“The beauty of the Opdivo and Yervoy, it works in the chest. It works through the bloodstream. So anywhere that you can see so many cells hiding, they can get there. So, can I guarantee that your ascites will go away? Unfortunately, I cannot. But if you enjoy a response to the treatment, it may very well decrease the ascites.”
Dr. Edward Levine, Head of the Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy program
“Dr. Strocel treated Trina Reif, a 20-year peritoneal survivor, and spoke to us about her case. He said, 'Trina had unexplained ascites. We did an exploratory laparotomy. We also did multiple peritoneal biopsies. She had an angry looking peritoneum. Her diagnosis was abdominal mesothelioma.'”
Dr. Anton Strocel, retired OB/GYN
“As a woman, especially as a young woman with abdominal pain being my major symptom, I had a really hard time convincing someone that I was in pain. Like, a really hard time. I was told it was just my period. If I had given up when they first told me, 'Oh, it's just a little period pain,' I might not be here today. You have to trust yourself and you have to trust your gut, no matter what people say to you.”
Jayda K., a peritoneal mesothelioma survivor whose exploratory laparoscopy revealed more than a gallon of fluid in her abdomen
Cancer link: Ascites occurs in more than 50% of peritoneal mesothelioma cases
Diagnosis limit: Cytology testing detects malignant mesothelioma in ascites fluid only about 34% of the time
Diagnosis limit: A 2022 review in the journal Cytopathology examined 210 peritoneal fluid samples. Cytology testing found malignant mesothelioma in about 33% of them.
Leading cause: Cirrhosis accounts for about 81% of all ascites cases
Most common symptom: Abdominal swelling and discomfort are the first signs of fluid buildup
Primary cancer cause: Cancer, including peritoneal mesothelioma, causes about 10% of ascites cases
Treatment approach: Doctors combine fluid drainage, chemotherapy and surgery to manage cancer-related ascites
Treatment research: A 2023 study found combining fluid drainage with chemo and nutritional support improves patient outcomes
Treatment research: A 2023 study of patients with gastric cancer and malignant ascites found that combining fluid drainage with chemotherapy and nutritional support improved survival.
“The beauty of the Opdivo and Yervoy, it works in the chest. It works through the bloodstream. So anywhere that you can see so many cells hiding, they can get there. So, can I guarantee that your ascites will go away? Unfortunately, I cannot. But if you enjoy a response to the treatment, it may very well decrease the ascites.”
Dr. Edward Levine, Head of the Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy program
“Dr. Strocel treated Trina Reif, a 20-year peritoneal survivor, and spoke to us about her case. He said, 'Trina had unexplained ascites. We did an exploratory laparotomy. We also did multiple peritoneal biopsies. She had an angry looking peritoneum. Her diagnosis was abdominal mesothelioma.'”
Dr. Anton Strocel, retired OB/GYN
“As a woman, especially as a young woman with abdominal pain being my major symptom, I had a really hard time convincing someone that I was in pain. Like, a really hard time. I was told it was just my period. If I had given up when they first told me, 'Oh, it's just a little period pain,' I might not be here today. You have to trust yourself and you have to trust your gut, no matter what people say to you.”
Jayda K., a peritoneal mesothelioma survivor whose exploratory laparoscopy revealed more than a gallon of fluid in her abdomen
Cancer link: Ascites occurs in more than 50% of peritoneal mesothelioma cases
Diagnosis limit: Cytology testing detects malignant mesothelioma in ascites fluid only about 34% of the time
Diagnosis limit: A 2022 review in the journal Cytopathology examined 210 peritoneal fluid samples. Cytology testing found malignant mesothelioma in about 33% of them.
Leading cause: Cirrhosis accounts for about 81% of all ascites cases
Most common symptom: Abdominal swelling and discomfort are the first signs of fluid buildup
Primary cancer cause: Cancer, including peritoneal mesothelioma, causes about 10% of ascites cases
Treatment approach: Doctors combine fluid drainage, chemotherapy and surgery to manage cancer-related ascites
Treatment research: A 2023 study found combining fluid drainage with chemo and nutritional support improves patient outcomes
Treatment research: A 2023 study of patients with gastric cancer and malignant ascites found that combining fluid drainage with chemotherapy and nutritional support improved survival.
