What is the definition of Ascites, a condition characterized by fluid accumulation in the abdominal cavity due to conditions such as liver disease (e.g. cirrhosis), heart failure, kidney (renal) failure, cancer, and other infections?

From the Guidelines

Patients with ascites should be treated with sodium restriction, diuretics, and paracentesis as needed, with the goal of improving morbidity, mortality, and quality of life. The management of ascites involves a multifaceted approach, including lifestyle modifications, pharmacological interventions, and procedural interventions. According to the guidelines on the management of ascites in cirrhosis 1, all patients with a new onset of ascites should have the fluid tested to determine the underlying cause and to rule out infection.

Diagnosis and Treatment

The initial treatment for patients with ascites involves taking medication, commonly known as 'water tablets' (diuretics), such as spironolactone and furosemide, which are begun at a small dose and gradually increased until the ascites is treated 1. Patients should also limit their salt intake to no more than 5g per day, which is equivalent to about one teaspoon of salt.

Monitoring and Follow-up

Patients should be monitored while taking these tablets, as diuretics can have side effects such as dehydration, confusion, abnormal levels of sodium and potassium, and kidney damage. Patients should monitor their weight daily, as sudden increases may indicate fluid retention, and should contact their healthcare provider if they experience rapid weight gain, increasing abdominal distension, shortness of breath, or signs of infection like fever or abdominal pain.

Refractory Ascites

In patients with untreatable ascites, alternatives to repeated hospital drainage include placing a small tube (stent) in the liver, known as a transjugular intrahepatic portosystemic shunt (TIPSS) 1. The TIPSS procedure is effective in reducing the need for repeated fluid drainage, but patients should be selected carefully for this procedure due to potential side effects. The only curative option for untreatable ascites is liver transplantation, and if the patient is not suitable for liver transplantation, medical care then focuses on controlling the ascites symptoms, known as palliative care.

Key Considerations

• Limit salt intake to no more than 5g per day
• Use diuretics, such as spironolactone and furosemide, as needed
• Monitor weight daily and report any sudden increases or signs of infection to a healthcare provider
• Consider TIPSS or liver transplantation for refractory ascites
• Focus on palliative care for patients who are not suitable for liver transplantation.

From the Research

Causes and Complications of Ascites

• Ascites is a condition where fluid builds up in the abdominal cavity, between the parietal and visceral peritoneum, and can be caused by various conditions, including liver disease, heart failure, kidney failure, cancer, and other infections 2
• The development of ascites indicates progression of the underlying cirrhosis and is associated with a 50% 2-year survival rate 2
• Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhotic ascites, with an overall mortality rate from an episode of SBP of approximately 20%, and a 1-year mortality rate of approximately 70% after an episode of SBP 2, 3, 4

Treatment Options for Ascites

• Conventional therapies used for the treatment of ascites include sodium restriction, diuretics, and large volume paracentesis (LVP) 2, 3, 5
• The most effective diuretic combination is that of a potassium-sparing, distal-acting diuretic (eg, spironolactone) with a loop diuretic (eg, furosemide) 2, 3, 5
• LVP provides rapid resolution of symptoms with minimal complications and is well tolerated by most patients, but may be associated with post-paracentesis circulatory dysfunction (PPCD) 2, 5
• Treatment options for refractory ascites include repeated paracentesis, transjugular intrahepatic portosystemic shunt (TIPS) placement, and liver transplantation 2, 4, 6

Management and Prevention of Ascites

• Mild to moderate ascites is treated by salt restriction and diuretic therapy, with spironolactone as the diuretic of choice 4
• Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy 4, 5
• Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require antibiotic prophylaxis 4
• Liver transplantation should be considered in all patients with ascites and liver cirrhosis 4, 6