Ascites - Diagnosis and Management Summary

Paracentesis studies: cell count + differential, albumin, protein, culture

 • Serum-ascites-albumin-gradient (SAAG): > 1.1 g/dL suggests portal hypertensive source

 • SBP: PMN count (WBC x PMN%) > 250 cells

 • Secondary Peritonitis: 2+ of following: protein > 1g/dL, glucose < 50mg/dL, LDH > ULN

 • Protein: level < 1-1.5g/dL suggests higher SBP risk. If > 2.5 g/dL, consider cardiac ascites

1) Sodium restriction

     <2g (88mmol) Na per day

     Not recommended to restrict Na intake more than above as this may lead to reduced overall caloric intake

2) Diuretic therapy

     Initial: spironolactone +/- furosemide

     Ratio: 100:40 (maintains K+ balance)

     Titrate: q3-5 days at start

     Diuretic resistance: inadequate diuresis at max doses

     Diuretic intolerance: limited by side effects ( severe AKI or ↓Na+)

3) Large-volume paracentesis

     Consider in: Large, tense ascites, Diuretic-resistance/intolerance

     Administer albumin to ↓ PPCD:

      • If LVP > 5L: 25% albumin, 6-8g/L removed

      • If AKI/CKD: give regardless of amount removed

4) TIPS - Consider in carefully selected patients with diuretic resistance/intolerance

     Compared to LVP: ↑ Control of ascites, ↑Risk of encephalopathy, ? Impact on survival depends on appropriate patient selection

5) Other

 • Midodrine: can increase response in diuretic-resistant

 • Medications to avoid: NSAIDs, ACE inhibitors, Angiotensin receptor blocker (ARBs), ? Beta-blockers (in ascites w/ ↓ BP)



- Dr. Hersh Shroff @HershShroff



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