Skip to main content

Advertisement

SpringerLink
Log in

Ascites

  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion statement

  • Ascites is the most common presentation of decompensated cirrhosis, and its development heralds a poor prognosis, with a 50% 2-year survival rate. Effective first-line therapy for ascites includes sodium restriction (2 g/d), use of diuretics, and large-volume paracentesis (LVP). Ideally, a combination of a loop-acting diuretic (eg, furosemide) and a distal-acting diuretic (eg, spironolactone) is used. LVP has the advantage of producing immediate relief from ascites and its associated symptoms. When 5 L or more ascitic fluid is removed, albumin (6 to 8 g per liter of fluid removed) should be administered intravenously to minimize hemodynamic and renal dysfunction.

  • The development of refractory ascites is particularly ominous, and 50% of such patients die within 6 months of its development. Liver transplantation is the only effective therapy for patients with refractory ascites associated with cirrhosis; unfortunately, this therapy is not available for many of those with refractory ascites. Other therapies that are available include LVP, peritoneovenous shunts, and transjugular intrahepatic portasystemic shunts (TIPS). LVP alleviates ascites rapidly, but ascites recurs universally, requiring repeated hospitalizations and paracenteses and decreasing patient quality of life. Peritoneovenous shunts rarely are used due to their high complication rate and tendency to become occluded. Recently, the use of TIPS has been shown to be an effective therapy for patients with refractory ascites. It is most effective when liver function is relatively well preserved. On the other hand, TIPS may hasten death in those with advanced liver failure. TIPS has not been shown to have a clear-cut beneficial effect on survival in patients with refractory ascites.

  • Spontaneous bacterial peritonitis is the most common complication of ascites and is associated with a worsening hyperdynamic circulation and a mortality rate of approximately 20%. Following an episode of spontaneous bacterial peritonitis, the 1-year mortality rate approaches 70%. Patients at risk should be considered for prophylaxis with an orally administered quinolone (eg, norfloxacin). Alternatives include trimethoprim/sulfamethoxazole. Active spontaneous bacterial peritonitis should be treated with an intravenously administered third-generation cephalosporins (eg, cefotaxime) in most circumstances.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Runyon BA: Ascites. In Diseases of the Liver. Edited by Schiff L, Schiff ER. Philadelphia: Lippincott; 1993:990–1015.

    Google Scholar 

  2. Runyon BA: Care of patients with ascites. N Engl J Med 1994, 330:337–342.

    Article  PubMed  CAS  Google Scholar 

  3. Gines P, Quintero E, Arroyo V, et al.: Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987, 7:122–128. A landmark article on the natural history of cirrhosis.

    Article  PubMed  CAS  Google Scholar 

  4. D’Amico G, Morabito A, Pagliaro L, Marubini E: Survival and prognostic indicators in compensated and decompensated cirrhosis. Dig Dis Sci 1986, 31:468–475.

    Article  PubMed  CAS  Google Scholar 

  5. Chronic liver disease and cirrhosis. In The Burden of Gastrointestinal Diseases [monograph]. Bethesda, MD: American Gastroenterological Association; 2001:41–42.

  6. Schrier RW, Arroyo V, Bernardi M, et al.: Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988, 8:1151–1157. An important article that outlines the peripheral arterial vasodilation hypothesis for the first time. This is the basis for the current understanding of the pathogenesis of ascites.

    Article  PubMed  CAS  Google Scholar 

  7. Cardenas A, Bataller R, Arroyo V: Mechanisms of ascites formation. Clin Liver Dis 2000, 4:447–465.

    Article  PubMed  CAS  Google Scholar 

  8. Gines P, Schrier RW: The arterial vasodilation hypothesis of ascites formation in cirrhosis. In Ascites and Renal Dysfunction in Liver Disease. Edited by Arroyo V, et al. Malden, MA: Blackwell Science, Inc.; 1999:411–427.

    Google Scholar 

  9. Martin PY, Gines P, Schrier RW: Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med 1998, 339:533–541.

    Article  PubMed  CAS  Google Scholar 

  10. Bernardi M, Trevisani F, Gasbarrini A, Gasbarrini G: Hepatorenal disorders: role of the renin-angiotensinaldosterone system. Semin Liver Dis 1994, 14:23–34.

