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{{Ascites}}
{{Ascites}}


{{CMG}} {{AE}} {{MUT}}
{{CMG}} {{AE}} {{EG}}


==Overview==
==Overview==


The mainstays of first-line treatment of patients with [[cirrhosis]] and ascites include (1) education regarding dietary [[sodium]] restriction (2000 mg per day [88 mmol per day]) and (2) oral [[diuretics]]. Medical therapy is based on different grades of ascites. Medical therapy would inhibit different processes in [[pathophysiology]] of ascites. First-line treatment of patients with [[cirrhosis]] and ascites consists of [[sodium]] restriction (88 mmol per day [2000 mg per day], [[diet]] education), and [[diuretics]] (oral [[spironolactone]] with or without oral [[furosemide]]).
==Ascites Treatment Recommendations (DO NOT EDIT)==


==Ascites Treatment (DO NOT EDIT)==
===Recommendations for the treatment of Ascites<ref name=":0">{{Cite web|url=https://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf|title=Management of adult patients with ascites due to cirrhosis: update 2012|last=Runyon|first=BA|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>===
* Patients with ascites who are thought to have an [[alcohol]] component to their [[liver]] injury should abstain from [[alcohol]] consumption.
* [[Baclofen]] can be given to reduce [[alcohol]] craving and [[alcohol]] consumption in patients with ascites in the setting of [[alcoholic liver disease]].
* First-line treatment of patients with [[cirrhosis]] and ascites consists of [[sodium]] restriction (88 mmol per day [2000 mg per day], [[diet]] education), and [[diuretics]] (oral [[spironolactone]] with or without oral [[furosemide]]).
* Fluid restriction is not necessary unless serum [[sodium]] is less than 125 mmol/L.
* Vaptans may improve serum [[sodium]] in patients with [[cirrhosis]] and ascites. However their use does not currently appear justified in view of their expense, potential risks, and lack of evidence of efficacy in clinically meaningful outcomes.
* An initial therapeutic [[Abdomen|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 [[Diuretic|diuretics]] rather than with serial [[Paracentesis|paracenteses]].
* Use of [[angiotensin converting enzyme inhibitors]] and [[angiotensin receptor blockers]] in patients with [[cirrhosis]] and ascites may be harmful, must be carefully considered in each patient, monitoring [[blood pressure]] and [[renal function]].
* The use of [[nonsteroidal anti-inflammatory drugs]] should be avoided in patients with [[cirrhosis]] and ascites, except in special circumstances.
* [[Liver transplantation]] should be considered in patients with [[cirrhosis]] and ascites.


===Recommendations for the treatment of Ascites===
===Recommendations for the treatment of Refractory Ascites<ref name=":0" />===
{{cquote|
* The risks versus benefits of [[beta blockers]] must be carefully weighed in each patient with refractory ascites. Systemic [[hypotension]] often complicates their use. Consideration should be given to discontinuing or not initiating these [[drugs]] in this setting.  
# Patients with ascites who are thought to have an alcohol component to their liver injury should abstain from alcohol consumption.
* The use of [[angiotensin converting enzyme inhibitors]] and [[angiotensin receptor blockers]] should be avoided in patients [[refractory]] ascites. Systemic [[hypotension]] often complicates their use.
# 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).
* Oral [[midodrine]] has been shown to improve clinical outcomes and survival in patients with [[refractory]] ascites; its use should be considered in this setting.
# Fluid restriction is not necessary unless serum sodium is less than 120 to 125 mmol/L.
* Serial therapeutic [[Paracentesis|paracenteses]] are a treatment option for patients with [[refractory]] ascite.
# An initial therapeutic abdominal paracentesis should be performed in patients with tense ascites. Sodium restriction and oral diuretics should then be initiated.
* Post-[[paracentesis]] [[albumin]] infusion may not be necessary for a single [[paracentesis]] of less than 4 to 5 L.
# Diuretic-sensitive patients should preferably be treated with sodium restriction and oral diuretics rather than with serial paracenteses.
* For large-volume [[Paracentesis|paracenteses]], an [[albumin]] infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended.
# Liver transplantation should be considered in patients with cirrhosis and ascites.}}
* Referral for [[liver transplantation]] should be expedited in patients with [[refractory]] ascites, if the patient is otherwise a candidate for [[transplantation]].
 
