Ascites medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: M.Umer Tariq [2]

Ascites Treatment (DO NOT EDIT)

Recommendations for the treatment of Ascites

“

Patients with ascites who are thought to have an alcohol component to their liver injury should abstain from alcohol consumption. First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2,000 mg per day]) and diuretics (oral spironolactone with or without oral furosemide). Fluid restriction is not necessary unless serum sodium is less than 120 to 125 mmol/L. An initial therapeutic abdominal paracentesis should be performed in patients with tense ascites. Sodium restriction and oral diuretics should then be initiated. Diuretic-sensitive patients should preferably be treated with sodium restriction and oral diuretics rather than with serial paracenteses. Liver transplantation should be considered in patients with cirrhosis and ascites.

”

Recommendations for the treatment of Refractory Ascites

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Serial therapeutic paracenteses are a treatment option in patients with refractory ascites. Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. For large-volume paracentesis, an albumin infusion of 6 to 8 g/L of fluid removed can be considered. Referral for liver transplantation should be expedited in patients with refractory ascites. Transjugular intrahepatic portasystemic stent-shunt (TIPS) should be considered in appropriately selected patients who meet criteria similar to those of published randomized trials. Peritoneovenous shunt, performed by a surgeon experienced with this technique, should be considered for patients with refractory ascites who are not candidates for paracenteses, transplant, or TIPS.

”

Medical Therapy

• Medical therapy is based on different grades of ascites.

Grade	Description	Therapy
Grade I	Mild fluid accumulation, only detectable with ultrasonography	No treatment
Grade II	Moderate fluid accumulation, detectable by physical examination	Sodium intake restriction and diuretics
Grade III	Severe fluid accumulation, detectable by inspection of flanks bulging	Large volume paracentesis followed by sodium intake restriction and diuretics

• Medical therapy would inhibit different processes in pathophysiology of ascites.

Portal hypertension

Vasodilator release

Splanchnic arteriolar vasodilation

Splancnic hypertension

Beta blockers

Hypovolemia and Arterial hypotension

Sympathetic nerve activation

Renin-angiotensin-aldosterone system activation

Aldosterone antagonists

Vasopressin activation

Increased lymph formation

Sodium and water retention

Loop diuretics

Paracentesis

Plasma volume expansion

Ascites

Dietary salt and water intake restriction

• Limitation of daily sodium intake results in negative sodium balance and also redistribution of fluid retention.
• Daily avoidance of prepared foods along with no added salt diet would lead to suitable sodium restriction (80–120 mMol, corresponded to 4.6–6.9 grams of salt/day).
• Water restriction is the absolute therapy for fluid accumulation in uncomplicated ascites. However, decreasing water input to <1 L/day is almost impossible in some patients.

Ascites

• 1 Grade I
  • No treatment is needed.
• 2 Grade II
  • 2.1 Adult
  • The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema and no more than 0.5 kg/day for patients with ascites alone.
    • Preferred regimen (1): Spironolactone 100 mg PO daily until adequate natriuresis (max. dose of 400 mg)
    • Preferred regimen (2): Furosemide up to 160 mg PO daily
    • Alternative regimen (1): Potassium canrenoate 200 mg PO daily
    • Alternative regimen (2): Amiloride 10-40 mg PO daily
  • 2.2 Pediatric
    • Preferred regimen (1): Spironolactone 2-3 mg/kg PO as a single morning dose (max. dose 2 mg/kg every 5-7 days)
    • Preferred regimen (2): Furosemide up to 1 mg/kg PO daily (max. dose 40 mg)
    • Preferred regimen (3): Albumin 25% up to 1 g/kg IV daily, up to q8h (until plasma level > 2.5 g/dL)

• 3 Grade III
  • Paracentesis followed by salt restriction and diuretics