Treatment

• All patients

  • 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

  • Antituberculosis therapy

• 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)

• 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).

Therapeutic paracentesis may be performed for symptom relief.

• Indications

  • Tense or large ascites (first-line)

  • Refractory ascites (can be repeated every ∼ 2 weeks)

  • Malignancy-related ascites

  • Contraindications for diuretic therapy

• Important considerations

  • Perform under ultrasound guidance to minimize complications.

  • A predetermined limit to the removed volume is usually not necessary.

  • Albumin replacement

    • Administer in patients undergoing large-volume paracentesis (> 5 L).

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

• Abdominal hernias (especially umbilical hernias)

• Spontaneous bacterial peritonitis (ascitic fluid infection): abdominal tenderness, fever, altered mental status

• See also: “Complications of cirrhosis”