Cirrhotic Ascites

Aka: Cirrhotic Ascites, Hepatic Ascites

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II. Epidemiology

  1. Most common complication of Cirrhosis
    1. Presents in 60% of patients within 10 years of Cirrhosis diagnosis

III. Pathophysiology

  1. Portal Hypertension
    1. Results in increased splanchnic Blood Volume with increased nitric oxide production
    2. Secondary splanchnic and arterial vasodilation
  2. Kidneys sense decreased perfusion
    1. Activates Renin-Angiotensin System
    2. Results in increased Sodium and water retention
  3. Hypoalbuminemia and decreased oncotic pressure
    1. Increased splanchnic pressure overcomes oncotic pressure
    2. Transudate leaks into peritoneum

IV. Evaluation

  1. See Paracentesis
  2. Diagnostic Paracentesis Indications
    1. Exclude Spontaneous Bacterial Peritonitis (keep a low threshold for evaluation)
    2. Exclude extrahepatic causes of Ascites (see Ascites)
    3. Unexplained Ascites
    4. New onset Ascites
    5. Hospitalized patients
    6. Clinical deterioration
  3. Ascites characteristics
    1. Portal Hypertension (Cirrhosis)
      1. Serum Albumin - Ascites Albumin exceeds 1.1 mg/dl
    2. Ascites not due to Portal Hypertension
      1. Albumin gradient (see above) <1.1 mg/dl
      2. Consider other Ascites Causes
        1. Peritoneal carcinomatosis
        2. Abdominal Tuberculosis
    3. Spontaneous Bacterial Peritonitis
      1. Ascitic Fluid Culture (at least 20 ml fluid)
        1. Split between 2 culture bottles (10 ml each), one aerobic and one anaerobic
        2. False Negative in 60% of cases
      2. Ascitic Fluid cell count and differential
        1. Total White Blood Cells (WBC ,Leukocytes) > 500/mm3
        2. Neutrophils (PMNs) > 250/mm3
        3. Test Sensitivity and Test Specificity: 93-94%

V. Differential Diagnosis

  1. See Ascites Causes

VI. Management: Medical Management

  1. See Spontaneous Bacterial Peritonitis
  2. Sodium restriction
    1. Maximum salt intake: 2 grams per day
    2. Salt Restriction controls Ascites in 10-20% patients
  3. Diuretics
    1. Spironolactone (Aldactone)
      1. Start 25-50 mg three times daily to four times daily (max 100 mg/day in divided dosing)
      2. Increase as needed by 100 mg every 3 days (max 400 mg/day in divided dosing)
      3. Effective in 40-75% of cases
    2. Furosemide (Lasix)
      1. Start 40 mg orally daily
      2. Increase as needed up to 160 mg/day in divided dosing (e.g. twice daily)
    3. Goal
      1. Urine Sodium exceeds Urine Potassium
      2. Do not allow Serum Creatinine to rise over 3.0
    4. Contraindications (reasons to avoid, decrease or eliminate Diuretics
      1. Hyponatremia <125 meq/L
      2. Hypokalemia
      3. Hyperkalemia
      4. Acute Kidney Injury
      5. Severe Muscle cramps
  4. Fluid Restriction
    1. Indicated for Serum Sodium <125 meq/L
    2. Limit to 1 to 1.5 L/day maximum if indicated
  5. Avoid provocative agents
    1. Avoid NSAIDs (increase renal Sodium retention)
    2. Avoid Beta Blockers, ACE Inhibitors and Angiotensin Receptor Blockers
      1. Associated with increased Hypovolemia and Hypotension risk
  6. Prophylactic Antibiotics (for prevention of Spontaneous Bacterial Peritonitis)
    1. Indications
      1. Liver failure (Child-Pugh Score >=9 and Serum Bilirubin >= 3 mg/dl)
      2. Renal dysfunction (Serum Creatinine >=1.2 mg/dl) or Hyponatremia (Serum Sodium <130 mEq/L)
      3. Ascitic fluid Protein <15 g/L
    2. Protocol
      1. Ciprofloxacin 400 mg orally daily

VII. Management: Interventions

  1. Therapeutic Paracentesis Indications
    1. Required in up to 10% of cases
    2. Up to 4-6 liters may be safely removed per Paracentesis without albumin replacement
      1. Risk of Paracentesis-induced circulatory dysfunction (PICD) with large volume Paracentesis
      2. Replace albumin if >6 Liters are removed
        1. Give 6 to 8 g/L of Ascites removed
    3. Indications
      1. Significant patient discomfort (tense Ascites)
      2. Respiratory compromise
      3. Large Umbilical Hernia
      4. Recurrent Bacterial peritonitis
  2. Refractory Ascites
    1. Mortality approaches 20% in 6 months
      1. Consider Palliative Care referral if not a Liver Transplant candidate
    2. Temporizing measures
      1. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
      2. Peritoneovenous Shunt
    3. Liver Transplantation
      1. See Cirrhosis
      2. Consider for all cirrhotic patients with Ascites

VIII. Prognosis

  1. Associated with increased mortality risk
  2. Poor prognostic sign for Cirrhosis course

IX. Complications

  1. Spontaneous Bacterial Peritonitis
  2. Umbilical Hernia with risk of rupture

X. References

  1. Swencki (2015) Crit Dec Emerg Med 29(11):2-10
  2. Garcia (2001) Postgrad Med 109(2):91-103 [PubMed]
  3. Keating (2022) Am Fam Physician 105(4): 412-20 [PubMed]
  4. Zervos (2001) Am J Surg 181(3):256-64 [PubMed]

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