What Is Ascites?
Ascites is a buildup of fluid in your peritoneal cavity (space in your belly containing your digestive organs). When fluid accumulates in this space, it can cause your belly to swell. Ascites is common in people with peritoneal mesothelioma and liver issues. Peritoneal effusion and ascites are two names for the same condition: Doctors use “peritoneal effusion” to describe fluid in the peritoneal cavity and they use “ascites” more often when liver disease is the cause. When cancer causes the fluid, doctors call it a malignant peritoneal effusion.
The peritoneum is a thin membrane that lines the inside of your abdominal cavity. Conditions such as cirrhosis or cancers, like peritoneal mesothelioma, can cause fluid to cross the peritoneum. When this happens, the fluid then collects in your peritoneal cavity, and you can notice swelling and other symptoms.
The Peritoneal Cavity: Where Peritoneal Fluid Collects
The peritoneal cavity is the narrow space between the two layers of the peritoneum, the membrane that lines the abdominal wall and covers the organs inside it. Doctors also call it the peritoneal space. Normally, the cavity holds only a small amount of lubricating fluid, typically 5 to 20 mL, enough to allow the organs to slide against each other. A peritoneal effusion means that volume has climbed far above normal and that’s when swelling and pressure begin.
Protein levels in your abdominal fluid are measured and used to help classify ascites or peritoneal effusions. An exudate is peritoneal fluid with a high protein level. A transudate is peritoneal fluid with a low protein level. This can help doctors find the cause of your peritoneal effusion. Cirrhosis, or liver disease, usually causes low protein levels. Cancer and infections usually cause high levels.
Fluid Type: Exudate vs. Transudate
Fluid Type
Protein Level
Usually Points To
Exudate
High protein, reported as roughly 2.5 g/dL or above
Cancer (including peritoneal mesothelioma) or infection
Transudate
Low protein, reported as below roughly 2.5 g/dL
Cirrhosis or other liver disease
What Causes Peritoneal Effusions?
Peritoneal effusions have several possible causes, and not all of them point to cancer. Cirrhosis and other liver conditions cause most cases, while cancers such as peritoneal mesothelioma, infections and heart or kidney problems account for the rest.
Each cause looks and behaves a little differently, which is why doctors run tests rather than guess based on symptoms alone. A fluid analysis can often point to the answer within a day or two.
Cirrhosis and Liver Disease
Cirrhosis, or scarring of the liver, is the most common cause of ascites. Cirrhosis can cause high pressure in your liver’s veins. This can force fluid into your abdominal cavity.
Cancer, Including Peritoneal Mesothelioma
Cancer, such as peritoneal mesothelioma, is the second most common cause of peritoneal effusions. Cancer cells can irritate your abdominal lining. This can cause excess fluid to build up. Peritoneal mesothelioma tumors, for example, can also cause the membrane to leak fluid. As the mesothelioma spreads, covering more of the peritoneal surface, ascites often worsens.
Infection and Peritonitis
Infections can also cause peritoneal effusions. Peritonitis is a nonspecific term for irritation of the abdominal lining. Any cause of peritonitis can cause fluid to build up. Tuberculosis and pancreatitis, for example, are causes. Bacterial infections, from conditions like a perforated ulcer or perforated appendicitis can also cause ascites to develop. Irritation of the peritoneum tends to be painful.
Heart and Kidney Failure
Heart or kidney failure can also cause ascites. When there’s less blood flow to your kidneys, sometimes because your heart isn’t pumping with enough force, your kidneys will respond, reducing urine output, and fluid retention can happen. Heart failure can also affect your liver, causing the pressure in the liver veins to increase. This can lead to the development of ascites.
Causes of Peritoneal Effusions and Percentage of Cases
Cause
Share of Cases
Cirrhosis or liver disease
About 80%
Cancer
About 10%
Heart failure
About 3%
Other causes
About 2%
Tuberculosis
About 2%
Dialysis
About 1%
Pancreatic disorder
About 1%
Percentages are rounded to the nearest whole number and may not total exactly 100%.
