Ascites

Dr. Komba
 Background
Definition:
Ascites describes
the condition of
pathologic fluid
collection within the
abdominal cavity.

Healthy men have

little or no
intraperitoneal fluid,
but women may
normally have as
much as 20 mL,
depending on the
phase of their Massive ascites
menstrual cycle.
 Pathophysiology
• Depends on the cause of ascites e.g. in
cirrhotic ascites the accumulation of ascitic
fluid represents a state of total-body sodium
and water excess, but the event that initiates
the unbalance is unclear.
– Three theories of ascites formation have been
proposed: underfilling, overflow, and peripheral
arterial vasodilation.
 History
• Patients with ascites often state that they have recently noticed an
increase in their abdominal girth.
• Because most cases of ascites are due to liver disease (80%),
patients with ascites should be asked about risk factors for liver
disease. These include the following:
– Long-term heavy alcohol use
– Chronic viral hepatitis or jaundice
– Intravenous drug use
– Multiple sexual partners
– Homosexual activity with a male partner, or heterosexual activity with
a bisexual male
– Transfusion with blood not tested for hepatitis virus
– Tattoos
– Living or birth in an area endemic for hepatitis
 History
• When a patient with a very long history of
stable cirrhosis develops ascites, the
possibility of superimposed hepatocellular
carcinoma (HCC) should be considered.
• Obesity, hypercholesterolemia, and type 2
diabetes mellitus are recognized causes of
nonalcoholic steatohepatitis, which can
progress to cirrhosis.
 History
• Patients with a history of cancer, especially
gastrointestinal cancer, are at risk for
malignant ascites.
• Malignancy-related ascites is frequently
painful, whereas cirrhotic ascites is usually
painless.
• Patients who develop ascites in the setting of
established diabetes or nephrotic syndrome
may have nephrotic ascites.
 Physical
• The physical examination in a patient with
ascites should focus on the signs of portal
hypertension and chronic liver disease.
• Physical findings suggestive of liver disease
include jaundice, palmar erythema, and spider
angiomas.
 Physical
• The liver may be difficult to palpate if a large
amount of ascites is present, but if palpable,
the liver is often found to be enlarged.
• When peritoneal fluid exceeds 500 mL, ascites
may be demonstrated by the presence of
shifting dullness or bulging flanks. A fluid-
wave sign is notoriously inaccurate.
 Physical
• Elevated jugular venous pressure may suggest a
cardiac origin of ascites.
• A firm nodule in the umbilicus, the so-called Sister
Mary Joseph nodule, is not common but suggests
peritoneal carcinomatosis originating from gastric,
pancreatic, or hepatic primary malignancy.
• A pathologic left-sided supraclavicular node (Virchow
node) suggests the presence of upper abdominal
malignancy.
• Patients with cardiac disease or nephrotic syndrome
may have anasarca.
 Causes--Normal peritoneum
• Portal hypertension (serum-ascites albumin
gradient [SAAG] >1.1 g/dL)
– Hepatic congestion
• congestive heart failure, constrictive pericarditis,
tricuspid insufficiency, Budd-Chiari syndrome
– Liver disease
• cirrhosis, alcoholic hepatitis, fulminant hepatic failure,
massive hepatic metastases
 Causes--Normal peritoneum
• Hypoalbuminemia (SAAG < 1.1 g/dL)
– Nephrotic syndrome
– Protein-losing enteropathy
– Severe malnutrition with anasarca
 Causes--Normal peritoneum
• Miscellaneous conditions (SAAG < 1.1 g/dL)
– Chylous ascites
– Pancreatic ascites
– Bile ascites
– Nephrogenic ascites
– Urine ascites
– Ovarian disease
Causes -- Diseased peritoneum (SAAG
< 1.1 g/dL)
• Infections
– Bacterial peritonitis
– Tuberculous peritonitis
– Fungal peritonitis
– Human immunodeficiency virus (HIV)-associated
peritonitis
Causes -- Diseased peritoneum (SAAG
< 1.1 g/dL)
• Malignant conditions
– Peritoneal carcinomatosis
– Primary mesothelioma
– Pseudomyxoma peritonei
– Hepatocellular carcinoma
Causes -- Diseased peritoneum (SAAG
< 1.1 g/dL)
• Other rare conditions
– Familial Mediterranean fever
– Vasculitis
– Granulomatous peritonitis
– Eosinophilic peritonitis
 Differential Diagnoses
• Acute Liver Failure • Hepatocellular Adenoma
• Alcoholic Hepatitis • Hepatorenal Syndrome
• Biliary Disease • Mediterranean Fever,
• Budd-Chiari Syndrome Familial
• Cardiomyopathy, Dilated • Nephrotic Syndrome
• Cardiomyopathy, • Portal Hypertension
Restrictive • Primary Biliary Cirrhosis
• Cirrhosis • Protein-Losing
• Hepatitis, Viral Enteropathy
 Workup
• The evaluation of a patient with ascites requires
that the cause of the ascites be established.
