Table of contents
Ascites
What's new
Updated 2021 AASLD and 2021 BSG/BASL guidelines for the evaluation and management of ascites.
Background
Overview
Definition
Ascites is a pathologic accumulation of fluid within the peritoneal cavity that usually develops as a result of liver disease, congestive HF, or nephrotic syndrome.
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Pathophysiology
Ascites is most frequently caused by portal hypertension occurring in the setting of cirrhosis. Other causes are broadly divided into pre-hepatic (portal vein thrombosis, lymphoma, abdominal lymphatic injury or obstruction, bowel perforation, renal failure, pancreatitis, peritoneal tuberculosis or malignancy with peritoneal implants) and post-hepatic (congestive HF, constrictive pericarditis, Budd-Chiari syndrome, and stricture/web formation in the IVC) causes.
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Disease course
Ascites causes clinical manifestations of abdominal distention, abdominal fullness, discomfort, shortness of breath, early satiation, and a sense of reduced mobility.
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Prognosis and risk of recurrence
Ascites is associated with a 1-year mortality of 40%. Refractory ascites has a median survival rate of 6 months.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of ascites are prepared by our editorial team based on guidelines from the International Collaboration for Transfusion Medicine Guidelines (ICTMG 2024), the American Gastroenterological Association (AGA 2023), the American Association for the Study of Liver Diseases (AASLD 2021,2014), the British Association for the Study of the Liver (BASL/BSG 2021), and the...
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Diagnostic investigations
Initial evaluation
As per EASL 2018 guidelines:
Obtain the following as part of the initial evaluation of patients with ascites:
history and physical examination
abdominal ultrasound
laboratory assessment of liver and renal functions, serum and urine electrolytes
ascitic fluid analysis
⁄
Use contrast media cautiously and implement appropriate preventive measures for renal impairment,
B
although the use of contrast media does not appear to be associated with an increased risk of renal impairment in patients with ascites and preserved renal function. B
Diagnostic procedures
Medical management
General principles
As per EASL 2018 guidelines:
Control and treat gastrointestinal hemorrhage, renal impairment, hepatic encephalopathy, hyponatremia, or alterations in serum potassium concentration before initiating diuretic therapy. Be cautious when initiating diuretic therapy and obtain frequent clinical and biochemical assessments.
B
Identify and treat etiological factors in patients with decompensated cirrhosis, particularly alcohol consumption and hepatitis B or C virus infection.
B
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Diuretic therapy
Intravenous albumin
Other agents
Medications to avoid
Management of hyponatremia
Nonpharmacologic interventions
Salt restriction: as per AASLD 2021 guidelines, Advise moderate sodium restriction (2 g or 90 mmol per day) in patients with cirrhosis and grade 2 ascites.
E
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Fluid restriction
Physical activity
Therapeutic procedures
Therapeutic paracentesis: as per AASLD 2021 guidelines, Perform large-volume paracentesis as first-line therapy in patients with grade 3 ascites. Advise sodium restriction and initiate diuretics after paracentesis.
E
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TIPS
Implantable peritoneal pump
Surgical interventions
Liver transplantation: as per AASLD 2021 guidelines, Consider referring patients with grade 2 or 3 ascites for evaluation for liver transplantation.
E
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Elective hernia repair
Specific circumstances
Pediatric patients: as per AASLD 2021 guidelines, Obtain a comprehensive evaluation of clinical history, physical examination, and diagnostic testing including abdominal ultrasound for the diagnosis of ascites and its cause in pediatric patients.
E
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Patients with bacterascites
Patients with hepatic hydrothorax
Follow-up and surveillance
Serial clinical and laboratory assessment: as per AASLD 2021 guidelines, Monitor body weight and serum creatinine and sodium regularly to assess response and to detect the development of adverse effects in patients receiving diuretics.
E
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Post-TIPS care
Management of inadequate response
Management of refractory ascites