Ascites is an accumulation of serous fluid within the peritoneal cavity. It is the most common complication of liver cirrhosis. In children, hepatic, renal and cardiac disorders are the most common causes. Portal hypertension and sodium and fluid retention are key factors in the pathophysiology of ascites. Peripheral arterial vasodilatation hypothesis is the most accepted mechanism for inappropriate sodium retention and formation of ascites. Diagnostic paracentesis is indicated in children with newly diagnosed ascites and in children with suspected complications of ascites. Ascitic fluid is evaluated for cell count, protein level, and culture. The serum-ascites albumin gradient (SAAG) is the best single test for classifying ascites into portal hypertensive (SAAG >1.1 g/dl) and non–portal hypertensive (SAAG <1.1 g/dl). A neutrophil count ≥250 cells/mm3 is highly suggestive of bacterial peritonitis. The treatment of ascites due to non-liver disease depends on the underlying condition. In liver disease, diuretics as monotherapy or dual therapy and salt restriction form the mainstay of treatment in children with mild to moderate ascites. Fluid restriction is helpful in children with hyponatremia. In non-responsive ascites or in children with large ascites, large volume paracentesis (LVP) with albumin infusion should be performed. In children with refractory ascites, LVP with albumin administration, transjugular intrahepatic porto-systemic shunt (TIPS), peritoneo-venous shunting and liver transplantation are other therapeutic modalities that need to be considered.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Kennedy M, Liacouras CA. Ascitis. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE, editors. Nelson textbook of pediatrics. New Delhi: Elsevier Saunders; 2012. p. 5041–4.
Sankaranarayanan VS. Ascites in children. In: Bavdekar AR, Mathai J, Malathi S, Yachha SK, editors. IAP Speciality series on pediatric gastroenterology. New Delhi: Jaypee; 2013. p. 270–80.
McKiernan PJ. The acutely ill baby. In: Kelly D, editor. Diseases of the liver and biliary system in children. Birmingham: Wiley-Blackwell; 2008. p. 106–26.
Garcia-Tsao G. Ascitis. In: Dooley JS, Lok ASF, Burroughs AK, Heathcote EJ, editors. Sherlock’s disease of the liver and biliary system. Birmingham: Wiley-Blackwell; 2011. p. 210–33.
Schrier RW, Arroyo V, Bernardi M, et al. Peripheral arterial vasodilation hypothesis—a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology. 1988;8:1151–7.
Wiest R, Groszmann RJ. The paradox of nitric oxide in cirrhosis and portal hypertension: too much, not enough. Hepatology. 2002;35:478–91.
European Association for the Study of Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53:397–417.
Oelsner DH, Caldwell SH, Coles M, Driscoll CJ. Subumbilical midline vascularity of the abdominal wall in portal hypertension observed at laparoscopy. Gastrointest Endosc. 1998;47:388–90.
Shepherd R. Complications and management of chronic liver disease. In: Kelly D, editor. Diseases of the liver and biliary system in children. Birmingham: Wiley-Blackwell; 2008. p. 351–78.
Rimola A, Garcia-Tsao G, Navasa M, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. J Hepatol. 2000;32:142–53.
Larcher VF, Manolaki N, Vegnent A, et al. Spontaneous bacterial peritonitis with chronic liver disease: clinical features and etiologic factors. J Pediatr. 1985;106:907–12.
Albillos A, Cuervas-Mons V, Millan I, et al. Ascitic fluid polymorphonuclear cell count and serum to ascites albumin gradient in the diagnosis of bacterial peritonitis. Gastroenterology. 1990;98:134–40.
Runyon BA, Antillon MR, Akriviadis EA, McHuchison JG. Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J Clin Microbiol. 1990;28:2811–2.
Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992;117:215–20.
McHutchison JG. Differential diagnosis of ascites. Semin Liver Dis. 1997;17:191–202.
Fernández J, Navasa M, Gómez J, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002;35:140–8.
Cholongitas E, Papatheodoridis GV, Lahanas A, et al. Increasing frequency of gram-positive bacteria in spontaneous bacterial peritonitis. Liver Int. 2005;25:57–61.
Narula N, Tsoi K, Marshall JK. Should albumin be used in all patients with spontaneous bacterial peritonitis? Can J Gastroenterol. 2011;25:373–6.
Gines P, Rimola A, Planas R, et al. Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial. Hepatology. 1990;12:716–24.
Pérez-Ayuso RM, Arroyo V, Planas R, et al. Randomized comparative study of efficacy of furosemide versus spironolactone in nonazotemic cirrhosis with ascites. Relationship between the diuretic response and the activity of the renin-aldosterone system. Gastroenterology. 1983;84:961–8.
Runyon BA. Management of adult patients with ascites due to cirrhosis. Hepatology. 2004;39:841–56.
Kramer RE, Sokol RJ, Yerushalmi B, et al. Large-volume paracentesis in the management of ascites in children. J Pediatr Gastroenterol Nutr. 2001;33:245–9.
Ginès A, Fernandez-Esparrach G, Monescillo A, et al. Randomized controlled trial comparing albumin, dextran-70 and polygelin in cirrhotic patients with ascites treated by paracentesis. Gastroenterology. 1996;111:1002–10.
Arroyo V, Gines P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology. 1996;23:164–76.
D’Amico G, Luca A, Morabito A, et al. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology. 2005;129:1282–93.
Albillos A, Banares R, Gonzalez M, et al. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. J Hepatol. 2005;43:990–6.
Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology. 2005;41:386–400.
Moore KP, Wong F, Ginès P, et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology. 2003;38:258–66.
Dumortier J, Pianta E, Le Derf Y, et al. Peritoneovenous shunt as a bridge to liver transplantation. Am J Transplant. 2005;5:1886–92.
AB: Literature review, manuscript review, editing and will act as guarantor for the paper; NT: Literature search, manuscript drafting, review and editing.
Conflict of Interest
Source of Funding
About this article
Cite this article
Bavdekar, A., Thakur, N. Ascites in Children. Indian J Pediatr 83, 1334–1340 (2016). https://doi.org/10.1007/s12098-016-2168-1