Approach to managing ascites
For management of malignant ascites in palliative care, see Ascites in palliative care.
The aim of treating ascites is to improve symptoms rather than to completely remove the fluid. A small volume of ascitic fluid detected on imaging is considered mild ascites and is generally not treated.
Symptomatic ascites (ie causing abdominal discomfort or distension) is considered moderate or severe and requires treatment. Management includes:
- sodium restriction
- adequate protein and energy intake
- diuretics
- large-volume paracentesis and intravenous albumin for severe or refractory ascites
- transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites
- liver transplantation for refractory ascites.
Sodium restriction is an important consideration in the management of ascites. Review the patient’s salt intake and advise them to follow a reduced-salt diet. Salt substitutes are not recommended. Avoid using drugs that cause sodium retention (eg nonsteroidal anti-inflammatory drugs [NSAIDs]) or contain relatively large amounts of sodium (eg antacids, effervescent preparations, intravenous penicillins). Fluid restriction is not indicated unless there is concomitant hyponatraemia.
It is common for patients with moderate or severe ascites to be significantly malnourished, which may not be recognised because of weight gain associated with fluid retention. Ascites contributes to malnutrition by physically limiting oral intake (ie early satiety) and increasing energy expenditure. It is essential to ensure an adequate intake of protein and energy (see High-protein high-energy diet). Oral nutrition support may be required and advice from an accredited practising dietitian is recommended.
Patients with moderate to severe ascites can be managed as outpatients, provided there are no complicating factors.
In any patient with ascites whose clinical condition deteriorates rapidly or unexpectedly, consider spontaneous bacterial peritonitis, hepatocellular carcinoma or portal vein thrombosis.