Overview
Hepatic ascites is the accumulation of excess fluid in the peritoneal cavity due to portal hypertension, most commonly caused by cirrhosis 1. It is a common complication of advanced liver disease and is associated with significant morbidity and mortality 1.Diagnosis
Diagnosis is primarily clinical, based on physical examination findings (e.g., shifting dullness, fluid wave) and confirmed by abdominal ultrasound 1.
Diagnostic paracentesis is recommended for all patients with new-onset ascites to rule out spontaneous bacterial peritonitis (SBP) 1.
Ascitic fluid analysis includes cell count with differential, total protein, albumin, and Gram stain 1.
Serum-ascites albumin gradient (SAAG) is a key diagnostic marker; SAAG ≥ 1.1 g/dL suggests portal hypertension 1.Management
First-line treatment:
* Sodium restriction (< 2 grams/day) 1.
* Diuretic therapy with spironolactone and furosemide 1. Doses should be carefully titrated based on urine sodium excretion and potassium levels 1.
Therapeutic paracentesis:
* Indicated for rapid, symptomatic relief of tense ascites 1.
* Large-volume paracentesis (> 5 liters) should be accompanied by intravenous albumin infusion (e.g., 6-8 g/L of ascites removed) to prevent circulatory dysfunction 1.
Adjunctive treatments:
* TIPS (transjugular intrahepatic portosystemic stent shunt) may be considered for refractory ascites 1.
* Antibiotic prophylaxis for SBP is recommended in patients with low ascitic fluid protein (< 1.5 g/dL) and impaired renal function or high bilirubin 1.Key Recommendations
Sodium restriction to < 2 grams/day is a cornerstone of ascites management 1. (Evidence: Strong)
Diuretic therapy with spironolactone and furosemide is the first-line pharmacological treatment for ascites 1. (Evidence: Strong)
Therapeutic paracentesis with concurrent albumin infusion is recommended for patients with tense ascites requiring rapid symptom relief 1. (Evidence: Strong)References
1 Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM et al.. Guidelines on the management of ascites in cirrhosis. Gut 2021. link