Introduction

Ascites and Banti’s syndrome are two terms you may never have heard of before! scites as a symptom is something that does occur fairly regularly within medicine, whereas Banti’s syndrome is a very rare condition that is not particularly well understood. In Banti’s syndrome, there is an enlargement of the spleen and increased pressure in the surrounding vessels which can cause fluid to leak into the abdomen, something which we call ascites. If you believe either yourself or someone you know may be suffering from either of these conditions, please seek medical help as soon as you can. Read on to discover more about ascites in Banti’s syndrome.

What is Banti’s Syndrome?

Banti’s syndrome is a chronic condition involving enlargement of the spleen and destruction of red and white blood cells.¹ The spleen is the organ that sits in the upper left quadrant of your abdomen. It plays an important role in the immune system because it makes white blood cells and antibodies that help us fight infections. It also stores and filters blood by removing old and damaged red blood cells. However, in Banti’s syndrome, the spleen starts to prematurely destroy blood cells, resulting in pancytopenia- when there is less than normal amount of red, white blood cells and platelets in the blood. 

What are the symptoms of Banti’s Syndrome?

The early stages of Banti’s syndrome can include:²

• Weakness
• Tiredness
• Anaemia 
• Enlarged Spleen
• Bruising easily

As the disease gets worse, this can lead to further symptoms:

• Very severe anaemia
• Ascites (fluid in the abdominal cavity)
• Vomiting blood or dark stools from swollen or burst blood vessels
• Cirrhosis of the liver 

What is the Pathophysiology of Banti’s Syndrome?

Banti’s syndrome is thought to be caused by a blockage in the veins around the spleen or liver, which leads to raised blood pressure within these vessels, called portal hypertension, and eventually an enlarged spleen. It can be caused by anything that obstructs these vessels, such as abnormalities present at birth, blood clots, or other disorders which obstruct the liver veins. There have been links made with increased arsenic intake, and in some patients taking long-term azathioprine.²

What are Ascites?

Ascites occur when you get a build-up of fluid in the abdominal cavity. Small amounts of fluid may not produce any symptoms, but larger amounts will lead to pain in the stomach, bloating and shortness of breath as the fluid presses on your diaphragm.³ Ascites is often caused by problems with the liver such as hepatitis C or B, long-term alcohol abuse, fatty liver and cirrhosis. It can also occur from conditions such as cancer in the abdomen, heart failure or pancreatitis.   

Why do you get Ascites in Banti’s Syndrome?

In Banti’s syndrome, raised blood pressure in the vessels around the liver and spleen causes portal hypertension. Once it rises above a certain level, the blood vessels vasodilate (widen), causing a drop in the blood volume in the arteries. In response to this, the body activates its systems to constrict the blood vessels. This includes increasing sodium and water retention, which, over time. then leads to fluid leakage into the abdominal cavity.^4,5

The portal hypertension itself is caused by blockages in the veins around the spleen and liver. To make matters worse, in Banti’s syndrome, the splenomegaly that occurs will also further increase this pressure, further aggravating the ascites.⁷

How do you diagnose Ascites in Banti’s syndrome? 

As with any ascites, the common symptoms are bloating in the stomach, abdominal pain and getting full easily. There will also be other associated symptoms of Banti’s syndrome, such as anaemia, tiredness, weakness and bruising easily. 

If a doctor suspects ascites, they will examine the abdomen to see if it is enlarged. There may also be thin and shiny skin from where it is stretched. The following examinations may then be performed to check for ascites:⁶

• Flank Dullness: percussing over the abdomen to check for any dull areas that would indicate fluid was present
• Shifting dullness: The above test is performed with the patient lying on their back, then the patient is turned onto their side and the test is performed again If ascites is present, the fluid will shift, causing fullness on the side they are lying on
• Fluid Wave: The doctor or patient holds both sides of the abdomen. The abdomen is tapped on one side- if ascites are present, a wave will be felt as the fluid moves from one side to the other

Imaging can also be used to evaluate for ascites and splenomegaly, which may both be seen in Banti’s syndrome. Ultrasound, MRI and CT scans can be used to scan the abdomen and pelvis. If ascites are present, these images will show fluid in the abdomen. Furthermore, if Banti’s syndrome is the cause of the ascites, they will also show an enlarged spleen. Dilated portal veins may also be present.¹

Assessment may also be done to assess for the cause of Banti’s syndrome, which may be a blood clot or other obstruction of the venous system. In this case, venographies may be used to assess for any evidence of a deep vein thrombosis which may be blocking the blood vessels. 