Symptoms of Peritoneal Effusion
The most common symptom of ascites is discomfort. As abdominal fluid develops, people can feel bloated or full. Some people also report feeling nausea and losing appetite. Symptoms can vary depending on the severity of the ascites and its cause. As the ascites worsens, pain and physical limitations can develop.
Symptoms of Abdominal Ascites
Abdominal pain
Abdominal swelling or distention
Chest pain
Fatigue
Loss of appetite
Nausea
Swollen ankles
Trouble breathing
Weight gain
Ascites is always a sign of a problem. It’s one of many signs and symptoms of mesothelioma. Ascites occurs in 60% to 100% of newly diagnosed peritoneal mesothelioma cases, according to a 2017 review in the journal Annals of Translational Medicine. It can also occur when other types of mesothelioma spread to the abdomen.
How Doctors Grade Ascites Severity
Doctors describe ascites in 3 broad levels of severity, sometimes written as grades 1 through 3, based on how much fluid has collected and how it’s detected. Mild cases often show up only on a scan, while moderate and severe cases are obvious on a physical exam.
Level
Also written as
What it means
Mild
Grade 1
Only detectable on an imaging scan such as ultrasound or CT, with little or no visible swelling
Moderate
Grade 2
Enough fluid to produce noticeable, symmetrical abdominal swelling on examination
Severe
Grade 3
Marked distension with pressure, breathlessness or difficulty eating, and usually a need for drainage
Pressure Versus Sharp Pain, and When to Call Your Doctor
Fluid buildup and peritoneal irritation feel different from each other. The fluid itself creates a steady sense of fullness, pressure and stretching as your abdomen swells. Irritation of the peritoneum, the membrane lining your abdomen, feels sharper and more localized and it often worsens when you move, cough or press on the area. See a doctor promptly if you have sudden or severe abdominal pain, since it can signal an infection in the fluid rather than the fluid alone.
Dr. Anton Strocel, an OB/GYN who treated Trina Reif, spoke to us about her case. Trina is a 20-year peritoneal survivor. Dr. Strocel said, “Trina had unexplained ascites. We did an exploratory laparotomy. We also did multiple peritoneal biopsies. She had an angry looking peritoneum. Her diagnosis was abdominal mesothelioma.”
Doctors use a mix of tests to diagnose ascites including a physical exam and imaging scans. Tests such as ultrasound and CT scans can show excess fluid in your abdominal space. A doctor will likely think of ascites if there is severe abdominal swelling.
If fluid is present, doctors need to collect a sample for analysis. The key to a diagnosis is the laboratory analysis of your peritoneal fluid. The fluid is often collected during a procedure known as a paracentesis. This procedure places a needle into your abdominal fluid to drain and collect it for analysis.
The sample is analyzed in a pathology lab and the type of ascites you have is determined. Pathologists look for potential cancer cells through cytology. A 2022 study in the journal Cytopathology reviewed cytology testing of 210 peritoneal fluid samples. About 33% of those samples contained malignant mesothelioma. This underscores why doctors rely on tissue biopsies most of the time for the diagnosis of peritoneal mesothelioma.
What a Peritoneal Fluid Analysis Measures
A paracentesis sample goes to the laboratory for several tests at once and it’s the combination of results, not any single value, that points to a cause. Some tests look for signs of infection or cancer directly, while others compare the fluid’s chemistry with that of a blood sample taken at the same time.
What is measured
What it helps show
Albumin
Compared against blood albumin to calculate the serum-ascites albumin gradient, which separates pressure-driven causes from other causes
Total protein
Separates exudative from transudative fluid
White blood cell count and differential
Points to infection, including infection of the fluid itself
Lactate dehydrogenase (LDH)
Raised levels suggest cancer or infection rather than liver disease
Glucose
Can fall with infection and with some cancers
Amylase
Raised levels point toward a pancreatic cause
Tumor markers and cytology
Looks for cancer cells and cancer-associated proteins in the fluid
Gram stain and culture
Identifies the specific bacteria if infection is present
SAAG: The Serum-Ascites Albumin Gradient
The serum-ascites albumin gradient, or SAAG, is the difference between the albumin level in a blood sample and the albumin level in the peritoneal fluid drawn at the same time. Doctors generally use it as the first calculation to narrow down why fluid is collecting, because it separates causes that arise from increased venous pressure from those that arise from the lining itself.
