What is the treatment for tense ascites?

Treatment of Tense Ascites

Initial therapeutic abdominal paracentesis should be performed in patients with tense ascites, followed by sodium restriction and oral diuretics to prevent reaccumulation. 1

First-line Management

• Large-volume paracentesis (LVP) is the initial treatment of choice for tense ascites as it rapidly relieves symptoms within minutes (compared to days or weeks with diuretics) 1
• A single 5-L paracentesis can be safely performed without post-paracentesis colloid infusion in patients with diuretic-resistant tense ascites 1
• For larger volumes of fluid removal, intravenous albumin (8 g/L of fluid removed) should be administered to prevent post-paracentesis circulatory dysfunction 1
• Following paracentesis, sodium restriction (88 mmol/day or 2000 mg/day) and oral diuretics must be initiated to prevent reaccumulation of fluid 1

Diuretic Therapy

• Spironolactone is the cornerstone of diuretic therapy for ascites due to its aldosterone antagonist activity that directly addresses the pathophysiology of sodium retention in cirrhosis 2, 3
• Initial diuretic regimen should include:
  • Spironolactone 50-100 mg/day 4, 2
  • Furosemide 20-40 mg/day 4, 5
• Diuretic doses should be titrated upward every 3-5 days until natriuresis and weight loss are achieved 1, 4
• Maximum diuretic doses before considering ascites refractory: spironolactone 400 mg/day and furosemide 160 mg/day 1, 6

Monitoring and Precautions

• Regular monitoring of weight, electrolytes, and renal function is essential during diuretic therapy 4
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 1, 4
• Target weight loss should not exceed 0.5 kg/day in patients without peripheral edema to avoid rapid fluid shifts 4
• NSAIDs should be strictly avoided as they can reduce diuretic efficacy and induce azotemia, potentially converting diuretic-sensitive patients to refractory 1, 5

Management of Refractory Ascites

• Refractory ascites is defined as fluid overload that is unresponsive to sodium restriction and maximum diuretic doses or recurs rapidly after therapeutic paracentesis 1
• Options for refractory ascites include:
  • Serial therapeutic paracenteses with albumin replacement 1, 7
  • Transjugular intrahepatic portosystemic shunt (TIPS) in selected patients 1, 8
  • Liver transplantation evaluation 1, 6

Special Considerations

• Albumin infusion (8-10 g/L of fluid removed) is recommended for large-volume paracentesis (>5L) to prevent post-paracentesis circulatory dysfunction 1, 9
• In patients with tense ascites and hypoalbuminemia, albumin administration may serve the dual purpose of supporting colloid osmotic pressure and preventing complications 9, 7
• Patients with ascites who have an alcohol component to their liver injury should abstain from alcohol consumption 1

Pitfalls to Avoid

• Avoid serial paracenteses without diuretic therapy in diuretic-sensitive patients, as this does not address the underlying sodium retention 1
• Be cautious with furosemide in patients with hepatic cirrhosis as sudden alterations of fluid and electrolyte balance may precipitate hepatic coma 5
• Monitor for diuretic complications including hepatic encephalopathy, renal impairment (serum creatinine >2.0 mg/dL), hyponatremia (serum sodium <120 mmol/L), or hyperkalemia (serum potassium >6.0 mmol/L) 1, 2
• Recognize that development of ascites in cirrhosis indicates poor prognosis, and liver transplantation should be considered in eligible patients 1, 6