• In most cases ascites appears as part of a well-
recognized illness, i.e., cirrhosis, congestive heart
failure, nephrosis, or disseminated
carcinomatosis.
– The physician should determine that the development
of ascites is indeed a consequence of the basic
underlying disease and not due to the presence of a
separate or related disease process.
 Workup
• This distinction is necessary even when the cause
of ascites seems obvious.
• For example, when the patient with compensated
cirrhosis and minimal ascites develops progressive
ascites that is increasingly difficult to control with
sodium restriction or diuretics, the temptation is to
attribute the worsening of the clinical picture to
progressive liver disease.
– However, an occult HCC, portal vein thrombosis, SBP,
alcoholic hepatitis, viral infection, or even tuberculosis
may be responsible for the decompensation.
 Workup
• Similarly, the patient with congestive heart
failure may develop ascites from a
disseminated carcinoma with peritoneal
seeding.
• It is important to note, however, that while
there are many different causes of ascites, in
the United States >80% of cases are due to
cirrhosis.
 Workup --Laboratory Studies
• Diagnostic paracentesis (50–100 mL) should
be part of the routine evaluation of the
patient with new-onset ascites of unknown
origin, and does not routinely require the
prior administration of platelets or fresh-
frozen plasma unless disseminated
intravascular coagulation is suspected.
 Workup --Laboratory Studies
• The fluid should be examined for its gross
appearance; total protein content, albumin
level, cell count, and differential cell count
should be determined; and Gram's and acid-
fast stains and culture should be performed.
• Cytologic and cell-block examination may
disclose an otherwise unsuspected carcinoma.
 Workup -- Laboratory Studies
• A serum ascites–albumin gradient (SAAG)
should be calculated to determine if the fluid
has the features of a transudate or an exudate
(Calculated by subtracting the ascitic fluid
albumin value from the serum albumin value,
it correlates directly with portal pressure --
The specimens should be obtained
simultaneously).
 Workup -- Laboratory Studies
• A gradient >1.1 g/dL (high gradient) is
characteristic of uncomplicated cirrhotic
ascites and differentiates ascites due to portal
hypertension from ascites not due to portal
hypertension >97% of the time.
– Other etiologies of high-gradient ascites include
alcoholic hepatitis, congestive heart failure,
hepatic metastases, constrictive pericarditis, and
Budd-Chiari syndrome.
 Workup -- Laboratory Studies
• A gradient <1.1 g/dL (low gradient) suggests that
the ascites is not due to portal hypertension with
>97% accuracy and mandates a search for other
causes such as peritoneal carcinomatosis,
tuberculous peritonitis, pancreatitis, serositis,
pyogenic peritonitis, and nephrotic syndrome
• The terms high-albumin gradient and low-
albumin gradient should replace the terms
transudative and exudative in the description of
ascites
 Workup -- Laboratory Studies
• Inspection of ascitic fluid:
– Most ascitic fluid is transparent and tinged yellow.
