From the Guidelines
Massive ascites and tense ascites are distinct entities, with massive ascites referring to a large volume of fluid in the peritoneal cavity, typically exceeding 5 liters, and tense ascites describing the physical characteristic of high intra-abdominal pressure, regardless of volume, which may require urgent therapeutic paracentesis to relieve pressure and associated symptoms. The key difference between massive and tense ascites lies in their definition and management approach. Massive ascites is characterized by a large volume of fluid, often accompanied by significant abdominal distention, weight gain, and peripheral edema, as noted in the guidelines on the management of ascites in cirrhosis 1. On the other hand, tense ascites is defined by the physical characteristic of the accumulated fluid, which creates high intra-abdominal pressure, resulting in a firm, non-compressible abdomen that feels tight upon palpation, as discussed in the diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases 1. Some key points to consider in the management of both conditions include:
- Treating the underlying cause, often liver cirrhosis
- Sodium restriction (2g/day)
- Diuretic therapy (spironolactone 100-400mg/day with furosemide 40-160mg/day)
- Therapeutic paracentesis for symptom relief, with tense ascites particularly benefiting from paracentesis to immediately reduce intra-abdominal pressure and improve patient comfort, as recommended in the guidelines 1
- Large-volume paracentesis (up to 5-6 liters) with albumin replacement (6-8g per liter removed) to prevent post-paracentesis circulatory dysfunction in massive ascites, as suggested in the practice guidance 1. It is essential to note that the management approach may vary depending on the specific patient needs and the underlying cause of ascites, and healthcare professionals should follow the most recent guidelines and practice guidance, such as those provided by the American Association for the Study of Liver Diseases 1 and the British Society of Gastroenterology 1, to ensure optimal patient outcomes.
From the Research
Definition of Massive and Tense Ascites
- Massive ascites refers to a large accumulation of fluid in the peritoneal cavity, often requiring frequent paracentesis for relief 2.
- Tense ascites is a condition where the abdominal cavity is filled with fluid to the point of causing significant discomfort and respiratory compromise, often requiring immediate treatment 3, 4, 5, 2.
Pathophysiology of Ascites
- The formation of ascites is a multifactorial process involving portal hypertension, splanchnic vasodilation, liver insufficiency, and cardiovascular dysfunction 5, 2.
- Severe sinusoidal portal hypertension and hepatic insufficiency lead to circulatory dysfunction, characterized by arterial vasodilation, arterial hypotension, high cardiac output, and hypervolemia, resulting in renal sodium and water retention 2.
Treatment of Massive and Tense Ascites
- Large-volume paracentesis associated with albumin infusion is the treatment of choice for tense ascites, as it is effective and rapid, with fewer complications than traditional treatment with sodium restriction and diuretics 3, 2.
- Diuretics should be given after paracentesis to prevent reaccumulation of ascites 3, 2.
- Refractory ascites can be treated with repeated large-volume paracentesis, transjugular intrahepatic portosystemic shunts, peritoneovenous shunts, or liver transplantation 4, 5, 2.
- A peritoneal dialysis system with extracorporeal ultrafiltration by a hemodialysis dialyzer can be used to manage refractory ascites, especially in patients with end-stage renal disease 6.