Ascites in adults with cirrhosis: Initial therapy
- José Such, MD, PhD
José Such, MD, PhD
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, UAE
- Clinical Professor, Lerner School of Medicine. Case Western Reserve University, OH, US
- Bruce A Runyon, MD
Bruce A Runyon, MD
- Section Editor — Cirrhosis and Its Complications
- Clinical Professor of Medicine
- University of New Mexico, Division of Gastroenterology and Hepatology
- Special Hepatology Consultant to the Indian Health Service
- Northern Navajo Medical Center, Shiprock, New Mexico
Cirrhosis is the most common cause of ascites in the United States, accounting for approximately 85 percent of cases . In addition, ascites is the most common complication of cirrhosis. Within 10 years after the diagnosis of compensated cirrhosis, approximately 58 percent of patients will have developed ascites . (See "Pathogenesis of ascites in patients with cirrhosis".)
Successful treatment of the patient with ascites depends upon an accurate diagnosis regarding the cause of ascites formation [3,4]. A careful history, physical examination, and abdominal paracentesis with appropriate ascitic fluid analysis can usually determine the cause of ascites formation [1,3]. Patients who have a cause for ascites formation other than cirrhosis may not respond to the treatments used in those with cirrhosis. This is particularly true for ascites due to peritoneal carcinomatosis, in which sodium restriction and diuretics cause intravascular volume depletion without mobilization of the ascitic fluid . (See "Evaluation of adults with ascites" and 'Diuretic therapy' below and "Malignancy-related ascites".)
This topic will review the initial therapy of ascites in patients with cirrhosis. The diagnosis and evaluation of patients with ascites, the treatment of refractory ascites, and the management of spontaneous bacterial peritonitis are discussed elsewhere. (See "Evaluation of adults with ascites" and "Ascites in adults with cirrhosis: Diuretic-resistant ascites" and "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis".)
The management of ascites in adults with cirrhosis is also discussed in a 2013 guideline from the American Association for the Study of Liver Diseases (table 1) [6,7]. The discussion that follows is consistent with that guideline.
GOALS OF THERAPY
The goals of therapy in patients with ascites are to minimize ascitic fluid volume and decrease peripheral edema, without causing intravascular volume depletion. Although there is no evidence that treatment of fluid overload in patients with cirrhosis improves survival, the following benefits have been noted:
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- GOALS OF THERAPY
- THRESHOLD FOR INITIATING TREATMENT
- THERAPEUTIC APPROACH
- Management of underlying liver disease
- - Alcohol abstinence
- - Management of other liver diseases
- Medications to avoid or use with caution
- - Avoidance of angiotensin inhibition
- - Propranolol
- - Avoidance of NSAIDs
- Dietary sodium restriction
- Fluid restriction
- Diuretic therapy
- - Diuretic regimen
- - Rate of fluid removal
- - Patient monitoring
- - Diuretic resistance
- Large-volume paracentesis
- Liver transplantation and shunts
- MANAGEMENT OF COMPLICATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS