From the Guidelines
The medical management for ascites involves a combination of dietary sodium restriction, diuretic therapy, and paracentesis to remove excess fluid from the abdominal cavity 1.
Key Components of Management
- Dietary sodium restriction: Patients should limit their daily salt intake to less than 5g, which is equivalent to about one teaspoon of salt, and read food labels to ensure they are within this limit 1.
- Diuretic therapy: Diuretics, such as 'water tablets', are started at a low dose and gradually increased until the ascites is treated, with careful monitoring for side effects like dehydration, confusion, and kidney damage 1.
- Paracentesis: Abdominal paracentesis with ascitic fluid analysis is essential for diagnosing ascites and its cause, and should be performed in all patients with new-onset Grade 2 or 3 ascites, or with any complication of cirrhosis 1.
Monitoring and Adjustments
- Patients should monitor their body weight daily to assess the efficacy of diuretics and prevent adverse effects, with a target weight loss of no more than 0.5 kg per day in patients without peripheral edema 1.
- Laboratory monitoring, including serum electrolyte concentrations, is necessary, particularly during the first weeks of treatment, to guide therapy and prevent complications like renal failure and hyponatremia 1.
Advanced Management
- In patients with untreatable or refractory ascites, alternatives to repeated hospital drainage include transjugular intrahepatic portosystemic shunt (TIPSS), which can reduce the need for repeated fluid drainage, but requires careful patient selection due to potential side effects 1.
- Liver transplantation is the only curative option for untreatable ascites, and medical care focuses on controlling symptoms, known as palliative care, in patients who are not suitable for transplantation 1.
From the Research
Medical Management of Ascites
The medical management of ascites involves a combination of lifestyle modifications, pharmacological interventions, and surgical procedures. The primary goals of treatment are to reduce fluid accumulation, alleviate symptoms, and improve quality of life.
First-Line Therapies
- Sodium restriction (2 g/d) to reduce fluid retention 2, 3
- Diuretic therapy with a combination of loop-acting diuretics (e.g., furosemide) and distal-acting diuretics (e.g., spironolactone) 2, 3, 4
- Large-volume paracentesis (LVP) for immediate relief from ascites and its associated symptoms 2, 3, 5
Management of Refractory Ascites
- LVP with intravenous albumin to minimize hemodynamic and renal dysfunction 2, 5
- Transjugular intrahepatic portosystemic shunts (TIPS) for patients with refractory ascites and relatively well-preserved liver function 2, 3, 5
- Peritoneovenous shunts, although rarely used due to high complication rates and occlusion tendency 2
- Vasoconstrictors, such as midodrine, as an alternative approach for patients who cannot undergo repeated LVP or TIPS 5
- Automated low flow pump systems, like Alfapump, which are designed to move ascites from the peritoneal cavity to the urinary bladder 5, 6
Prevention and Treatment of Complications
- Prophylaxis with orally administered quinolones (e.g., norfloxacin) or trimethoprim/sulfamethoxazole to prevent spontaneous bacterial peritonitis in high-risk patients 2
- Intravenous third-generation cephalosporins (e.g., cefotaxime) for the treatment of spontaneous bacterial peritonitis 2