Management of Ascites

Indications and Recommendations

Patients with ascites admitted to the hospital should undergo abdominal paracentesis to determine the cause of the ascites and rule out spontaneous bacterial peritonitis, as recommended by the American Association for the Study of Liver Diseases and the British Society of Gastroenterology 1, 2, 3
Diagnostic paracentesis should be performed in all cirrhotic patients with ascites on hospital admission, as stated by the British Society of Gastroenterology 3

New-onset ascites requires evaluation to determine the serum-ascites albumin gradient (SAAG) and assess ascitic fluid cell count to rule out spontaneous bacterial peritonitis (SBP), as recommended by the American Association for the Study of Liver Diseases 1, 2, 4
Diffusely increased hepatic echogenicity suggests underlying liver disease, which is a common cause of portal hypertension and ascites, as noted by the British Society of Gastroenterology and the American Association for the Study of Liver Diseases 3, 1

Abdominal paracentesis is a safe procedure even with abnormal coagulation profiles commonly seen in patients with liver disease, as stated by the American Association for the Study of Liver Diseases 1, 2
The left lower quadrant is the preferred location for paracentesis (2 cm cephalad and 2 cm medial to the anterior superior iliac spine), as recommended by the American Association for the Study of Liver Diseases 2
Complications are rare, with approximately 1% risk of abdominal wall hematomas, as noted by the American Association for the Study of Liver Diseases 1

No prophylactic transfusion of fresh frozen plasma or platelets is needed unless there is clinically evident fibrinolysis or disseminated intravascular coagulation, as recommended by the American Association for the Study of Liver Diseases 1, 2
If ascitic fluid neutrophil count ≥250 cells/mm³, start empiric antibiotic therapy (e.g., cefotaxime 2g IV every 8 hours) and administer albumin infusion, as recommended by the American Association for the Study of Liver Diseases 3, 1, 5
Perform large-volume paracentesis (LVP) for immediate relief of tense ascites, as recommended by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases 6, 1
Initiate sodium restriction (88 mmol/day or 2000 mg/day) to manage ascites, as suggested by the American Association for the Study of Liver Diseases 1

The following table outlines the classification and treatment approach for ascites in cirrhosis:

Grade	Description	Treatment Approach	Duration
Grade 1 (mild)	Only detected by ultrasound	Sodium restriction alone	Indefinite while ascites present
Grade 2 (moderate)	Moderate abdominal distension	Sodium restriction + diuretics	Indefinite while ascites present
Grade 3 (large)	Marked abdominal distension	Initial paracentesis + sodium restriction + diuretics	Indefinite while ascites present

Start diuretic therapy with spironolactone 50-100 mg/day (can be increased up to 400 mg/day) and add furosemide 20-40 mg/day (can be increased up to 160 mg/day) for patients with cirrhosis and ascites, as recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 1, 5, 3, 4
Maintain a spironolactone:furosemide ratio of approximately 2.5:1 to 5:1, as recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 5, 3, 4
Implement moderate sodium restriction (80-120 mmol/day or 4.6-6.9 g salt/day) and avoid extreme sodium restriction (<40 mmol/day), as recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 5, 7
Fluid restriction is not necessary unless serum sodium is <120-125 mmol/L, as recommended by the American Association for the Study of Liver Diseases 1
Ensure adequate caloric intake (35-40 kcal/kg/day) and maintain protein intake (1.2-1.5 g/kg/day) for patients with ascites, as recommended by the Clinical and Molecular Hepatology guidelines 4
Provide supplemental oxygen as needed to maintain adequate oxygenation, and consider ICU admission for closer monitoring in severe cases, as recommended by the American Association for the Study of Liver Diseases 8

Avoid NSAIDs as they can reduce urinary sodium excretion and induce azotemia, as warned by the American Association for the Study of Liver Diseases 1
Avoid rapid correction of hyponatremia (not more than 8-12 mmol/L per day) to prevent central pontine myelinolysis, as suggested by the European Association for the Study of the Liver 7
Avoid high doses of beta-blockers in patients with severe or refractory ascites, as recommended by the European Association for the Study of the Liver 7

Age >70 years is a relative contraindication for liver transplantation, according to the European Association for the Study of the Liver 6
Consider hepatopulmonary syndrome (HPS) as a potential cause of hypoxemia, characterized by intrapulmonary vascular dilatation/right-to-left shunt, as suggested by the American Association for the Study of Liver Diseases 8
Consider serial therapeutic paracenteses for refractory ascites, as recommended by the American Association for the Study of Liver Diseases 1
Consider transjugular intrahepatic portosystemic shunt (TIPS) in appropriate candidates with refractory ascites, as suggested by the European Association for the Study of the Liver 3
All patients with cirrhosis and ascites should be considered for liver transplantation evaluation, as it offers definitive treatment, as recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 1, 3
Use the Model for End-Stage Liver Disease (MELD) score to predict mortality in patients with cirrhosis, with a score ≥15 indicating a high risk of death, as recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 9, 10
After recovery from SBP, start norfloxacin 400 mg daily or ciprofloxacin 500 mg daily for secondary prophylaxis, as recommended by the American Association for the Study of Liver Diseases 5, 3