What are the symptoms and management of ascites?

Symptoms and Management of Ascites

Ascites is the pathological accumulation of fluid in the peritoneal cavity, most commonly caused by liver cirrhosis, and requires a systematic approach to diagnosis and treatment based on severity.

Symptoms of Ascites

Ascites presents with several characteristic symptoms:

• Abdominal distension (most common symptom)
• Increased abdominal girth
• Weight gain
• Early satiety
• Nausea and vomiting
• Dyspnea (difficulty breathing)
• Lower extremity edema
• Reduced mobility
• Abdominal discomfort or pain
• Dyspnea (particularly when lying flat)

Grading of Ascites

Ascites is classified into three grades 1:

• Grade 1 (Mild): Only detectable by ultrasound examination
• Grade 2 (Moderate): Causing moderate symmetrical distension of the abdomen
• Grade 3 (Large): Causing marked abdominal distension

Diagnostic Approach

When ascites is suspected:

1. Diagnostic paracentesis is essential for all patients with new-onset ascites or hospitalized cirrhotic patients with ascites 1
2. Ascitic fluid analysis should include:
   • Serum-ascites albumin gradient (SAAG)
   • Cell count with differential
   • Total protein
   • Culture (bedside inoculation into blood culture bottles)
   • Ascitic amylase (if pancreatic disease is suspected)

Management Algorithm

First-Line Treatment

1. Dietary sodium restriction:

   • Limit to 5 g salt/day (88 mmol sodium/day) 1
   • No added salt at the table
   • Patients should read food labels to confirm daily salt intake

2. Diuretic therapy:

   • Grade 1: Treat underlying disease, provide nutritional support, discontinue NSAIDs/ACE inhibitors 1
   • Grade 2-3: Add diuretics 1
     • First-line: Spironolactone (start at 100 mg/day, can increase to 400 mg/day) 1, 2
     • Add-on: Furosemide (20-40 mg/day, can increase to 160 mg/day) if spironolactone alone is insufficient 1, 2, 3

Management of Large Volume Ascites (Grade 3)

Large volume paracentesis is the first-line treatment for patients with large or refractory ascites 1:

• For paracentesis <5 liters: Use synthetic plasma expander (150-200 ml of gelofusine or haemaccel)
• For paracentesis >5 liters: Administer albumin (8g albumin/L of ascites removed) 1

Management of Refractory Ascites

Refractory ascites occurs when:

• Ascites cannot be mobilized despite maximum diuretic therapy (spironolactone 400 mg/day and furosemide 160 mg/day) 1
• Early recurrence of ascites after therapeutic paracentesis
• Diuretic-induced complications prevent effective dosing

Treatment options:

1. Repeated large volume paracentesis with albumin replacement
2. Transjugular intrahepatic portosystemic shunt (TIPS) for suitable candidates 1
3. Liver transplantation (definitive treatment) 1

Monitoring and Complications

Electrolyte Monitoring

Monitor for diuretic-related complications 1, 2:

• Hyperkalemia (with spironolactone)
• Hypokalemia (with furosemide)
• Hyponatremia
• Renal impairment

Management of Hyponatremia 1:

• Serum sodium 126-135 mmol/L with normal creatinine: Continue diuretics with close monitoring
• Serum sodium 121-125 mmol/L with normal creatinine: Consider stopping diuretics
• Serum sodium 121-125 mmol/L with elevated creatinine: Stop diuretics and give volume expansion
• Serum sodium <120 mmol/L: Stop diuretics and consider volume expansion

Spontaneous Bacterial Peritonitis (SBP)

• Perform diagnostic paracentesis in all cirrhotic patients with ascites on hospital admission 1
• Start empiric antibiotic therapy if ascitic fluid neutrophil count >250 cells/mm³ 1
• Third-generation cephalosporins are most effective for treatment 1
• Consider albumin administration (1.5 g/kg initially, then 1 g/kg on day 3) for patients with SBP and signs of renal impairment 1

Important Considerations

• Development of ascites is an important milestone in cirrhosis, with approximately 20% of patients dying within the first year of diagnosis 1
• Liver transplantation should be considered for all patients with cirrhotic ascites 1
• Excessive bed rest is not recommended for patients with ascites 1
• Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers in patients with ascites 1

By following this systematic approach to diagnosis and management, the morbidity and mortality associated with ascites can be significantly reduced.