– Bloody fluid from a traumatic tap is
heterogeneously bloody, and the fluid will clot.
– Nontraumatic bloody fluid is homogeneously red
and does not clot because the blood has already
clotted and lysed.
– Cloudy ascitic fluid with a purulent consistency
indicates infection.
 Workup -- Laboratory Studies
• Cell count:
– Normal ascitic fluid contains fewer than 500
leukocytes/µL and fewer than 250
polymorphonuclear leukocytes (PMNs)/µL.
– Any inflammatory condition can cause an elevated
white blood cell count.
– A PMN count of greater than 250 cells/µL is highly
suggestive of bacterial peritonitis.
– In tuberculous peritonitis and peritoneal
carcinomatosis, lymphocytes usually predominate.
 Workup -- Laboratory Studies
• Total protein:
– In the past, ascitic fluid has been classified as an
exudate if the protein level is greater than or
equal to 2.5 g/dL (accuracy is only approximately
56%)
– An elevated SAAG and a high protein level are
observed in cases of ascites due to hepatic
congestion.
– The combination of a low SAAG and a high protein
level is characteristic of malignant ascites
 Workup -- Laboratory Studies
• Culture/Gram stain:
– Culture has a 92% sensitivity for the detection of
bacteria in ascitic fluid, provided that samples are
inoculated into blood culture bottles immediately, at
the bedside.
– In contrast, Gram stain is only 10% sensitive for
visualizing bacteria in early-detected spontaneous
bacterial peritonitis.
– Approximately 10,000 bacteria/mL are required for
detection by Gram stain; the median concentration of
bacteria in spontaneous bacterial peritonitis is 1
organism/mL.
 Workup -- Laboratory Studies
• Cytology:
– Cytology smears are reported to be 58-75%
sensitive for detection of malignant ascites.
 Workup -- Laboratory Studies
• some features are sufficiently characteristic to
suggest certain diagnostic possibilities.
• For example, blood-stained fluid with >25 g/L
protein is unusual in uncomplicated cirrhosis but
is consistent with tuberculous peritonitis or
neoplasm.
• Cloudy fluid with a predominance of
polymorphonuclear cells (>250/ L) and a positive
Gram's stain are characteristic of bacterial
peritonitis; if most cells are lymphocytes,
tuberculosis should be suspected.
 Workup -- Laboratory Studies
• The complete examination of each fluid is most
important, for occasionally only one finding may
be abnormal.
– For example, if the fluid is a typical transudate but
contains >250 white blood cells per microliter, the
finding should be recognized as atypical for cirrhosis
and should warrant a search for tumor or infection.
• This is especially true in the evaluation of
cirrhotic ascites where occult peritoneal infection
may be present with only minor elevations in the
white blood cell count of the peritoneal fluid
(300–500/L).
 Workup -- Laboratory Studies
• Since Gram's stain of the fluid may be
negative in a high proportion of such cases,
careful culture of the peritoneal fluid is
mandatory.
• Bedside inoculation of blood culture flasks
with ascitic fluid results in a dramatically
increased incidence of positive cultures when
bacterial infection is present (90 vs. 40%
positivity with conventional cultures done by
the laboratory).
 Workup -- Laboratory Studies
• Direct visualization of the peritoneum
(laparoscopy) may disclose peritoneal
deposits of tumor, tuberculosis, or metastatic
disease of the liver.
• Biopsies are taken under direct vision, often
adding to the diagnostic accuracy of the
procedure.