Finally, laboratory tests can also be used as a diagnostic test to determine the cause of ascites. In particular, analysis of the Serum-ascites albumin gradient (SAAG) in the ascites fluid can tell you where the fluid is coming from. A high gradient would indicate portal hypertension, such as in Banti’s syndrome.⁸ Other tests, such as liver function tests, can also be used to rule out other causes of ascites. 

How do you manage ascites from Banti’s Syndrome?

How the ascites and Banti’s syndrome if treated will be dependent on the cause. 

• Often the ascites fluid will be drained to relieve abdominal discomfort
• If the cause is determined to be linked to arsenic or azathioprine, then these exposures must be stopped
• To reduce portal hypertension, beta-blockers may be used as they lower blood pressure. This will help to reduce the ascites
• If there is any bleeding from swollen blood vessels, vasoconstrictor drugs may be used. If this is not successful, possible options such as a surgical shunt to divert the blood flow may be used²
• Treatment of the anaemia associated with Banti’s syndrome may require blood transfusions¹
• In very severe cases when bleeding cannot be stopped, a splenectomy may be indicated

Prognosis and Long-term Management of ascites in Banti’s syndrome?

The extent of management of ascites and Banti’s syndrome depends on how successfully the portal hypertension is controlled. If portal hypertension is kept under control, the ascites is unlikely to return. The prognosis of Banti’s syndrome also depends on whether any internal bleeding from swollen blood vessels can be kept under control. With successful treatment,  patients with Banti’s syndrome have a five-year survival up to 100%.¹ Patients can expect to be regularly monitored for any of these complications. 

Summary

Banti’s syndrome is a rare condition involving the enlargement of the spleen and the destruction of red and white blood cells. Sufferers may also experience ascites, which is where fluid accumulates in the abdomen due to increased pressure in the veins around the liver and spleen. Most cases occur due to an obstruction in these veins, such as a DVT or birth abnormalities, but some cases have been linked to too much exposure to arsenic or azathioprine. The diagnosis of ascites can be made by a medical professional, so please seek help immediately if you feel you may be affected. Treatment of the condition will depend on the cause of Banti's syndrome, but overall the condition can be fairly well managed, with a 5-year survival rate of 100% if under treatment. 

FAQ’s

What is the cause of Banti’s syndrome?

Banti’s syndrome is thought to be caused by a blockage in the veins around the spleen or liver, which leads to raised blood pressure within these vessels, called portal hypertension, and eventually an enlarged spleen. It can be caused by anything that obstructs these vessels, such as abnormalities present at birth, blood clots, or other disorders which cause obstruction of the liver veins. There have been links made with increased arsenic intake and in some patients taking long-term azathioprine.²

Can the spleen cause ascites?

Ascites is when you get a build-up of fluid in the abdominal cavity. Ascites is often caused by problems with the liver such as hepatitis C or B, long-term alcohol abuse, fatty liver and cirrhosis but, In Banti’s syndrome, the ascites is linked to the spleen. In fact, raised blood pressure in the vessels around the liver and spleen causes portal hypertension. Once it rises above a certain level, the blood vessels vasodilate (widen), causing a drop in the blood volume in the arteries. In response to this, the body activates its systems to constrict the blood vessels. This includes increasing sodium and water retention, which, over time. then leads to fluid leakage into the abdominal cavity.^4,5 To make matters worse, in Banti’s syndrome, the splenomegaly that occurs will also further increase this pressure, further aggravating the ascites.⁷