Pathological accumulation of fluid in the peritoneal cavity.
Clinical features
- Ascites not infected and not associated with hepatorenal syndrome
| CLASSIFICATION | FEATURES |
|---|---|
| Grade 1 Ascites (mild) |
Only detectable by ultrasound examination |
| Grade 2 Ascites (moderate) |
Ascites causing moderate symmetrical distension of the abdomen |
| Grade 3 Ascites (severe) |
Ascites causing marked abdominal distension |
Clinical diagnosis
- Fluid thrill (fluid wave)
- Shifting dullness
Investigations
- Abdominal ultrasound scan
- Peritoneal tap (paracentesis)
- Analysis of fluid
Management
The main principles of management are: diet modification, daily monitoring, diuretics and drainage
Diet
- 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
encephalopathy) - Restrict water if oedema and hyponatremia are present
- Abstain from alcohol, NSAIDS, herbs
Daily monitoring
- Daily weight, BP, pulse, stool for melaena, encephalopathy
Diuretics
- 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
Drainage
- 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