 Characteristics of Ascitic Fluid in Various Disease States
Condition Gross Protein, g/L Serum- Cell Count Other Tests
Appearance Ascites Red Blood White Blood
Albumin Cells, >10,000/ Cells, per L
Gradient, L
g/dL

Cirrhosis Straw-colored <25 (95%) >1.1 1% <250 (90%)a;

or bile-stained predominantly
mesothelial

Neoplasm Straw-colored, >25 (75%) <1.1 20% >1000 (50%); Cytology, cell
hemorrhagic, variable cell block,
mucinous, or types peritoneal
chylous biopsy
Tuberculous Clear, turbid, >25 (50%) <1.1 7% >1000 (70%); Peritoneal
peritonitis hemorrhagic, usually >70% biopsy, stain
chylous lymphocytes and culture for
acid-fast
bacilli
Nephrosis Straw-colored <25 (100%) <1.1 Unusual <250; If chylous,
or chylous mesothelial, ether
mononuclear extraction,
Condition Gross Protein, Serum- Cell Count Other tests
Appearanc g/L Ascites Red White Blood
e Albumin Blood Cells, per L
Gradient Cells,
, g/dL >10,000
/L
Pyogenic Turbid or If purulent, <1.1 Unusual Predominantly Positive
peritonitis purulent >25 polymorphonucle Gram's
ar leukocytes stain,
culture
Congestive Straw- Variable, >1.1 10% <1000 (90%);
heart failure colored 15–53 usually
mesothelial,
mononuclear
Pancreatic Turbid, Variable, <1.1 Variabl Variable Increased
ascites hemorrhagi often >25 e, may amylase in
(pancreatiti c, or be ascitic fluid
s, chylous blood- and serum
pseudocyst) stained
 Workup -- Laboratory Studies
• Chylous ascites refers to a turbid, milky, or
creamy peritoneal fluid due to the presence of
thoracic or intestinal lymph.
• Such a fluid shows Sudan-staining fat globules
microscopically and an increased triglyceride
content by chemical examination.
• A triglyceride concentration of >2.3 mmol/L
(>200 mg/dL) is sufficient for the diagnosis.
 Workup -- Laboratory Studies
• A turbid fluid due to leukocytes or tumor cells
may be confused with chylous fluid
(pseudochylous), and it is often helpful to
carry out alkalinization and ether extraction
of the specimen.
• Alkali tend to dissolve cellular proteins and
thereby reduce turbidity; ether extraction
leads to clearing if the turbidity of the fluid is
due to lipid.
 Workup -- Laboratory Studies
• Chylous ascites is most often the result of
lymphatic disruption or obstruction from
cirrhosis, tumor, trauma, tuberculosis,
filariasis, or congenital abnormalities. It may
also be seen in the nephrotic syndrome.
• Rarely, ascitic fluid may be mucinous in
character, suggesting either pseudomyxoma
peritonei or rarely a colloid carcinoma of the
stomach or colon with peritoneal implants.
 Workup -- Laboratory Studies
• On occasion, ascites may develop as a seemingly
isolated finding in the absence of a clinically
evident underlying disease.
• Then, a careful analysis of ascitic fluid may
indicate the direction the evaluation should take.
• A useful framework for the workup starts with an
analysis of whether the fluid is classified as a high
(transudate) or low (exudate) gradient fluid.
 Workup -- Laboratory Studies
• High-gradient (transudative) ascites of unclear
etiology is most often due to occult cirrhosis,
right-sided venous hypertension raising
hepatic sinusoidal pressure, Budd-Chiari
syndrome, or massive hepatic metastases.
• Cirrhosis with well-preserved liver function
(normal albumin) resulting in ascites is
invariably associated with significant portal
hypertension .
 Workup -- Laboratory Studies
• Evaluation should include liver function tests and
a hepatic imaging procedure (i.e., CT or
ultrasound) to detect nodular changes in the liver
suggesting portal hypertension.
• On occasion, a wedged hepatic venous pressure
can be useful to document portal hypertension.
• If clinically indicated, a liver biopsy will confirm
the diagnosis of cirrhosis and perhaps suggest its
etiology.
 Workup -- Laboratory Studies
• Other etiologies may result in hepatic venous
congestion and resultant ascites.
– Right-sided cardiac valvular disease and particularly
constrictive pericarditis should raise a high index of
suspicion and may require cardiac imaging and cardiac
catheterization for definitive diagnosis.
