eMedicine Specialties > Gastroenterology > Systemic Disease

Ascites: Follow-up

Author: Rahil Shah, MD, Consulting Staff, Department of Gastroenterology, University Medical Center
Coauthor(s): Janice M Fields, MD, Consulting Staff, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital, William Beaumont Hospital, St. John Macomb-Oakland Hospital
Contributor Information and Disclosures

Updated: May 8, 2009

Follow-up

Further Inpatient Care

  • Patients can actually be maintained free of ascites if sodium intake is limited to 10 mmol/d. However, this is not practical outside a metabolic ward.
  • Twenty-four – hour urinary sodium measurements are useful in patients with ascites related to portal hypertension in order to assess the degree of sodium avidity, monitor the response to diuretics, and assess compliance with diet.
  • For grade 3 or 4 ascites, therapeutic paracentesis may be necessary intermittently.

Further Outpatient Care

  • The best method of assessing the effectiveness of diuretic therapy is by monitoring body weight and urinary sodium levels.
  • In general, the goal of diuretic treatment of ascites should be to achieve a weight loss of 300-500 g/d in patients without edema and 800-1000 g/d in patients with edema.
  • Once ascites has disappeared, diuretic treatment should be adjusted to maintain the patient free of ascites.

Inpatient & Outpatient Medications

  • Diuretics should be initiated in patients whose ascites does not respond to sodium restriction. A useful regimen is to start with spironolactone at 100 mg/d. The addition of loop diuretics may be necessary in some cases to increase the natriuretic effect. If no response occurs after 4-5 days, the dosage may be increased stepwise up to spironolactone at 400 mg/d plus furosemide at 160 mg/d.

Complications

  • The most common complication of ascites is the development of spontaneous bacterial peritonitis (ascitic fluid with PMN count of >250 μ L).
    • Performing repeated physical examinations and paying particular attention to abdominal tenderness may be the best way to become aware of the possible development of this complication. In a study of 133 hospitalized patients with ascites, abdominal pain and abdominal tenderness were more common in patients with spontaneous bacterial peritonitis (P <0.01), but no other physical sign or laboratory test could separate spontaneous bacterial peritonitis cases from other cases.12
    • Any patient with ascites and fever should have a paracentesis with bedside blood culture inoculation and cell count. Patients with a protein level of less than 1 g/dL in ascitic fluid are at high risk for the development of spontaneous bacterial peritonitis. Prophylactic antibiotic therapy with a quinolone is often recommended.
  • Complications of paracentesis include infection, electrolyte imbalances, bleeding, and bowel perforation. Bowel perforation should be considered in any patient with recent paracentesis who develops a new onset of fever and/or abdominal pain. All patients with long-standing ascites are at risk of developing umbilical hernias. Large-volume paracentesis often results in large intravascular fluid shifts. This can be avoided by administering albumin replacement if more than 5 L is removed.

Prognosis

  • The prognosis for patients with ascites due to liver disease depends on the underlying disorder, the degree of reversibility of a given disease process, and the response to treatment.

Patient Education

  • The most important aspect of patient education is determining when therapy is failing and recognizing the need to see a physician. Unfortunately, in most cases, liver failure has a dismal prognosis. All patients must be taught which complications are potentially fatal and the signs and symptoms that precede them.
  • Abdominal distention and/or pain despite maximal diuretic therapy are common problems, and patients must realize the importance of seeing a physician immediately.

Miscellaneous

Medicolegal Pitfalls

  • The most important consideration in a patient with a new onset of ascites is to perform a peritoneal tap and to ascertain the cause. A peritoneal tap is also indicated in a patient with known liver disease who presents with sudden clinical deterioration, worsening encephalopathy, or unexplained fever. A missed or delayed diagnosis of spontaneous bacterial peritonitis could potentially lead to sepsis and significant morbidity and mortality.
 


More on Ascites

Overview: Ascites
Differential Diagnoses & Workup: Ascites
Treatment & Medication: Ascites
Follow-up: Ascites
Multimedia: Ascites
References
Further Reading
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References

  1. [Best Evidence] Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results?. JAMA. Mar 12 2008;299(10):1166-78. [Medline].

  2. Han CM, Lee CL, Huang KG, et al. Diagnostic laparoscopy in ascites of unknown origin: Chang Gung Memorial Hospital 20-year experience. Chang Gung Med J. Jul-Aug 2008;31(4):378-83. [Medline]. [Full Text].

  3. American Association for the Study of Liver Diseases. Management of adult patients with ascites due to cirrhosis. National Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=5259&nbr=003590&string=ascites.. Accessed March 20, 2009.

  4. Gines P, Cardenas A. The management of ascites and hyponatremia in cirrhosis. Semin Liver Dis. Feb 2008;28(1):43-58. [Medline].

  5. Ginès P, Wong F, Watson H, et al, for the HypoCAT Study Investigators. Effects of satavaptan, a selective vasopressin V(2) receptor antagonist, on ascites and serum sodium in cirrhosis with hyponatremia: a randomized trial. Hepatology. Jul 2008;48(1):204-13. [Medline].

  6. Sola-Vera J, Minana J, Ricart E, et al. Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites. Hepatology. May 2003;37(5):1147-53. [Medline]. [Full Text].

  7. Lata J, Marecek Z, Fejfar T, Zdenek P, et al. The efficacy of terlipressin in comparison with albumin in the prevention of circulatory changes after the paracentesis of tense ascites--a randomized multicentric study. Hepatogastroenterology. Oct-Nov 2007;54(79):1930-3. [Medline].