* [[Transjugular intrahepatic portosystemic shunt|TIPS]] may be considered in appropriately selected patients who meet [[criteria]] similar to those of published randomized trials.  
===Recommendations for the treatment of Refractory Ascites===
* [[Peritoneovenous shunt]], performed by a [[surgeon]] or inteventional [[Radiologists|radiologist]] experienced with this technique, should be considered for patients with [[refractory]] ascites who are not candidates for [[Paracentesis|paracenteses]], [[transplant]], or [[TIPS]].  
{{cquote|
# 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==
* The mainstays of first-line treatment of patients with [[cirrhosis]] and ascites include:<ref name=":0" />
** Education regarding dietary [[sodium]] restriction (2000 mg per day [88 mmol per day])
** Oral [[diuretics]]
* Medical therapy is based on different grades of ascites.<ref name="pmid20633946">{{cite journal |vauthors= |title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis |journal=J. Hepatol. |volume=53 |issue=3 |pages=397–417 |year=2010 |pmid=20633946 |doi=10.1016/j.jhep.2010.05.004 |url=}}</ref>
{| class="wikitable"
!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.<ref name="pmid25954497">{{cite journal| author=Pedersen JS, Bendtsen F, Møller S| title=Management of cirrhotic ascites. | journal=Ther Adv Chronic Dis | year= 2015 | volume= 6 | issue= 3 | pages= 124-37 | pmid=25954497 | doi=10.1177/2040622315580069 | pmc=4416972 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25954497  }}</ref>
{{family tree/start}}
{{family tree/start}}
{{family tree| | | | | |,|-|-| A01 |-|-|.| | | | | | | |A01='''''[[Portal hypertension]]'''''}}
{{family tree| | | | | |,|-|-| A01 |-|-|.| | | | | | | |A01='''''[[Portal hypertension]]'''''}}
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{{family tree/end}}
Ascites is generally treated simultaneously while an underlying etiology is sought in order to prevent complications, to relieve symptoms and to prevent further progression. In patients with mild ascites, therapy is usually as an outpatient. 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.<ref name="pmid4910836">{{cite journal |author=Shear L, Ching S, Gabuzda GJ |title=Compartmentalization of ascites and edema in patients with hepatic cirrhosis |journal=N. Engl. J. Med. |volume=282 |issue=25 |pages=1391-6 |year=1970 |pmid=4910836 |doi=}}</ref> In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis.<ref name="pmid3297907">{{cite journal |author=Ginés P, Arroyo V, Quintero E, ''et al'' |title=Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study |journal=Gastroenterology |volume=93 |issue=2 |pages=234-41 |year=1987 |pmid=3297907 |doi=}}</ref><ref name="pmid3655306">{{cite journal |author=Salerno F, Badalamenti S, Incerti P, ''et al'' |title=Repeated paracentesis and i.v. albumin infusion to treat 'tense' ascites in cirrhotic patients. A safe alternative therapy |journal=J. Hepatol. |volume=5 |issue=1 |pages=102-8 |year=1987 |pmid=3655306 |doi=}}</ref>


