What are the criteria and management options for removing ascites fluid in patients with symptomatic ascites?

From the Guidelines

Paracentesis is indicated for symptomatic ascites when patients experience discomfort, respiratory compromise, early satiety, or mobility limitations, and large-volume paracentesis (LVP) removing more than 5 liters should be accompanied by intravenous albumin administration (6-8 g per liter of fluid removed) to prevent post-paracentesis circulatory dysfunction, as recommended by the most recent guidelines 1. The criteria for removing ascites fluid include the presence of symptomatic ascites, with patients experiencing discomfort, respiratory compromise, early satiety, or mobility limitations.

• The procedure involves inserting a needle or catheter into the peritoneal cavity, typically in the left or right lower quadrant, after confirming the presence of ascites through physical examination or ultrasound guidance.
• Diuretic therapy with spironolactone (starting at 100 mg daily) and furosemide (starting at 40 mg daily) is the mainstay of long-term management, with doses adjusted based on response and sodium restriction (2000 mg/day) recommended, as supported by studies 1.
• Patients should be monitored for complications including electrolyte abnormalities, renal dysfunction, and encephalopathy.
• Therapeutic paracentesis provides immediate symptomatic relief by reducing intra-abdominal pressure, while diuretics address the underlying sodium and fluid retention that contributes to ascites formation in conditions like cirrhosis, where portal hypertension and altered hemodynamics drive fluid accumulation in the peritoneal cavity, as explained in 1.
• The frequency and volume of large-volume paracentesis can be determined from a patient’s sodium intake, and adherence to a sodium-restricted diet (88 mmoL/d) should result in ascites accumulation of <4 L/wk, as noted in 1.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. Supplemental potassium chloride and, if required, an aldosterone antagonist are helpful in preventing hypokalemia and metabolic alkalosis By competing with aldosterone for receptor sites, Spironolactone provides effective therapy for the edema and ascites in those conditions.

The criteria to remove ascites fluid include initiating therapy in a hospital setting for patients with hepatic cirrhosis and ascites.

• Hospital setting: Therapy should be initiated in the hospital for patients with hepatic cirrhosis and ascites.
• Supplemental treatment: Supplemental potassium chloride and an aldosterone antagonist, such as spironolactone, may be helpful in preventing hypokalemia and metabolic alkalosis.
• Aldosterone antagonist: Spironolactone provides effective therapy for edema and ascites by competing with aldosterone for receptor sites 2.
• Diuretic therapy: Furosemide tablets may be used to remove ascites fluid, but therapy should be initiated in a hospital setting and with careful observation 3.

From the Research

Criteria for Removing Ascites Fluid

The decision to remove ascites fluid is based on the presence of symptomatic ascites, which can cause discomfort, pain, and difficulty breathing. The criteria for removing ascites fluid include:

• Presence of tense ascites, which is defined as ascites that is causing significant discomfort or pain
• Presence of large-volume ascites, which is defined as ascites that is causing significant abdominal distention
• Failure of medical therapy, such as diuretics and sodium restriction, to control ascites
• Presence of refractory ascites, which is defined as ascites that is unresponsive to medical therapy 4

Management Options for Removing Ascites Fluid

The management options for removing ascites fluid include:

• Large-volume paracentesis, which is the removal of at least 5L of ascitic fluid 5
• Serial therapeutic paracentesis, which is the repeated removal of ascitic fluid to relieve symptoms
• Transjugular intrahepatic stent-shunt (TIPS), which is a procedure that creates a shunt between the hepatic vein and the portal vein to reduce portal pressure
• Peritoneovenous shunt, which is a procedure that creates a shunt between the peritoneal cavity and the venous system to remove ascitic fluid
• Liver transplantation, which is the replacement of the diseased liver with a healthy one 4, 6, 7

Considerations for Removing Ascites Fluid

When removing ascites fluid, it is essential to consider the following:

• The need for plasma volume expansion, such as with albumin infusion, to prevent hypovolemia and renal impairment 6, 8
• The risk of complications, such as hepatic encephalopathy, renal impairment, and hyponatremia, associated with paracentesis and diuretic therapy 6, 8
• The need for ongoing medical therapy, such as diuretics and sodium restriction, to prevent reaccumulation of ascites 4, 8