Hepatology International

, Volume 7, Issue 1, pp 188–198 | Cite as

Ascites in patients with hepatocellular carcinoma: prevalence, associated factors, prognostic impact, and staging strategy

  • Chia-Yang Hsu
  • Yun-Hsuan Lee
  • Yi-Hsiang Huang
  • Cheng-Yuan Hsia
  • Chien-Wei Su
  • Han-Chieh Lin
  • Rheun-Chuan Lee
  • Yi-You Chiou
  • Fa-Yauh Lee
  • Teh-Ia Huo
  • Shou-Dong Lee
Original Article



Ascites may develop in patients with hepatocellular carcinoma (HCC) with coexisting liver cirrhosis. Few studies had specifically evaluated the role of ascites in HCC. This study investigated its prevalence, associated factors, prognostic impact, and staging strategy in a large HCC patient cohort.

Patients and methods

A total of 2,203 HCC patients were analyzed. The grading of ascites was according to the European Association for the Study of Liver. The prognostic ability of the Cancer of the liver Italian Program (CLIP), Barcelona Clinic Liver Cancer, Japan Integrated Scoring system, and Taipei Integrated Scoring system in HCC patients with ascites was compared using the Akaike information criterion (AIC).


Ascites was present in 498 (23%) patients at diagnosis. Grades 1, 2, and 3 ascites were found in 13, 5, and 5% of the patients, respectively. The severity of ascites significantly correlated with hyperbilirubinemia, hypoalbuminemia, hyponatremia, prothrombin time (PT) prolongation, and renal insufficiency (all p < 0.001). Large tumor burden and more frequent vascular invasion were often observed in patients with more severe ascites (both p < 0.001). In the Cox proportional hazard model, ascites was identified as an independent prognostic predictor with 80–94% increased risk of mortality (p < 0.001). Among HCC patients with ascites, the CLIP system had the lowest AIC value.


Ascites is often seen in HCC patients and is associated with both tumoral and cirrhosis factors and decreased long-term survival. The CLIP staging system is a more feasible prognostic model for HCC patients with ascites. The optimal treatment strategy for these patients remains to be investigated.


Ascites Hepatocellular carcinoma Liver cirrhosis MELD 





Akaike information criterion


Barcelona Clinic Liver Cancer


Confidence interval


Cancer of the Liver Italian Program


Computed tomography




Hepatitis B virus


Hepatitis C virus


Hepatocellular carcinoma


International normalized ratio


Japan Integrated Scoring


Model for end-stage liver disease


Percutaneous acetic acid injection


Percutaneous ethanol injection


Radiofrequency ablation


Standard deviation


Transarterial chemoembolization



We thank Ms Ya-Ju Tsai for her help on data collection and manuscript preparation. This study was supported by grants from the Center of Excellence for Cancer Research at Taipei Veterans General Hospital, Taiwan (DOH100-TD-C-111-007), Taipei Veterans General Hospital, Taipei, Taiwan (V100C1-155), National Yang-Ming University Hospital, Yilan, Taiwan (RD-2011-017), and the Ministry of Education, Aim for the Top University Plan, Taiwan (100AC-D103).


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Copyright information

© Asian Pacific Association for the Study of the Liver 2012

Authors and Affiliations

  • Chia-Yang Hsu
    • 1
    • 4
    • 5
  • Yun-Hsuan Lee
    • 1
    • 5
  • Yi-Hsiang Huang
    • 1
    • 5
  • Cheng-Yuan Hsia
    • 1
    • 2
    • 5
  • Chien-Wei Su
    • 1
    • 5
  • Han-Chieh Lin
    • 1
    • 5
  • Rheun-Chuan Lee
    • 3
    • 5
  • Yi-You Chiou
    • 3
    • 5
  • Fa-Yauh Lee
    • 1
    • 5
  • Teh-Ia Huo
    • 1
    • 5
  • Shou-Dong Lee
    • 1
    • 5
  1. 1.Division of Gastroenterology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
  2. 2.Department of SurgeryTaipei Veterans General HospitalTaipeiTaiwan
  3. 3.Department of RadiologyTaipei Veterans General HospitalTaipeiTaiwan
  4. 4.Department of MedicineNational Yang-Ming University HospitalYilanTaiwan
  5. 5.National Yang-Ming University School of MedicineTaipeiTaiwan

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