Pathological accumulation of fluid in the peritoneal cavity.

Clinical features

  • Ascites not infected and not associated with hepatorenal syndrome
Grade 1 Ascites
Only detectable by ultrasound
Grade 2 Ascites
Ascites causing moderate symmetrical
distension of the abdomen
Grade 3 Ascites
Ascites causing marked abdominal

Clinical diagnosis

  • Fluid thrill (fluid wave)
  • Shifting dullness


  • Abdominal ultrasound scan
  • Peritoneal tap (paracentesis)
  • Analysis of fluid


The main principles of management are: diet modification, daily monitoring, diuretics and drainage


  • Restrict dietary salt to a no-add or low salt diet
  • Avoid protein malnutrition (associated with higher mortality), so consume plant proteins
    liberally and animal proteins occasionally (titrate to symptoms and signs of hepatic
  • Restrict water if oedema and hyponatremia are present
  • Abstain from alcohol, NSAIDS, herbs

Daily monitoring

  • Daily weight, BP, pulse, stool for melaena, encephalopathy


  • Use spironolactone 50-100 mg/day in the morning, to reach goal of weight loss: 300–500 g/
    day. If needed, doses to be increased every 7 days up to maximum of 400 mg/day of spironolactone
  • Furosemide can be added at a starting dose of 20–40 mg/day and subsequently increased to 160
    mg/day if needed. Best used if pedal oedema is present; monitor for hypotension
  • For maintenance, it is best to titrate to the lowest diuretic dose. Most patients do well with
    spironolactone 50 mg/day if they have no ascites


  • Indicated for severe ascites (Grade 3). Paracentesis is always followed by spironolactone

How much should you tap?

  • Small volume (less than 5 L in 3–4 hours) or large volume (5–10 L) with infusion of a plasma
    expander (e.g. 8 g albumin per litre of ascites removed)
  • Monitor for hypotension or reduced urine output
  • Refer if patient has or develops complicated ascites