– Hepatic vein thrombosis is evaluated by visualizing the
hepatic veins with imaging techniques (Doppler
ultrasound, angiography, CT scans, MRI) to demonstrate
obliteration, thrombosis, or obstruction by tumor.
– Uncommonly, transudative ascites may be associated with
benign tumors of the ovary, particularly fibroma (Meigs'
syndrome) with ascites and hydrothorax.
 Workup -- Laboratory Studies
• Low-gradient (exudative) ascites should
initiate an evaluation for primary peritoneal
processes, most importantly infection and
tumor.
• Tuberculous peritonitis is best diagnosed by
peritoneal biopsy, either percutaneously or
via laparoscopy.
• Histologic examination invariably shows
granulomata that may contain acid-fast bacilli.
 Workup -- Laboratory Studies
• Since cultures of peritoneal fluid and biopsies for
tuberculosis may require 6 weeks, characteristic
histology with appropriate stains allows
antituberculosis therapy to be started promptly.
• The diagnosis of peritoneal seeding by tumor can
usually be made by cytologic analysis of
peritoneal fluid or by peritoneal biopsy if
cytology is negative.
• Appropriate diagnostic studies can then be
undertaken to determine the nature and site of
the primary tumor.
 Workup -- Laboratory Studies
• Pancreatic ascites is invariably associated with
an extravasation of pancreatic fluid from the
pancreatic ductal system, most commonly
from a leaking pseudocyst.
• Ultrasound or CT examination of the pancreas
followed by visualization of the pancreatic
duct by direct cannulation -- ERCP usually
discloses the site of leakage and permits
resective surgery to be carried out.
 Workup -- Imaging Studies
• Chest and plain abdominal films
– Elevation of the diaphragm, with or without
sympathetic pleural effusions (hepatic
hydrothorax), is visible in the presence of massive
ascites.
– More than 500 mL of fluid is usually required for
ascites to be diagnosed based on findings from
abdominal films.
 Workup -- Imaging Studies
• Many nonspecific signs suggest ascites, such as
– diffuse abdominal haziness
– bulging of the flanks
– indistinct psoas margins
– poor definition of the intra-abdominal organs
– erect position density increase
– separation of small bowel loops, and
– centralization of floating gas containing small bowel.
 Workup -- Imaging Studies
• The direct signs are more reliable and specific.
– The lateral liver edge is medially displaced from the
thoracoabdominal wall (Hellmer sign).
– In the pelvis, fluid accumulates in the rectovesical
pouch and then spills into the paravesical fossa. The
fluid produces symmetric densities on both sides of
the bladder, which is termed a "dog's ear" or "Mickey
Mouse" appearance.
– Medial displacement of the cecum and ascending
colon and lateral displacement of the properitoneal
fat line
– Although obliteration of the hepatic angle
 Workup -- Ultrasonography
• Ultrasonography
– Real-time ultrasonography is the easiest and
most sensitive technique for the detection of
ascitic fluid.
– Volumes as small as 5-10 mL can be visualized.
– Uncomplicated ascites appears as a
homogeneous, freely mobile, anechoic collection
in the peritoneal cavity that demonstrates deep
acoustic enhancement.
 Workup -- Ultrasonography
• The smallest amounts of fluid tend to collect
in the Morison pouch (posterior subhepatic
space) and around the liver as a sonolucent
band.
• With massive ascites, the small bowel loops
have a characteristic polycyclic, "lollipop," or
arcuate appearance because they are arrayed
on either side of the vertically floating
mesentery.
 Workup -- Ultrasonography
• Certain ultrasonographic findings suggest that the
ascites may be infected, inflammatory, or malignant.
• These findings include
– coarse internal echoes (blood)
– fine internal echoes (chyle)
– multiple septa (tuberculous peritonitis, pseudomyxoma
peritonei)
– loculation or atypical fluid distribution
– matting or clumping of bowel loops, and
– thickening of interfaces between fluid and adjacent
structures.