A SAAG of 1.1 g/dL or higher points to a pressure-driven cause such as cirrhosis or heart failure, while a SAAG below 1.1 g/dL points toward the peritoneum itself, including cancers such as peritoneal mesothelioma, infection and pancreatic disease. SAAG has largely replaced the protein-based exudate and transudate classification described above, because it’s the more accurate test. Doctors may still note the protein level, but SAAG is usually the deciding factor.
What the Color of Peritoneal Fluid Can Indicate
The first thing a doctor notices about a fluid sample is how it looks, which narrows the possibilities before any laboratory result comes back. A clear fluid points in one direction, while a cloudy, bloody or milky sample points in others.
How the fluid looks
What it can suggest
Clear and straw-colored
Most often a pressure-driven cause such as cirrhosis
Cloudy
Infection, including infection of the fluid itself
Blood-stained
Cancer, including peritoneal mesothelioma, or a recent injury
Milky
Lymphatic fluid in the abdomen, which can occur with cancer or injury to lymph vessels
Bile-stained or greenish
A leak from the gallbladder, bile ducts or bowel
Appearance is only a first impression. The laboratory tests described above confirm the cause.
Jayda K.
Verified Asbestos.com Survivor
Recurrent Ascites Leads to Peritoneal Mesothelioma Diagnosis
“As a young woman with abdominal pain, I had a really hard time convincing someone I was in pain. A really hard time. I was told it was just my period,” Jayda said. Her doctors finally did a laparoscopy. Her peritoneal effusion turned out to be more than a gallon of fluid and the surgeon saw growths on her peritoneum. A biopsy confirmed her peritoneal mesothelioma diagnosis.
Treatments for abdominal ascites depend on its cause. Treatments for cancer-related ascites typically involve a combination of fluid drainage, chemo, surgical procedures and possibly emerging therapies. These approaches aim to relieve symptoms while controlling the underlying condition. A multidisciplinary approach, involving input from medical doctors, surgeons and oncologists is warranted to evaluate and treat abdominal ascites.
Important in mesothelioma treatment, customizing treatment for each person with ascites supports better symptom management and improves quality of life. Abdominal ascites results from benign or malignant diseases. Management varies accordingly, focusing on symptom relief in benign cases and combining multiple treatments when cancer like mesothelioma is involved.
Ongoing clinical studies continue to refine treatment. A 2023 study in the Journal of Surgical Oncology looked at patients with gastric cancer and malignant ascites, and found that combining fluid drainage with chemo and nutritional support improved survival.
Surgeons have combined cytoreductive surgery with heated intraperitoneal chemotherapy since the 1980s and it’s now considered standard treatment for peritoneal surface malignancies, including peritoneal mesothelioma. PIPAC, by contrast, remains under study in clinical trials and researchers are still working toward the phase III results needed to confirm its benefit over existing treatments. Among the 16 peritoneal mesothelioma survivors whose stories Asbestos.com published between 2017 and 2024, 6 received cytoreductive surgery combined with heated intraperitoneal chemotherapy.
Treatment Options for Peritoneal Effusions
Treatment usually combines something that removes the fluid already there with something that slows the process putting it there. The right combination depends on how much fluid has built up and how often it returns. Paracentesis is generally the first choice when fluid needs to come off quickly or only occasionally, while doctors generally consider an indwelling catheter when the fluid keeps returning and repeated needle drainage becomes a burden.
Option
How It Helps
Chemo
Kills the cancer cells driving fluid buildup, reducing malignant ascites and controlling disease progression.
Intraperitoneal catheter
A surgically placed tube allows ongoing drainage without repeated needle procedures in severe, recurrent cases.
Pressurized intraperitoneal aerosol chemo is an emerging therapy that delivers chemo as an aerosol into the abdomen.
Tumor-removing surgery and HIPEC
Cytoreductive surgery removes visible tumors, and heated intraperitoneal chemo helps control remaining malignant ascites.