    PubMed  CAS  Google Scholar 

  11. Esler M, Dudley F, Jennings G, et al.: Increased sympathetic nervous activity and the effects of its inhibition with clonidine in alcoholic cirrhosis. Ann Intern Med 1992, 116:446–455.

    PubMed  CAS  Google Scholar 

  12. Claria J, Jimenez W, Arroyo V, et al.: Effect of V1-vasopressin receptor blockade on arterial pressure in conscious rats with cirrhosis and ascites. Gastroenterology 1991, 100:494–501.

    PubMed  CAS  Google Scholar 

  13. Reynolds TB, Geller HM, Kuzma OT, Redeker AG: Spontaneous decrease in portal pressure with clinical improvement in cirrhosis. N Engl J Med 1960, 263:734–739.

    Article  PubMed  CAS  Google Scholar 

  14. Runyon BA: Management of adult patients with ascites caused by cirrhosis. Hepatology 1998, 27:264–272. Clinical practice guidelines from the American Association for the Study of Liver Disease on the management of patients with ascites.

    Article  PubMed  CAS  Google Scholar 

  15. Fogel MR, Sawhney VK, Neal EA, et al.: Diuresis in the ascitic patient: a randomized controlled trial of three regimens. J Clin Gastroenterol 1981, 3(suppl 1):73–80.

    Article  PubMed  Google Scholar 

  16. Sungaila I, Bartle WR, Walker SE, et al.: Spironolactone pharmacokinetics and pharmacodynamics in patients with cirrhotic ascites. Gastroenterology 1992, 102:1680–1685.

    PubMed  CAS  Google Scholar 

  17. Gines P, Arrovo V, Rodes J: Pharmacotherapy of ascites associated with cirrhosis. Drugs 1992, 43:316–332.

    PubMed  CAS  Google Scholar 

  18. Mirouze D, Zipser RD, Reynolds TB: Effect of inhibitors of prostaglandin synthesis on induced diuresis in cirrhosis. Hepatology 1983, 3:50–55.

    Article  PubMed  CAS  Google Scholar 

  19. Angeli P, Dalla PM, De BeiE, et al.: Randomized clinical study of the efficacy of amiloride and potassium canrenoate in nonazotemic cirrhotic patients with ascites. Hepatology 1994, 19:72–79.

    PubMed  CAS  Google Scholar 

  20. Li CP, Lee FY, Hwang SJ, et al.: Treatment of mastalgia with tamoxifen in male patients with liver cirrhosis: a randomized crossover study. Am J Gastroenterol 2000, 95:1051–1055.

    Article  PubMed  CAS  Google Scholar 

  21. Stanley MM, Ochi S, Lee KK, et al.: Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites. N Engl J Med 1989, 321:1632–1638.

    Article  PubMed  CAS  Google Scholar 

  22. Gines P, Tito L, Arroyo V, et al.: Randomized comparative gnstudy of therapeutic paracentesis with and without intravenous albumin in cirrhosis.Gastroenterology1988,94:1493–1502.

    PubMed  CAS  Google Scholar 

  23. Gines A, Fernandez-Esparrach G, Monescillo A, et al.: Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology 1996, 111:1002–1010.

    Article  PubMed  CAS  Google Scholar 

  24. McVay PA, Toy PT: Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991, 31:164–171.

    Article  PubMed  CAS  Google Scholar 

  25. Rossle M, Ochs A, Gulberg V, et al.: A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000, 342:1701–1707.

    Article  PubMed  CAS  Google Scholar 

  26. Lebrec D, Giuily N, Hadengue A, et al.: Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. French Group of Clinicians and a Group of Biologists. J Hepatol 1996, 25:135–144.

