
• Include sufficient protein unless a specialist identifies a specific reason for modification.
• Prefer balanced meals with vegetables, fruits, pulses, soy, tofu and other suitable protein sources.
• Reduce excess salt as advised.
• Avoid prolonged fasting.
• Avoid crash diets and unnecessary food restrictions.
• Avoid alcohol completely in cirrhosis.
• Work with a dietitian if appetite or nutritional intake is poor.

Do not automatically restrict protein because of cirrhosis or ascites. Adequate protein is important for preserving muscle mass.

Fluid restriction is also not routinely necessary for every patient with ascites. It is generally considered in selected circumstances, particularly significant dilutional hyponatraemia, under medical supervision.

What medicines should patients with ascites avoid?

People with cirrhosis and ascites need to be particularly careful with medicines that can affect kidney function or fluid balance.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen and diclofenac, may be unsuitable in patients with advanced cirrhosis and ascites.

Some blood pressure medicines and other drugs may also need review depending on blood pressure, kidney function and the severity of liver disease.

Do not stop prescribed medicines independently. Ask your treating doctor to review all prescription medicines, painkillers, over-the-counter products and herbal supplements.

What are the complications of untreated or worsening ascites?

Ascites can be associated with several serious complications, particularly in advanced cirrhosis.

These include:

• Spontaneous bacterial peritonitis.
• Kidney dysfunction and hepatorenal syndrome.
• Worsening hyponatraemia.
• Increased abdominal pressure and breathlessness.
• Umbilical or abdominal wall hernias.
• Malnutrition and muscle loss.
• Repeated hospital admissions.

Early assessment and appropriate monitoring can help identify complications and guide treatment.

When is ascites an emergency?

Patients with cirrhosis and ascites should seek urgent medical attention if they develop:

• Fever or chills.
• New or worsening abdominal pain.
• Abdominal tenderness.
• Sudden increase in abdominal swelling.
• New confusion, unusual behaviour or excessive drowsiness.
• Reduced urine output.
• Severe weakness or fainting.
• Breathlessness.
• Vomiting blood.
• Black, tarry stools.

These symptoms may indicate infection, bleeding, kidney dysfunction or another serious complication.

Do not wait for a routine clinic appointment if these symptoms occur. Go to the nearest emergency department. MedlinePlus

Ascites treatment and liver evaluation in Faridabad

Abdominal fluid accumulation requires more than temporary relief through fluid drainage. Identifying the cause, assessing liver and kidney function, preventing infection and managing portal hypertension are all important.

Dr Vishal Khurana is a gastroenterologist and liver specialist practising in Faridabad.

Patients with abdominal swelling, suspected ascites, cirrhosis, portal hypertension or unexplained fluid accumulation may require an individualised clinical evaluation.

Depending on the findings, assessment may involve blood investigations, abdominal ultrasound with Doppler, FibroScan for liver fibrosis assessment and diagnostic paracentesis.

Treatment is selected according to the cause and severity. Some patients require medicines and dietary management, while others may need hospital-based fluid drainage, specialist intervention or transplant evaluation.

For appointment enquiries, call or WhatsApp 7289840710.

You can also explore the liver and gastroenterology services in Faridabad.

Remember: New abdominal fluid accumulation should be investigated. Fever, abdominal pain, confusion, reduced urine output or gastrointestinal bleeding in a patient with ascites requires urgent medical attention.

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Frequently Asked Questions About Ascites

1. What is ascites in the stomach?

Ascites is the accumulation of excess fluid in the abdominal cavity, around the abdominal organs. It can cause abdominal swelling, discomfort, early fullness and sometimes breathlessness.

2. Does ascites always mean liver cirrhosis?

No. Cirrhosis is an important cause, but ascites can also occur due to heart failure, abdominal tuberculosis, cancer, pancreatitis and certain other medical conditions. Investigations are needed to identify the cause.

3. Can ascites be cured completely?

The outcome depends on the underlying condition. Some causes may improve substantially with appropriate treatment. In advanced cirrhosis, ascites may recur and require ongoing management. A cure cannot be promised for every patient.

4. Is abdominal ultrasound enough to diagnose ascites?

Ultrasound can detect abdominal fluid and assess the liver and other abdominal structures. However, it may not identify the cause. New-onset ascites often requires diagnostic fluid analysis when sampling is feasible.

5. What is a diagnostic paracentesis?

Diagnostic paracentesis is a procedure in which a small sample of abdominal fluid is removed using a sterile needle or catheter. The fluid is analysed to help determine the cause of ascites and check for infection.

6. Is paracentesis painful?

Patients may experience brief discomfort during the procedure, but local anaesthesia is commonly used. The procedure is performed using appropriate sterile precautions, and ultrasound guidance may be used when required.

7. Can ascites cause breathlessness?

Yes. Large amounts of abdominal fluid can push the diaphragm upwards and restrict comfortable expansion of the lungs, causing breathlessness.

8. Can ascites come back after fluid drainage?

Yes. Paracentesis removes existing fluid but does not necessarily correct the underlying cause. Fluid may accumulate again unless the underlying disease and fluid retention are managed.

9. Should patients with ascites stop drinking water?

No. Fluid restriction is not necessary for everyone with ascites. It may be advised in selected patients, particularly those with significant low blood sodium, under medical supervision.

10. Can patients with ascites eat protein?

Yes. Adequate protein is generally important in cirrhosis because patients are at risk of muscle loss and malnutrition. Protein restriction should not be started routinely without a specific medical indication.

11. What is spontaneous bacterial peritonitis?

Spontaneous bacterial peritonitis is an infection of ascitic fluid, particularly in people with cirrhosis. It can cause fever, abdominal pain, confusion or sudden deterioration, but symptoms may sometimes be subtle. It requires urgent medical assessment and treatment.

12. What is refractory ascites?

Refractory ascites is fluid accumulation that cannot be adequately controlled with appropriate medical treatment or that returns early despite treatment. It may require repeated paracentesis, evaluation for TIPS and consideration of liver transplantation.

13. Does FibroScan diagnose ascites?

No. FibroScan assesses liver stiffness and can estimate liver fat. It helps evaluate liver fibrosis but does not replace ultrasound for detecting abdominal fluid or paracentesis for analysing ascitic fluid.

14. Which doctor should I consult for ascites in Faridabad?

A gastroenterologist or hepatologist can evaluate ascites, investigate its cause and plan appropriate treatment. Patients with fever, abdominal pain, confusion or other emergency symptoms should go directly to a hospital.

Medical disclaimer: This article is for general patient education and does not replace an individual medical consultation. Ascites requires evaluation of its underlying cause. Treatment, medicines, dietary changes and fluid management must be individualised.