From the Guidelines
Worsening ascites is characterized by progressive abdominal distention, weight gain, and increasing abdominal girth, and is often accompanied by worsening shortness of breath, early satiety, loss of appetite, peripheral edema, abdominal pain or heaviness, and deteriorating mobility. The most concerning signs of worsening ascites include:
- Worsening fatigue
- Decreased urine output despite fluid accumulation
- Mental confusion, which may indicate hepatic encephalopathy
- Fever or abdominal tenderness, suggesting possible spontaneous bacterial peritonitis, a serious infection of the ascitic fluid 1. These symptoms typically indicate that the underlying liver disease is progressing or that current management strategies are insufficient, requiring prompt medical evaluation for potential adjustment of diuretic therapy (typically spironolactone and furosemide), consideration of therapeutic paracentesis, or assessment for other complications of advanced liver disease 1. Some key points to consider in the management of worsening ascites include:
- The importance of diagnostic paracentesis to rule out spontaneous bacterial peritonitis (SBP) in all cirrhotic patients with ascites on hospital admission 1
- The use of empiric antibiotic therapy, such as cefotaxime, in patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 or signs or symptoms of infection 1
- The need for careful monitoring of patients with ascites, including regular assessment of liver function, renal function, and electrolyte levels 1
- The potential benefits and risks of therapeutic paracentesis, including the risk of post-paracentesis circulatory dysfunction 1.
From the Research
Worsening Signs and Symptoms of Ascites
The worsening signs and symptoms of ascites include:
- Increased abdominal girth and discomfort due to fluid accumulation 2, 3
- Respiratory distress and decreased mobility 4, 5
- Spontaneous bacterial peritonitis (SBP), characterized by an ascitic neutrophil count > 250 cells/mm(3) 3, 6
- Hepatorenal syndrome (HRS), a type of kidney dysfunction that can occur in patients with ascites 3, 4
- Decreased quality of life and significant mortality 4, 6
Complications of Ascites
Complications of ascites that can worsen its signs and symptoms include:
- SBP, which requires prompt treatment with antibiotics 3, 6
- HRS, which can be treated with a combination of terlipressin and albumin 3
- Refractory ascites, which may require repeated large volume paracentesis and transjugular intrahepatic portosystemic shunt placement 2, 3
Treatment of Ascites
Treatment of ascites aims to reduce fluid accumulation and manage its complications. This includes:
- Modest salt restriction and stepwise diuretic therapy with spironolactone and loop-diuretics 2
- Large volume paracentesis followed by plasma volume expansion or transjugular intrahepatic portosystemic shunt for tense and refractory ascites 2, 3
- Antibiotic treatment for SBP 3, 6
- Consideration for liver transplantation in patients with ascites and liver cirrhosis 2, 3