    Article  PubMed  CAS  Google Scholar 

  27. Malinchoc M, Kamath PS, Gordon FD, et al.: A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000, 31:864–871.

    Article  PubMed  CAS  Google Scholar 

  28. Gines P, Arroyo V, Vargas V, et al.: Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991, 325:829–835.

    Article  PubMed  CAS  Google Scholar 

  29. Stanley MM, Reyes CV, Greenlee HB, et al.: Peritoneal fibrosis in cirrhotics treated with peritoneovenous shunting for ascites. An autopsy study with clinical correlations. Dig Dis Sci 1996, 41:571–577.

    Article  PubMed  CAS  Google Scholar 

  30. Such J, Runyon BA: Spontaneous bacterial peritonitis. Clin Infect Dis 1998, 27:669–674.

    PubMed  CAS  Google Scholar 

  31. Garcia NJr, Sanyal AJ: Minimizing ascites. Complication of cirrhosis signals clinical deterioration. Postgrad Med 2001, 109:91–103.

    PubMed  Google Scholar 

  32. Runyon BA: Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology 1990, 12(4 pt 1):710–715.

    Article  PubMed  CAS  Google Scholar 

  33. Runyon BA, Akriviadis EA, Sattler FR, Cohen J: Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis. Dig Dis Sci 1991, 36:1782–1786.

    Article  PubMed  CAS  Google Scholar 

  34. Navasa M, Follo A, Llovet JM, et al.: Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996, 111:1011–1017.

    Article  PubMed  CAS  Google Scholar 

  35. Ricart E, Soriano G, Novella MT, et al.: Amoxicillinclavulanic acid versus cefotaxime in the therapy of bacterial infections in cirrhotic patients. J Hepatol 2000, 32:596–602.

    Article  PubMed  CAS  Google Scholar 

  36. Fong TL, Akriviadis EA, Runyon BA, Reynolds TB: Polymorphonuclear cell count response and duration of antibiotic therapy in spontaneous bacterial peritonitis. Hepatology 1989, 9:423–426.

    Article  PubMed  CAS  Google Scholar 

  37. Runyon BA, McHutchison JG, Antillon MR, et al.: Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients. Gastroenterology 1991, 100:1737–1742.

    PubMed  CAS  Google Scholar 

  38. Follo A, Llovet JM, Navasa M, et al.: Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology 1994, 20:1495–1501.

    Article  PubMed  CAS  Google Scholar 

  39. Sort P, Navasa M, Arroyo V, et al.: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999, 341:403–409.

    Article  PubMed  CAS  Google Scholar 

  40. Bass NM: Intravenous albumin for spontaneous bacterial peritonitis in patients with cirrhosis. N Engl J Med 1999, 341:443–444.

    Article  PubMed  CAS  Google Scholar 

  41. Brand RE: Intravenous albumin in patients with cirrhosis and spontaneous bacterial peritonitis: is it worth the cost? Am J Gastroenterol 1999, 94:3404.

    Article  PubMed  CAS  Google Scholar 

  42. Rolachon A, Cordier L, Bacq Y, et al.: Ciprofloxacin and long-term prevention of spontaneous bacterial peritonitis: results of a prospective controlled trial. Hepatology 1995, 22(4 pt 1):1171–1174.

    PubMed  CAS  Google Scholar 

  43. Singh N, Gayowski T, Yu VL, Wagener MM: Trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial. Ann Intern Med 1995, 122:595–598.

    PubMed  CAS  Google Scholar 

  44. Gines P, Rimola A, Planas R, et al.: Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial. Hepatology 1990, 12(4 pt 1):716–724.

    Article  PubMed  CAS  Google Scholar 

  45. Bernard B, Grange JD, Khac EN, et al.: Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999, 29:1655–1661.

    Article  PubMed  CAS  Google Scholar 

  46. Llach J, Rimola A, Navasa M, et al.: Incidence and predictive factors of first episode of spontaneous bacterial peritonitis in cirrhosis with ascites: relevance of ascitic fluid protein concentration. Hepatology 1992, 16:724–727.

    Article  PubMed  CAS  Google Scholar 

  47. Garcia-Tsao G: Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology 2001, 120:726–748.

    Article  PubMed  CAS  Google Scholar 

  48. Grange JD, Roulot D, Pelletier G, et al.: Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial. J Hepatol 1998, 29:430–436.

