Describe the approach.
Identify and treat the underlying condition.
Therapeutic paracentesis for tense or large ascites
Patients with cirrhotic ascites
Treatment of cirrhosis, including avoidance of certain medications such as NSAIDs and ACE inhibitors
Sodium restriction and diuretics are the mainstays of medical and supportive therapy.
Consider advanced therapies for refractory ascites, e.g., liver transplant.
Patients with noncirrhotic ascites: treatment of the underlying cause, e.g.
Surgery or radiochemotherapy for malignancy
Treatment of heart failure
Describe the salt and fluid restriction.
Dietary sodium restriction: 2 g/day or 88 mEq/d (2 g of sodium = 5 g of salt)
Fluid restriction: 1 L/day (only if serum Na+ < 125 mEq/L)
Describe the use of diuretics.
Monotherapy with spironolactone may be preferable for new-onset ascites, mild ascites, moderate ascites, and outpatients.
Combination therapy with spironolactone PLUS furosemide may be preferable for recurrent gross ascites or when faster resolution of ascites is required (e.g., in hospitalized patients).
Describe therapeutic paracentesis.
Therapeutic paracentesis may be performed for symptom relief.
Tense or large ascites (first-line)
Refractory ascites (can be repeated every ∼ 2 weeks)
Contraindications for diuretic therapy
Perform under ultrasound guidance to minimize complications.
A predetermined limit to the removed volume is usually not necessary.
Administer in patients undergoing large-volume paracentesis (> 5 L).
Describe the management of refractory ascites.
Ascites is considered refractory if it does not respond to treatment or recurs after therapeutic paracentesis despite dietary sodium restriction and high-dose diuretic therapy.
Rule out transient refractoriness to diuretic therapy.
Optimize medications and ensure adherence to a low-sodium diet.
Repeat large-volume paracentesis (with IV albumin).
Evaluate for invasive management options.
Transjugular intrahepatic portosystemic shunt (TIPS)
Liver transplant: patients with significant liver dysfunction and/or failed TIPS