Refractory ascites

In patients with refractory ascites it is not possible to effectively mobilise the fluid or prevent ascites from reaccumulating, despite salt restriction and diuretic therapy—this occurs because diuretics are either ineffective or not tolerated.

Refractory ascites requires specialised care; treatment options may include:

• repeated large-volume paracentesis
• reduction of portal pressure by percutaneous insertion of a shunt between the hepatic and portal veins (transjugular intrahepatic portosystemic shunt [TIPS])
• liver transplantation.

Large-volume paracentesis (eg draining 5 to 10 L of ascitic fluid over 1 to 6 hours) can improve symptoms in patients with tense or refractory ascites. In many centres, large-volume paracentesis can be performed as a day procedure and may not require overnight hospitalisation. Adjustment of diuretic therapy and close monitoring of electrolytes and kidney function is required. A sample of ascitic fluid should be examined to exclude spontaneous bacterial peritonitis.

Albumin is recommended for patients undergoing large-volume paracentesis to reduce complications related to fluid shifts and improve survival. During, or immediately after, paracentesis, use:

Correction of an elevated international normalised ratio (INR) or thrombocytopenia is generally not required before paracentesis in patients who are clinically stable (eg without disseminated intravascular coagulation [DIC], sepsis or kidney impairment), because risk of bleeding is low. The degree of coagulopathy and risk of bleeding are poorly correlated in patients with cirrhosis (see Coagulopathy in patients with cirrhosis).

In patients with refractory ascites, beta blockers should be stopped if systolic blood pressure is less than 90 mmHg, serum sodium concentration is less than 130 mmol/L, or the patient has acute kidney injury.

Liver transplant referral should be considered in eligible patients who require repeated paracentesis. In carefully selected patients with refractory ascites, TIPS insertion reduces mortality and may delay or avoid the need for liver transplantation. Patients who have had TIPS insertion require ongoing specialist follow-up and 6-monthly Doppler ultrasonography to monitor for stent thrombosis.

In patients with ascites who require repeated paracentesis and who are not eligible for liver transplantation or TIPS, establish whether an advance care plan is in place, and consider referral for palliative care.