    Article  PubMed  CAS  Google Scholar 

  49. Chang CS, Yang SS, Kao CH, et al.: Small intestinal bacterial overgrowth versus antimicrobial capacity in patients with spontaneous bacterial peritonitis. Scand J Gastroenterol 2001, 36:92–96.

    PubMed  CAS  Google Scholar 

  50. Morencos FC, las Heras CG, Martin RL, et al.: Small bowel bacterial overgrowth in patients with alcoholic cirrhosis. Dig Dis Sci 1995, 40:1252–1256.

    Article  PubMed  CAS  Google Scholar 

  51. Sandhu BJ, Jain R, Singh J, et al.: Combination of norfloxacin and cisapride in prevention of SBP in high risk patients: a new approach [abstract]. Gastroenterology 2001, 120(supp 1):A376.

    Google Scholar 

  52. Unbiased Prescription Drug Comparison Shopper [online database]. Accessed June 26, 2001. URL: pillbot.com.

  53. Gines P, Arroyo V: Is there still a need for albumin infusions to treat patients with liver disease? Gut 2000, 465:588–590.

    Article  Google Scholar 

  54. Milliner DS, Shinaberger JH, Shuman P, Coburn JW: Inadvertent aluminum administration during plasma exchange due to aluminum contamination of albumin-replacement solutions. N Engl J Med 1985, 312:165–167.

    Article  PubMed  CAS  Google Scholar 

  55. Ott SM, Maloney NA, Klein GL, et al.: Aluminum is associated with low bone formation in patients receiving chronic parenteral nutrition. Ann Intern Med 1983, 98:910–914.

    PubMed  CAS  Google Scholar 

  56. Wills MR, Savory J: Aluminium poisoning: dialysis encephalopathy, osteomalacia, and anaemia. Lancet 1983, 2:29–34.

    Article  PubMed  CAS  Google Scholar 

  57. Ring J, Seifert J, Lob G, et al.: Human serum albumin incompatibility: clinical and immunological investigations (author’s transl) [in German]. Klin Wochenschr 1974, 52:595–598.

    Article  PubMed  CAS  Google Scholar 

  58. Soriano G, Guarner C, Tomas A, et al.: Norfloxacin prevents bacterial infection in cirrhotics with gastrointestinal hemorrhage. Gastroenterology 1992, 103:1267–1272.

    PubMed  CAS  Google Scholar 

  59. Inadomi J, Sonnenberg A: Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis. Gastroenterology 1997, 113:1289–1294.

    Article  PubMed  CAS  Google Scholar 

  60. Tito L, Gines P, Arroyo V, et al.: Total paracentesis associated with intravenous albumin management of patients with cirrhosis and ascites. Gastroenterology 1990, 98:146–151.

    PubMed  CAS  Google Scholar 

  61. Lake JR: The role of transjugular shunting in patients with ascites. N Engl J Med 2000, 342:1745–1747.

    Article  PubMed  CAS  Google Scholar 

  62. Sanyal AJ, Freedman AM, Purdum PP, et al.: The hematologic consequences of transjugular intrahepatic portosystemic shunts. Hepatology 1996, 23:32–39.

    Article  PubMed  CAS  Google Scholar 

  63. Sanyal AJ, Reddy KR: Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology 1998, 115:110–115.

    Article  PubMed  CAS  Google Scholar 

  64. Campbell PJ, Greig PD, Blendis LM: The LeVeen shunt: mechanisms of action, indications and contraindications to its use. Dig Dis 1986, 4:178–192.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Virginia-Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980711, 23298-0711, Richmond, VA, USA

    Nelson Garcia Jr. MD & Arun J. Sanyal MBBS, MD

Authors
  1. Nelson Garcia Jr. MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Arun J. Sanyal MBBS, MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Garcia, N., Sanyal, A.J. Ascites. Curr Treat Options Gastro 4, 527–537 (2001). https://doi.org/10.1007/s11938-001-0018-2

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-001-0018-2

Keywords

Search

Navigation