Ascites and Peritoneal Mesothelioma Prognosis
Ascites that returns after drainage or keeps building during treatment is one of the signals doctors watch, because it can indicate that peritoneal mesothelioma is progressing. It’s a signal, not a verdict. A prognosis is the overall outlook and clinicians build it from several things at once: how much tumor is present in the peritoneal cavity, how well a person is managing day to day, the cell type of the mesothelioma, and how the disease responds to treatment.
The volume of fluid on its own doesn’t determine an outlook and fluid buildup that shrinks after treatment is generally a sign the treatment is working. Fluid buildup is only one input into a mesothelioma prognosis, which weighs cell type, stage, tumor burden and overall health together. If your ascites keeps returning, that’s a reason to talk with a mesothelioma specialist about whether the treatment plan should change, not a reason to assume the worst.
Expert Insight
The prognosis, if you’re diagnosed with this, is going to depend on several items. It’s going to depend on how much tumor you have in the peritoneal cavity, and we determine that with something called a peritoneal cancer index, which we abbreviate PCI. This number goes from zero to 39. Low scores are better, so the lower the score when we diagnose this, the better the outcome.
Dr. Edward Levine, Head of the Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy program
What to Do About Persistent Fluid Buildup
Most cases of ascites come from liver disease, not cancer and the lab analysis of the fluid is what tells the difference. What matters most isn’t the first episode of swelling, but what happens next: fluid that keeps coming back after drainage, or that builds up during treatment, is the signal to push for answers. If your fluid buildup has no clear explanation, or it keeps returning, ask your doctor about a fluid analysis and about getting a second opinion from a mesothelioma specialist.
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Some measures can reduce the risk of liver disease and certain cancers, but they can’t guarantee prevention. Adopting a healthy lifestyle may lower the chance of developing cirrhosis. Key steps include avoiding alcohol and tobacco use, maintaining regular exercise and following a balanced diet. Reducing salt intake also helps limit fluid retention and doctors commonly recommend keeping daily sodium intake under about 2,000 milligrams for people with ascites.
What are the complications associated with abdominal ascites?
Ascites can exert pressure on abdominal organs and the chest, causing discomfort. Persistent fluid accumulation increases the risk of infection, such as spontaneous bacterial peritonitis. Additional complications may include abdominal hernias, abdominal pain, difficulty breathing, fluid buildup in the lungs and a heightened risk of further infections. Loss of appetite can lead to nutritional issues.
Are there any risk factors for developing abdominal ascites?
Several factors increase the likelihood of developing ascites. These include: abdominal infections, abdominal or pelvic cancers, alcohol abuse, congestive heart failure, genetic liver diseases, hepatitis B or C and nonalcoholic fatty liver disease.
Conditions that lead to cirrhosis represent the most significant risk. Certain cancers and infections markedly raise the risk as well. Heart or kidney failure can also contribute to fluid accumulation in the abdomen.
Can peritoneal effusions recur?
Peritoneal effusions often recur after treatment, depending on their cause. Fluid buildup may return within days or months. In malignant ascites, recurrent ascites can indicate advancing cancer. Persistent or recurrent ascites may be a sign of cancers such as mesothelioma. In such cases, seeking a second medical opinion and consulting a mesothelioma specialist can be beneficial.
Is ascites always a sign of cancer?
No. Ascites isn’t always caused by cancer. Cirrhosis and other liver diseases are the most common causes, accounting for about 80% of cases, while cancer, including peritoneal mesothelioma, causes about 10%. Because ascites can point to several serious conditions, persistent or unexplained fluid buildup should always be evaluated by a doctor.
Is ascites a sign that mesothelioma is getting worse?
Ascites can be a sign that peritoneal mesothelioma is progressing, especially when fluid returns after drainage or treatment. Recurrent or worsening ascites is one reason doctors monitor fluid buildup closely. If your ascites keeps coming back, talk with your mesothelioma specialist, because a change in treatment may help.
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Asbestos.com. (2026, September 23). Ascites (Peritoneal Effusion): Causes, Symptoms and Treatment. Retrieved September 28, 2026, from https://www.asbestos.com/mesothelioma/peritoneal-effusion/
Asbestos.com. "Ascites (Peritoneal Effusion): Causes, Symptoms and Treatment." Last modified September 23, 2026. https://www.asbestos.com/mesothelioma/peritoneal-effusion/.
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