===High SAAG===
=== Dietary salt and water intake restriction ===
====Salt restriction====
* Limitation of daily [[sodium]] intake results in negative [[sodium]] balance and also redistribution of [[fluid retention]].
Salt restriction is the initial treatment, which allows [[diuresis]] (production of urine) since the patient now has more fluid than salt concentration. Salt restriction is effective in about 15% of patients.<ref name="pmid1860680">{{cite journal |author=Gatta A, Angeli P, Caregaro L, Menon F, Sacerdoti D, Merkel C |title=A pathophysiological interpretation of unresponsiveness to spironolactone in a stepped-care approach to the diuretic treatment of ascites in nonazotemic cirrhotic patients |journal=Hepatology |volume=14 |issue=2 |pages=231-6 |year=1991 |pmid=1860680 |doi=}}</ref>
* 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).
====Diuretics====
* 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.<ref name="pmid18293276">{{cite journal |vauthors=Ginès P, Cárdenas A |title=The management of ascites and hyponatremia in cirrhosis |journal=Semin. Liver Dis. |volume=28 |issue=1 |pages=43–58 |year=2008 |pmid=18293276 |doi=10.1055/s-2008-1040320 |url=}}</ref>
Since salt restriction is the basic concept in treatment, and [[aldosterone]] is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be sought. [[Spironolactone]] (or other distal-tubule diuretics such as [[triamterene]] or [[amiloride]]) is the drug of choice since they block the aldosterone receptor in the collecting tubule. This choice has been confirmed in a [[randomized controlled trial]].<ref name="pmid7035545">{{cite journal |author=Fogel MR, Sawhney VK, Neal EA, Miller RG, Knauer CM, Gregory PB |title=Diuresis in the ascitic patient: a randomized controlled trial of three regimens |journal=J. Clin. Gastroenterol. |volume=3 Suppl 1 |issue= |pages=73-80 |year=1981 |pmid=7035545 |doi=}}</ref> Diuretics for ascites should be dosed once per day.<ref name="pmid8277955">{{cite journal |author=Runyon BA |title=Care of patients with ascites |journal=N. Engl. J. Med. |volume=330 |issue=5 |pages=337-42 |year=1994 |pmid=8277955 |doi=}}</ref> Generally, the starting dose is oral spironolactone 100 mg/day (max 400 mg/day).
40% of patients will respond to spironolactone.<ref name="pmid1860680" /> For nonresponders, a [[loop diuretic]] may also be added and generally, [[furosemide]] is added at a dose of 40 mg/day (max 160 mg/day), or alternatively ([[bumetanide]] or [[torasemide]]). The ratio of 100:40 reduces risks of potassium imbalance.<ref name="pmid8277955" /> Serum [[potassium]] level and renal function should be monitored closely while on these medications.<ref name="pmid15084697">{{cite journal |author=Ginès P, Cárdenas A, Arroyo V, Rodés J |title=Management of cirrhosis and ascites |journal=N. Engl. J. Med. |volume=350 |issue=16 |pages=1646-54 |year=2004 |pmid=15084697 |doi=10.1056/NEJMra035021}}</ref>


'''Monitoring diuresis''': Diuresis can be monitored by weighing the patient daily. 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.<ref name="pmid4910836">{{cite journal |author=Shear L, Ching S, Gabuzda GJ |title=Compartmentalization of ascites and edema in patients with hepatic cirrhosis |journal=N. Engl. J. Med. |volume=282 |issue=25 |pages=1391-6 |year=1970 |pmid=4910836 |doi=}}</ref>
=== 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.<ref name="pmid4910836">{{cite journal |author=Shear L, Ching S, Gabuzda GJ |title=Compartmentalization of ascites and edema in patients with hepatic cirrhosis |journal=N. Engl. J. Med. |volume=282 |issue=25 |pages=1391-6 |year=1970 |pmid=4910836 |doi=}}</ref>  
***Preferred regimen (1): [[Spironolactone]] 100 mg [[Per os|PO]] daily until adequate natriuresis (max. dose of 400 mg)
***Preferred regimen (2): [[Furosemide]] up to 160 mg [[Per os|PO]] daily
***Alternative regimen (1): [[Potassium canrenoate]] 200 mg [[Per os|PO]] daily
***Alternative regimen (2): [[Amiloride]] 10-40 mg [[Per os|PO]] daily
**2.2 '''Pediatric'''<ref name="GieferMurray2011">{{cite journal|last1=Giefer|first1=Matthew J|last2=Murray|first2=Karen F|last3=Colletti|first3=Richard B|title=Pathophysiology, Diagnosis, and Management of Pediatric Ascites|journal=Journal of Pediatric Gastroenterology and Nutrition|volume=52|issue=5|year=2011|pages=503–513|issn=0277-2116|doi=10.1097/MPG.0b013e318213f9f6}}</ref>
***Preferred regimen (1): [[Spironolactone]] 2-3 mg/kg [[Per os|PO]] as a single morning dose (max. dose 2 mg/kg every 5-7 days)
***Preferred regimen (2): [[Furosemide]] up to 1 mg/kg [[Per os|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)


