What is the management approach for abdominal fluid accumulation?

From the Guidelines

The management of abdominal fluid accumulation (ascites) primarily involves treating the underlying cause while addressing fluid retention, with the initial approach including sodium restriction and diuretic therapy, as recommended by the most recent guidelines 1. The goal of treatment is to reduce fluid accumulation, alleviate symptoms, and improve quality of life, while also addressing the underlying cause of ascites, such as liver disease, heart failure, or cancer. Key components of the management approach include:

• Sodium restriction, with a daily intake of no more than 5 g of salt, as recommended by the British Society of Gastroenterology 1
• Diuretic therapy, typically starting with spironolactone 100 mg daily, often combined with furosemide 40 mg daily, with doses gradually increased as needed and monitored for electrolyte imbalances and kidney function 1
• Large-volume paracentesis (removal of 5-10 liters of fluid) for patients with severe or refractory ascites, accompanied by albumin infusion to prevent circulatory dysfunction, as supported by recent studies 1
• Consideration of TIPS (transjugular intrahepatic portosystemic shunt) procedure for patients with recurrent ascites despite medical therapy, as recommended by the American Association for the Study of Liver Diseases 1
• Prompt antibiotic treatment with third-generation cephalosporins or fluoroquinolones in cases of spontaneous bacterial peritonitis, as emphasized by recent guidelines 1 The management approach should be individualized based on the underlying cause of ascites, the severity of symptoms, and the patient's overall health status, with regular monitoring and adjustments to treatment as needed to optimize outcomes and improve quality of life.

From the FDA Drug Label

Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume. Sequestration of Protein Rich Fluids(7) This occurs in such conditions as acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis. The magnitude of loss into the third space may require treatment of reduced volume or oncotic activity with an infusion of albumin

The management approach for abdominal fluid accumulation may involve the use of albumin infusion to support blood volume, especially in cases where removal of ascitic fluid may cause hypovolemic shock 2. Additionally, in conditions such as acute peritonitis, pancreatitis, or extensive cellulitis, albumin infusion may be used to treat reduced volume or oncotic activity 2. Key considerations include:

• Monitoring hemodynamic response
• Avoiding circulatory overload
• Adjusting dosage based on patient's condition and weight
• Using diuretics in conjunction with albumin infusion in certain cases, such as Adult Respiratory Distress Syndrome (ARDS) 2

From the Research

Management Approach for Abdominal Fluid Accumulation

The management of abdominal fluid accumulation, also known as ascites, involves a comprehensive approach that includes evaluation, treatment, and prevention of complications.

• Evaluation of patients with ascites should include a thorough history, physical exam, laboratory tests, ascitic fluid analysis, and radiological tests 3.
• The initial treatment of ascites typically involves a low-sodium diet and diuretic therapy, with spironolactone being the primary diuretic used due to its ability to counteract aldosterone 4, 5.
• For patients with tense ascites, large-volume paracentesis (LVP) associated with intravenous albumin infusion is the treatment of choice, as it is effective and rapid, with fewer complications compared to traditional diuretic therapy 4, 6, 7.
• Patients with refractory ascites may benefit from transjugular intrahepatic portosystemic shunts (TIPS) or other alternative therapies such as vasoconstrictors or automated low-flow pump systems, although data on these treatments is limited 3, 7.
• The use of peritoneovenous shunts is also an option for patients with refractory ascites, but it is limited by the high incidence of complications and obstruction of the prosthesis 4, 6.
• Diuretics should be administered after paracentesis to prevent reaccumulation of ascites, and patients with moderate ascites should be treated with diuretics as initial therapy 7, 5.

Treatment Options

• Diuretic therapy: spironolactone and loop diuretics such as furosemide or torasemide 4, 5.
• Large-volume paracentesis (LVP) with intravenous albumin infusion 4, 6, 7.
• Transjugular intrahepatic portosystemic shunts (TIPS) 3, 7.
• Peritoneovenous shunts 4, 6.
• Automated low-flow pump systems 3.
• Vasoconstrictors such as midodrine 3.