 Workup -- Ultrasonography
• In malignant ascites, the bowel loops do not float
freely but may be
– tethered along the posterior abdominal wall
– plastered to the liver or other organs, or
– surrounded by loculated fluid collections.
• Most patients (95%) with carcinomatous peritonitis
have a gallbladder wall that is less than 3 mm thick.
• Mural thickening of the gallbladder is associated with
benign ascites in 82% of cases.
• The thickening of the gallbladder is primarily a
reflection of cirrhosis and portal hypertension.
Workup -- Computed tomography (CT)
scanning
• Computed tomography (CT) scanning: Ascites
is demonstrated well on CT scan images. Small
amounts of ascitic fluid localize in the right
perihepatic space, the posterior subhepatic
space, and the Douglas pouch (rectouterine
pouch). See the image below.
 This computed tomography scan demonstrates
free intraperitoneal fluid due to urinary ascites.
Workup -- Computed tomography (CT)
scanning
• A number of CT scan features suggest neoplasia.
– Hepatic, adrenal, splenic, or lymph node lesions
associated with masses arising from the gut, ovary, or
pancreas are suggestive of malignant ascites.
– Patients with malignant ascites tend to have
proportional fluid collections in the greater and lesser
sacs; whereas, in patients with benign ascites, the
fluid is observed primarily in the greater sac and not
in the lesser omental bursae.
 Other Tests
• Laparoscopy may be valuable for the diagnosis
of otherwise unexplained cases, especially if
malignant ascites is suspected.
• This may be of particular importance in the
diagnosis of malignant mesothelioma.
 Procedures-- Abdominal paracentesis
• Most rapid and perhaps the most cost-effective
method of diagnosing the cause of ascites formation.
• Guidelines from the American Association for the
Study of Liver Diseases (AASLD) for management of
adult patients with ascites due to cirrhosis advocate
paracentesis in all patients with clinically apparent
new-onset ascites (grade II-3 recommendation).[4]
• Bleeding from paracentesis is sufficiently uncommon
that the AASLD does not recommend the prophylactic
use of fresh frozen plasma or platelets beforehand
(grade III).
 Staging
• Ascites may be semi-quantified using the
following system:
– Stage 1+ is detectable only after careful
examination.
– Stage 2+ is easily detectable but of relatively small
volume.
– Stage 3+ is obvious, but not tense, ascites.
– Stage 4+ is tense ascites.
 Medical Care
• Sodium restriction (20-30 mEq/d) and diuretic
therapy constitute the standard medical
management for ascites and are effective in
approximately 95% of patients.
• Water restriction only if persistent hyponatremia
is present
– Recent research has focused on the treatment of
refractory ascites with aquaretics—vasopressin V2-
receptor antagonists that promote excretion of
electrolyte-free water and thus might be beneficial in
patients with ascites and hyponatremia.
 Medical Care
• Therapeutic paracentesis may be performed in
patients who require rapid symptomatic relief for
refractory or tense ascites.
• When small volumes of ascitic fluid are removed,
saline alone is an effective plasma expander.
• The removal of 5 L of fluid or more is considered
large-volume paracentesis.
• Total paracentesis, that is, removal of all ascites
(even >20 L), can usually be performed safely.
 Medical Care
• Supplementing 8-10 g of albumin per each liter
over 5 L of ascitic fluid removed decreases
complications of paracentesis, such as electrolyte
imbalances and increases in serum creatinine
levels secondary to large shifts of intravascular
volume.
• To avoid exposing patients to blood products, the
use of terlipressin (eg, 1 mg every 4 hours for 48
hours) rather than albumin has been proposed
for prevention of circulatory dysfunction after
large-volume paracentesis.
 Medical Care
• Repeated therapeutic paracentesis can be used
to treat refractory ascites.
• For palliative care in patients with advanced
cancer, an alternative to serial paracenteses is
placement of an indwelling peritoneal catheter;
ascitic fluid can then be removed by continuous
drainage or intermittent drainage with a
proprietary system utilizing vacuum bottles,
which can be performed in the patient’s home.
