para>Carefully approach diuresis; aggressive diuresis can induce prerenal acute kidney injury, encephalopathy, and hyponatremia. Monitor creatinine and electrolytes closely. Serum creatinine >2 mg/dL or serum sodium <120 mmol/L should prompt withdrawal of diuretics. NSAIDs may cause (or worsen) oliguria or azotemia and should be avoided. ACE inhibitors and angiotensin receptor blockers (ARBs) may be harmful in patients with cirrhosis/ascites due to an increased risk of hypotension and renal failure (1)[C]; ACE inhibitors and ARBs should be avoided in refractory ascites (1)[B]. Consider discontinuing β-blockers in patients with refractory ascites, worsening hypotension, or azotemia (1)[B].
First Line
- Sodium restriction and diuretics are the mainstay of treatment for patients with elevated portal pressures (1)[A]; other causes (e.g. carcinomatosis) are less likely to respond to medical therapy.
- Spironolactone 100 to 400 mg daily PO; typical initial dose is 100 to 200 mg given in am
- Diuretic of choice due to its antialdosterone effects; can be used as single agent in patients with minimal ascites
- Furosemide 40 to 160 mg daily PO (avoid IV if possible); typical initial dose is 40 mg given in am
- Antinatriuretic effect helps to achieve negative sodium balance.
- Not first-line as monotherapy but is an effective adjunct to potentiate the effect of spironolactone
- Most common (and preferred) regimen is spironolactone and furosemide together (maintaining a 100:40 ratio) for maximum efficacy and to maintain potassium homeostasis.
- Titrate dose to desired result and monitor renal function regularly.
- Follow daily weight.
- Diuretic-intractable ascites (10% of patients): persistent or worsening ascites despite maximum doses of spironolactone (400 mg/day) and furosemide (160 mg/day) and sodium restriction or progressive rise in creatinine to 2.0
- Ensure compliance with dietary sodium restriction using 24-hour urine sodium excretion: in general, if <78 mEq/day, patient is compliant with 2-g dietary sodium restriction.
- Therapeutic paracentesis or serial large-volume paracentesis (LVP) (see "Surgery/Other Procedures")
Second Line
- Midodrine 7.5 mg TID can be added to diuretic resistant or hypotensive patients and may improve survival (1)[B].
- Alternatives to spironolactone: amiloride up to 40 mg/day; triamterene up to 200 mg/day in divided doses (1)[C]
- Alternatives to furosemide: torsemide up to 100 mg/day; bumetanide up to 4 mg per day (1)[C]
- Vaptans may have a beneficial effect on hyponatremia and ascites, but routine use in ascites is not yet supported (2)[A].
ISSUES FOR REFERRAL
Consider referral for liver transplant in patients with decompensated liver disease, whether or not ascites is present/controlled. Liver transplant is the definitive treatment for portal hypertension (1)[B].
SURGERY/OTHER PROCEDURES
- Therapeutic paracentesis
- Initial therapy if tense ascites is present (1)[C].
- Serial (generally every 2 weeks) paracentes can be used as second-line after diuretics in patients with elevated portal pressures (3)[B].
- Complications: infection, hemodynamic collapse, acute renal failure
- Similar complication rate as diuretics (3)[B]
- Replace albumin when removing >5 L of ascites: 5.5 to 8 g albumin for each liter removed has been shown to decrease renal dysfunction, hyponatremia post paracentesis, and overall morbidity (4)[A] for patients with portal hypertension; likely not needed for malignant ascites
- Continue diuretics at 1/2 previous dose if transitioning to serial paracentesis in patients who fail diuretics alone.
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Used only in patients with elevated portal pressures
- Flurosopically placed conduit from portal to hepatic vein for intractable ascites (5)[A]
- At time of placement, portal pressure should drop ≥20 mm Hg or to <12 mm Hg, and ascites should be readily controlled with diuretics.
- Yearly US to confirm shunt is functional.
- 4 weeks after TIPS, urinary sodium and serum creatinine improve significantly and can normalize after 6 to 12 months in combination with diuretics (5). Dilation/replacement may be required after 2 years.
- Encephalopathy is a primary complication.
- TIPS is superior to paracentesis for controlling ascites. No difference in mortality (5)[A].
- Peritoneovenous shunt (LeVeen or Denver shunt): drains ascites directly into the inferior vena cava
- Clinical trials show poor long-term shunt patency, no survival advantage compared with medical therapy.