If daily weights cannot be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs.<ref name="pmid8277955" />  A random urine sodium-to-potassium ratio of > 1 is 90% [[sensitivity (tests)|sensitivity]] in predicting negative balance (> 78-mmol/day sodium excretion).<ref name="Runyon1996">Runyon BA, Heck M. Utility of 24-hour urine sodium collection and urine Na/K ratios in the management of patients with cirrhosis and ascites [abstract]. Hepatology. 1996;24:571A.</ref>
* '''3 Grade III'''
 
** [[Paracentesis]] followed by [[salt]] restriction and [[diuretics]]
'''Diuretic resistance''': Diuretic resistance can be predicted by giving 80 mg intravenous furosemide after 3 days without diuretics and on a 80 mEq sodium/day diet.  The urinary sodium excretion over 8 hours < 50 mEq/8 hours predicts resistance.<ref name="pmid11124817">{{cite journal |author=Spahr L, Villeneuve JP, Tran HK, Pomier-Layrargues G |title=Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites |journal=Hepatology |volume=33 |issue=1 |pages=28-31 |year=2001 |pmid=11124817 |doi=10.1053/jhep.2001.20646}}</ref>
* '''4 Refractory'''  
====Water restriction====
** 4.1 '''Adult'''
Water restriction is needed if hyponatremia < 130 mmol per liter develops.<ref name="pmid15084697" />
*** Preferred regimen (1): [[Midodrine]] 7.5 mg [[Per os|PO]] q8h
 
====Paracentesis====
{{main|Paracentesis}}
In those with severe (tense) ascites, therapeutic [[paracentesis]] may be needed in addition to medical treatments listed above.<ref name="pmid3297907" /><ref name="pmid3655306" /> As this may deplete [[serum albumin]] levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed.
 
===Low SAAG===
Exudative ascites generally does not respond to manipulation of the salt balance or diuretic therapy. Repeated paracentesis and treatment of the underlying cause is the mainstay of treatment.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category: Medicine]]
[[Category: Up-To-Date]]
[[Category: Gastroenterology]]
[[Category: Hepatology]]
[[Category: Emergency medicine]]


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Latest revision as of 14:58, 26 January 2018

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

Overview

The mainstays of first-line treatment of patients with cirrhosis and ascites include (1) education regarding dietary sodium restriction (2000 mg per day [88 mmol per day]) and (2) oral diuretics. Medical therapy is based on different grades of ascites. Medical therapy would inhibit different processes in pathophysiology of ascites. First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2000 mg per day], diet education), and diuretics (oral spironolactone with or without oral furosemide).

Ascites Treatment Recommendations (DO NOT EDIT)

Recommendations for the treatment of Ascites[1]

Recommendations for the treatment of Refractory Ascites[1]

Medical Therapy

  • The mainstays of first-line treatment of patients with cirrhosis and ascites include:[1]
    • Education regarding dietary sodium restriction (2000 mg per day [88 mmol per day])
    • Oral diuretics
  • Medical therapy is based on different grades of ascites.[2]
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
 
 
 
 
 
 
 
 
 
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.[4]

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.[5]
    • 2.2 Pediatric[6]
      • 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)

References

  1. ↑ 1.0 1.1 1.2 Runyon, BA. "Management of adult patients with ascites due to cirrhosis: update 2012" (PDF).
  2. ↑ "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J. Hepatol. 53 (3): 397–417. 2010. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.
  3. ↑ Pedersen JS, Bendtsen F, Møller S (2015). "Management of cirrhotic ascites". Ther Adv Chronic Dis. 6 (3): 124–37. doi:10.1177/2040622315580069. PMC 4416972. PMID 25954497.
  4. ↑ Ginès P, Cárdenas A (2008). "The management of ascites and hyponatremia in cirrhosis". Semin. Liver Dis. 28 (1): 43–58. doi:10.1055/s-2008-1040320. PMID 18293276.
  5. ↑ Shear L, Ching S, Gabuzda GJ (1970). "Compartmentalization of ascites and edema in patients with hepatic cirrhosis". N. Engl. J. Med. 282 (25): 1391–6. PMID 4910836.
  6. ↑ Giefer, Matthew J; Murray, Karen F; Colletti, Richard B (2011). "Pathophysiology, Diagnosis, and Management of Pediatric Ascites". Journal of Pediatric Gastroenterology and Nutrition. 52 (5): 503–513. doi:10.1097/MPG.0b013e318213f9f6. ISSN 0277-2116.

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