 Medical Care -- TIPS
• The transjugular intrahepatic portosystemic shunt
(TIPS) is the most effective treatment for patients
with diuretic-resistant ascites.
• In the procedure, which is performed with the patient
under conscious sedation or general anesthesia, an
interventional radiologist places a stent
percutaneously from the right jugular vein into the
hepatic vein, thereby creating a connection between
the portal and systemic circulations. TIPS is gradually
becoming the standard of care in patients with
diuretic-refractory ascites.
 Surgical Care -- Peritoneovenous
shunt.
• An alternative for patients with medically
intractable ascites
• This is a megalymphatic shunt that returns the
ascitic fluid to the central venous system.
• The AASLD suggests considering peritoneovenous
shunting for patients with refractory ascites who
are not candidates for paracentesis or TIPS
• The AASLD recommends that patients with
cirrhosis and ascites be considered for liver
transplantation.
Peritoneovenous shunt.
 Surgical Care -- Diet
• Sodium restriction of 500 mg/d (22 mmol/d) is
feasible in a hospital setting; however, it is
unrealistic in most outpatient settings.
– A more appropriate sodium restriction is 2000
mg/d (88 mmol).
• Indiscriminate fluid restriction is
inappropriate.
– Fluids need not be restricted unless the serum
sodium level drops below 120 mmol/L.
 Further Inpatient Care
• Patients can actually be maintained free of ascites if
sodium intake is limited to 10 mmol/d. However, this is
not practical outside a metabolic ward.
• Twenty-four – hour urinary sodium measurements
are useful in patients with ascites related to portal
hypertension in order to assess the degree of sodium
avidity, monitor the response to diuretics, and assess
compliance with diet.
• For grade 3 or 4 ascites, therapeutic paracentesis may
be necessary intermittently.
 Further Outpatient Care
• The best method of assessing the effectiveness of
diuretic therapy is by monitoring body weight
and urinary sodium levels.
• In general, the goal of diuretic treatment of
ascites should be to achieve a weight loss of 300-
500 g/d in patients without edema and 800-1000
g/d in patients with edema.
• Once ascites has disappeared, diuretic treatment
should be adjusted to maintain the patient free
of ascites.
 Inpatient & Outpatient Medications
• Diuretics should be initiated in patients whose
ascites does not respond to sodium restriction.
• A useful regimen is to start with spironolactone
at 100 mg/d.
• The addition of loop diuretics may be necessary
in some cases to increase the natriuretic effect.
• If no response occurs after 4-5 days, the dosage
may be increased stepwise up to spironolactone
at 400 mg/d plus furosemide at 160 mg/d.
 Complications
• The most common complication of ascites is
the development of spontaneous bacterial
peritonitis -SBP (ascitic fluid with PMN count
of >250 μ L).
– Perform repeated physical examinations and
paying particular attention to abdominal
tenderness
– Abdominal pain and abdominal tenderness are
more common in patients with SBP
 Complications
• Any patient with ascites and fever should
have a paracentesis with bedside blood
culture inoculation and cell count.
• Patients with a protein level of less than 1
g/dL in ascitic fluid are at high risk for the
development of spontaneous bacterial
peritonitis.
– Prophylactic antibiotic therapy with a quinolone is
often recommended.
 Complications
• Complications of paracentesis include
– infection, electrolyte imbalances, bleeding, and bowel
perforation.
• Bowel perforation should be considered in any patient
with recent paracentesis who develops a new onset of
fever and/or abdominal pain.
• All patients with long-standing ascites are at risk of
developing umbilical hernias.
• Large-volume paracentesis often results in large
intravascular fluid shifts.
– This can be avoided by administering albumin replacement
if more than 5 L is removed.
 Prognosis
• The prognosis for patients with ascites due to
liver disease depends on the underlying
disorder, the degree of reversibility of a given
disease process, and the response to
treatment.