Ascites
Cardiac ascites, cirrhosis or both? Constriction, severe TR and RV failure hide as 'liver disease'.
Echo approach, step by step
Ascites is cardiac when right-sided filling pressure is chronically raised. The key diagnoses are constriction, severe TR, RV failure from PH, and restrictive cardiomyopathy. In cirrhosis, echo also screens for cirrhotic cardiomyopathy and the two pulmonary vascular complications [57,204,208].
- IVC and hepatic veinsPlethora; systolic reversal (TR) or expiratory diastolic reversal (constriction) [4,57].
- Constriction screenSeptal bounce, respiratory variation, medial e′, annulus reversus [57,179].
- TR and RVTR grade, RV size and function, PASP [3,4].
- LVRestrictive filling, amyloid features [30].
- PericardiumEffusion.
- In cirrhosisLV systolic and diastolic function (cirrhotic cardiomyopathy); PASP (portopulmonary hypertension); saline study (hepatopulmonary syndrome) [204,208].
- IVC and hepatic vein pattern
- Constriction criteria
- TR, RV, PASP
- LV filling / restriction
- Pericardial effusion
- Cirrhotic cardiomyopathy criteria (if cirrhosis)
- Saline study (if hypoxaemic)
Causes & echo clues
| Cause | Echo clue | Next |
|---|---|---|
| Constrictive pericarditis | Mayo criteria | CT, CMR, catheterisation [57] |
| Severe TR / RV failure | Dilated RV and RA, systolic hepatic reversal | TR pathway [6] |
| Pulmonary hypertension | High TR velocity, RV dysfunction | PH work-up [8] |
| Restrictive cardiomyopathy | Thick walls, restrictive filling | Amyloid work-up [30] |
| Cirrhosis | Normal RA pressure; hyperdynamic circulation | Hepatology [208] |
| Portopulmonary hypertension | High PASP in portal hypertension | Right-heart catheterisation [204] |
| Malignant / tuberculous | Pericardial effusion or thickening | Paracentesis cytology, culture [31] |
Clinical pathway to the diagnosis
- Diagnostic paracentesisSerum–ascites albumin gradient (SAAG) and ascitic total protein. A high SAAG with high protein suggests cardiac (post-sinusoidal) ascites; a high SAAG with low protein suggests cirrhosis.
- JVP and NT-proBNPVery high values point to a cardiac cause.
- Liver ultrasound with DopplerLiver texture, hepatic veins, portal flow.
- EchoConstriction, TR, RV, PH [57].
- If discordantCT or CMR of the pericardium; right-heart catheterisation [31].
Clinical pearls & pitfalls
PitfallLong-standing cardiac congestion causes cardiac cirrhosis. The two conditions coexist. Treating the heart (pericardiectomy, TR intervention) can reverse the ascites [31,57].
- Cirrhotic cardiomyopathy criteria: systolic dysfunction (LVEF ≤50% or absolute GLS <18%), or advanced diastolic dysfunction (≥3 of septal e′ <7 cm/s, E/e′ ≥15, LAVI >34 mL/m², TR >2.8 m/s) [208].
Red flags
- Raised JVP with ascites → cardiac cause (constriction, TR, RV failure) [57]
- Ascites with a pericardial effusion → malignancy, tuberculosis, hypothyroidism [31,201]
- Cirrhosis with dyspnoea or hypoxaemia → portopulmonary hypertension or hepatopulmonary syndrome [204]