What is the approach to a patient with ascites (accumulation of fluid in the peritoneal cavity)?

From the Guidelines

The approach to a patient with ascites should begin with a thorough history, physical examination, and diagnostic paracentesis, as recommended by the British Society of Gastroenterology and the British Association for the Study of the Liver 1. This initial assessment is crucial for determining the cause of ascites and guiding further management. The paracentesis should include analysis of the ascitic fluid for protein and white cell count to help differentiate between cirrhosis and other causes of ascites, as well as to identify any potential infections 1.

Key Components of Ascites Management

• Diagnostic paracentesis: essential for determining the cause of ascites and identifying any potential infections 1
• Sodium restriction: limiting daily salt intake to no more than 5g, which is equivalent to one teaspoon, to help reduce fluid accumulation 1
• Diuretic therapy: starting with spironolactone and potentially adding furosemide, with careful monitoring for complications such as dehydration, confusion, and kidney damage 1
• Infection management: prompt treatment of spontaneous bacterial peritonitis with antibiotics, such as third-generation cephalosporins, and consideration of prophylaxis for patients at high risk 1

Refractory Ascites Management

For patients with refractory ascites, consideration of transjugular intrahepatic portosystemic shunt (TIPS) or liver transplantation evaluation is recommended 1. These options can help reduce the need for repeated fluid drainage and improve patient outcomes. However, careful patient selection is necessary to minimize potential risks and complications associated with these procedures 1.

Ongoing Care and Monitoring

Regular monitoring of patients with ascites is crucial to prevent complications and ensure optimal management. This includes regular assessment of ascitic fluid protein and white cell count, as well as monitoring for signs of infection or other complications 1. By prioritizing these key components of ascites management, healthcare providers can help improve patient outcomes and reduce morbidity and mortality associated with this condition.

From the FDA Drug Label

By competing with aldosterone for receptor sites, Spironolactone provides effective therapy for the edema and ascites in those conditions. Spironolactone can cause sudden alterations of fluid and electrolyte balance which may precipitate impaired neurological function, worsening hepatic encephalopathy and coma in patients with hepatic disease with cirrhosis and ascites. In these patients, initiate spironolactone in the hospital In patients with cirrhosis, start with lowest initial dose and titrate slowly

The approach to a patient with ascites includes using Spironolactone as an aldosterone antagonist to provide effective therapy for edema and ascites. However, caution is advised when using Spironolactone in patients with hepatic disease and cirrhosis, as it may precipitate hepatic encephalopathy and coma.

• Initiation of Spironolactone in a hospital setting is recommended for patients with hepatic disease and cirrhosis.
• Starting with the lowest initial dose and titrating slowly is advised for patients with cirrhosis 2, 2.
• Additionally, Furosemide therapy should also be initiated in the hospital for patients with hepatic cirrhosis and ascites, with careful monitoring to avoid hypokalemia and metabolic alkalosis 3.

From the Research

Approach to a Patient with Ascites

The approach to a patient with ascites involves a comprehensive evaluation to determine the underlying cause and guide therapy.

• The differential diagnosis of ascites is broad, with roughly 80-85% of cases related to underlying chronic liver disease, but cardiac failure, tuberculosis, malignancy-related ascites, and other less common causes should also be considered 4.
• A careful evaluation of the patient, including a clinical history, physical examination, and diagnostic paracentesis, should be performed to determine the cause of ascites 4, 5.
• Calculation of the serum-ascites albumin gradient provides useful diagnostic information, with high gradients usually indicating portal hypertension, while low gradients may indicate infection or carcinomatosis 4, 5.

Management of Ascites

Management of ascites is directed toward alleviating the underlying cause and reducing symptoms.

• Initial management typically involves restriction of salt intake to 2 g per day and diuretic therapy, with spironolactone as the usual first-choice agent, which may be combined with furosemide in selected patients 6, 5, 7.
• Large-volume paracentesis, peritoneovenous portosystemic shunting, transjugular intrahepatic shunting, or liver transplantation may be required if diuretic therapy is unsuccessful 6, 5, 8.
• Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy, while refractory ascites may require repeated paracentesis, transjugular intrahepatic portosystemic shunt placement, or liver transplantation 6, 8, 7.

Complications of Ascites

Potential complications of ascites include spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS).

• SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm(3) and is treated with antibiotics, while patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require antibiotic prophylaxis 6.
• The prognosis of untreated HRS type 1 is grave, and treatment consists of a combination of terlipressin and albumin, with hemodialysis serving as a bridging therapy to liver transplantation in selected patients 6, 7.