- Complications include:
- Bacteremia, bowel obstruction, and variceal bleed as a result of rapid volume overload from ascitic fluid into systemic circulation
- Usually reserved for patients with refractory ascites who are not candidates for TIPS or liver transplant, and who have numerous abdominal adhesions, making repeated paracentesis unsafe (1)[A].
- Indwelling catheters with external drainage
- Most useful in malignant ascites as a palliative measure
- Overall low rate of infection
- Can be drained at home
- Percutaneous endoscopic gastrostomy should be avoided in patients with ascites due to an associated high mortality rate following this procedure (1)[B].
COMPLEMENTARY & ALTERNATIVE MEDICINE
Caution advices with many herbal and other dietary supplements (risk drug interactions, hepatotoxicity, coagulopathy)
ONGOING CARE
PROGNOSIS
- Prognosis varies depending on underlying cause.
- Ascites in itself is rarely life threatening but can signify life-threatening disease (e.g., cancer, end-stage liver disease)
COMPLICATIONS
- Spontaneous bacterial peritonitis (SBP)
- Ascitic fluid polymorphonuclear (PMN) leukocyte count ≥250 cells/mm3 or positive culture
- Broad-spectrum antibiotics are as follows: cefotaxime 2 g q8h or similar 3rd-generation cephalosporin is the treatment of choice for suspected SBP. Covers 95% of flora (including Escherichia coli, Klebsiella, pneumococci) (1)[A]
- Lifetime antibiotic prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole (TMP-SMX) is indicated in some patients who survive an episode of SBP (1)[A]. Reduced incidence of SBP, delayed development of hepatorenal syndrome, and improved survival in cirhossis (6)[C]
- Suspect primary bacterial peritonitis (PBP) due to bowel perforations when ascitic fluid >250 cells/mm3 (often >5,000 cells/mm3), and any two of the following:
- Ascitic fluid total protein >1 g/dL (often >3 g/dL)
- Ascitic fluid glucose <50 mg/dL (or 2.8 mmol/L)
- Ascitic fluid LDH that is 3-fold greater than serum LDH
- Hepatorenal syndrome: acute worsening of renal function diagnosed when possible causes of acute renal failure are excluded, and at least 2 days of diuretic withdrawal and maximal intravascular volume expansion with albumin (see "Hepatorenal Syndrome")
- Cellulitis is increasingly common in obese patients with brawny edema and should be treated with diuretics and appropriate antibiotics (1)[B].
REFERENCES
11 Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. http://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf. Accessed May 5, 2015.22 Watson H, Jepsen P, Wong F, et al. Satavaptan treatment for ascites in patients with cirrhosis: a meta-analysis of effect on hepatic encephalopathy development. Metab Brain Dis. 2013;28(2):301-305.33 Gin ©s P, Arroyo V, Quintero E, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology. 1987;93(2):234-241.44 Bernardi M, Caraceni P, Navickis RJ, et al. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology. 2012;55(4):1172-1181.55 R ¶ssle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update. Gut. 2010;59(7):988-1000.66 Fern ¡ndez J, Navasa M, Planas R, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007;133(3):818-824.
ADDITIONAL READING
- Becker G, Galandi D, Blum HE. Malignant ascites: systematic review and guideline for treatment. Eur J Cancer. 2006;42(5):589-597.
- Perumalswami PV, Schiano TD. The management of hospitalized patients with cirrhosis: the Mount Sinai experience and a guide for hospitalists. Dig Dis Sci. 2011;56(5):1266-1281.
SEE ALSO
- Cirrhosis of the Liver; Hepatorenal Syndrome
- Algorithms: Congestive Heart Failure: Differential Diagnosis; Nephrotic Syndrome
CODES
ICD10
- R18.8 Other ascites
- R18.0 Malignant ascites
- K70.31 Alcoholic cirrhosis of liver with ascites
- K70.11 Alcoholic hepatitis with ascites
ICD9
- 789.59 Other ascites
- 789.51 Malignant ascites
SNOMED
- 389026000 Ascites (disorder)
- 236005001 Malignant ascites (disorder)
- 236004002 Hepatic ascites (disorder)
- 52985009 chylous ascites (disorder)
CLINICAL PEARLS
- Cirrhosis remains the most common cause of ascites.
- Patients with new-onset ascites or hospitalized patients with ascites should have a diagnostic paracentesis.
- ACE inhibitors, ARBs, and β-blockers should be avoided in patients with ascites.
- Most common cause of "diuretic-intractable ascites" is noncompliance with dietary sodium restriction.
- First-line management of ascites is diuretics. Serial paracentesis or TIPS are second-line therapies.
- Ensure early referral of cirrhosis patients who are potential candidates for liver transplant.