Ascites

Ascites is a major complication of cirrhosis,1occurring in 50% of patients over 10 years of follow up. 

The development of ascites is an important landmark in the natural history of cirrhosis as it is associated with a 50% mortality over two years, and signifies the need to consider liver transplantation as a therapeutic option. 

The majority (75%) of patients who present with ascites have underlying cirrhosis,

with the remainder being due to :

malignancy(10%), 

heart failure (3%), 

tuberculosis (2%),

pancreatitis (1%), 

Grades of ascites:

-Grade 1 (mild). Ascites is only detectable by ultrasound examination.

-Grade 2 (moderate). Ascites causing moderate symmetrical distension of the abdomen.

-Grade 3 (large). Ascites causing marked abdominal distension.

Types of ascites:

1-Uncomplicated ascites:

Not infected and respond well to duretics treatment.

2-Refractory ascites

Ascites that cannot be mobilised or early recurrence. 

-Diuretic resistant ascites—ascites that is refractory to dietary sodium restriction and intensive diuretic treatment (spironolactone 400 mg/day and frusemide 160 mg/day for at least one week, and a salt restricted diet of less than 90 mmol/day (5.2 g of salt)/day).

-Diuretic intractable ascites—ascites that is refractory to therapy due to the development of diuretic induced complications that preclude the use of an effective diuretic dosage.

The initial ascitic fluid analysis should include serum ascites-albumin gradient in preference to ascitic protein.

Serum to Ascites Albumin Gradient (97% accurate of portal hypertention)

SAAG > 1.1 g/dL:Portal HT

SAAG < 1.1 g/dL:Other causes

Ascitic amylase should be measured when there is clinical suspicion of pancreatic disease.

Ascitic fluid should be inoculated into blood culture bottles at the bedside and examined by microscopy for a neutrophil count.

Management:

Bed rest is not recommended for the treatment of ascites.

Dietary salt should be restricted to a no added salt diet of 90 mmol salt/day (5.2 g salt/day).

Firstline treatment of ascites should be spironolactone alone, increasing from 100 mg/day to a dose of 400 mg/day.

If this fails to resolve ascites, frusemide should be added in a dose of up to 160 mg/day but this should be done with careful biochemical and clinical monitoring.

Therapeutic paracentesis

Therapeutic paracentesis is the firstline treatment for patients with large or refractory ascites.

Paracentesis of 5 litre of uncomplicated ascites should be followed by plasma expansion with a synthetic plasma expander (150–200 ml of gelofusine or haemaccel), and does not require volume expansion with albumin.

Large volume paracentesis should be performed in a single session with volume expansion being given once paracentesis is complete, preferably using 8 g albumin/l of ascites removed (100 ml of 20% albumin/3 l ascites).

TIPS could be used for the treatment of refractory ascites requiring frequent therapeutic paracentesis or hepatic hydrothorax with appropriate assessment of risk benefit ratio.

Liver transplantation should be considered in patients with cirrhotic ascites.

All patients with SBP should be considered for referral for liver transplantation.