  8. Singh V, Kumar R, Nain CK, Singh B, Sharma AK. Terlipressin versus albumin in paracentesis-induced circulatory dysfunction in cirrhosis: a randomized study. J Gastroenterol Hepatol. Jan 2006;21(1 pt 2):303-7. [Medline].

  9. Mercadante S, Intravaia G, Ferrera P, Villari P, David F. Peritoneal catheter for continuous drainage of ascites in advanced cancer patients. Support Care Cancer. Aug 2008;16(8):975-8. [Medline].

  10. Courtney A, Nemcek AA Jr, Rosenberg S, et al. Prospective evaluation of the PleurX catheter when used to treat recurrent ascites associated with malignancy. J Vasc Interv Radiol. Dec 2008;19(12):1723-31. [Medline].

  11. Seike M, Maetani I, Sakai Y. Treatment of malignant ascites in patients with advanced cancer: peritoneovenous shunt versus paracentesis. J Gastroenterol Hepatol. Dec 2007;22(12):2161-6. [Medline].

  12. Wallerstedt S, Olsson R, Simren M, et al. Abdominal tenderness in ascites patients indicates spontaneous bacterial peritonitis. Eur J Intern Med. Jan 2007;18(1):44-7. [Medline].

  13. Albornoz L, Motta A, Alvarez D, et al. Nitric oxide synthase activity in the splanchnic vasculature of patients with cirrhosis: relationship with hemodynamic disturbances. J Hepatol. Oct 2001;35(4):452-6. [Medline].

  14. Amadon MN, Arroyo V. Ascites and spontaneous bacterial peritonitis. In: Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff's Diseases of the Liver. 8th ed. Philadelphia, Pa: Lippincott Raven; 1999:503-44.

  15. Cardenas A, Bataller R, Arroyo V. Mechanisms of ascites formation. Clin Liver Dis. May 2000;4(2):447-65. [Medline].

  16. [Best Evidence] D'Amico G, Luca A, Morabito A, Miraglia R, D'Amico M. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology. Oct 2005;129(4):1282-93. [Medline].

  17. Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology. Feb 2001;120(3):726-48. [Medline].

  18. Jeffery J, Murphy MJ. Ascitic fluid analysis: the role of biochemistry and haematology. Hosp Med. May 2001;62(5):282-6. [Medline].

  19. Oguntona SA, Alebiosu CO. Current concepts in the management of refractory cirrhotic ascites. Niger J Med. Jul-Sep 2006;15(3):197-202. [Medline].

  20. Pauly RP, Sood MM, Chan CT. Management of refractory ascites using nocturnal home hemodialysis. Semin Dial. Jul-Aug 2008;21(4):367-70. [Medline].

  21. Reynolds TB. Ascites. Clin Liver Dis. Feb 2000;4(1):151-68, vii. [Medline].

  22. Runyon B. Approach to the patient with ascites. In: Yamada T, Alpers DH, Laine L, Owyang C, Powell DW, eds. Textbook of Gastroenterology. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:966-91.

  23. Wong F, Blendis L. Hepatorenal failure. Clin Liver Dis. Feb 2000;4(1):169-89. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials

National Guideline Clearinghouse

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Keywords

ascites, fluid collection, fluid accumulation, fluid retention, distended abdomen, portal hypertension, hypoalbuminemia, hepatic congestion, congestive heart failure, constrictive pericarditis, tricuspid insufficiency, Budd-Chiari syndrome, liver disease, cirrhosis, alcoholic hepatitis, fulminant hepatic failure, massive hepatic metastases,

nephrotic syndrome, protein-losing enteropathy, severe malnutrition, anasarca, chylous ascites, pancreatic ascites, bile ascites, nephrogenic ascites, urine ascites, ovarian disease, bacterial peritonitis, tuberculous peritonitis, fungal peritonitis, HIV-associated peritonitis, malignancy, peritoneal carcinomatosis, primary mesothelioma, pseudomyxoma peritonei, hepatocellular carcinoma, HCC,

familial Mediterranean fever, vasculitis, granulomatous peritonitis, eosinophilic peritonitis, alcohol use, chronic viral hepatitis, jaundice, intravenous drug use, blood transfusions, alcoholic liver disease, obesity, hypercholesterolemia, type 2 diabetes mellitus, nonalcoholic steatohepatitis, gastrointestinal cancer, malignant ascites, cirrhotic ascites, nephrotic ascites, palmar erythema, spider angiomas, puddle sign, Sister Mary Joseph nodule, gastric malignancy, pancreatic malignancy, hepatic primary malignancy, left-sided supraclavicular node, Virchow node

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Contributor Information and Disclosures

Author

Rahil Shah, MD, Consulting Staff, Department of Gastroenterology, University Medical Center
Rahil Shah, MD is a member of the following medical societies: American College of Gastroenterology and American Society for Gastrointestinal Endoscopy
Disclosure: Takeda Consulting fee Speaking and teaching; Santarus Consulting fee Speaking and teaching

Coauthor(s)

Janice M Fields, MD, Consulting Staff, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital, William Beaumont Hospital, St. John Macomb-Oakland Hospital
Janice M Fields, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and National Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert J Fingerote, MD, MSc, BSc, FRCPC, Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Richmond Hill, Ontario
Robert J Fingerote, MD, MSc, BSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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