Current Treatment Options in Gastroenterology

, Volume 9, Issue 6, pp 530–537 | Cite as

Treatment of refractory ascites

  • Praveena G. Velamati
  • H. Franklin Herlong

Opinion statement

In 1996, the International Ascites Club defined “refractory ascites” as ascites that cannot be mobilized by medical therapy or that recurs early after initial mobilization despite continued treatment. Of all patients with ascites, 5% to 10% will become refractory to medical therapy. Management of refractory ascites should attempt to control fluid accumulation, reduce the likelihood of developing complications such as spontaneous bacterial peritonitis (SBP) and the hepatorenal syndrome, and improve the patient’s nutritional status and overall well-being. Measures to control ascites accumulation include documenting medication and dietary compliance and eliminating potentially nephrotoxic agents that promote sodium retention. Large volume paracentesis is an effective first step in managing these patients and can be performed routinely in an outpatient setting. When more than 5 L of fluid are removed during a paracentesis, intravenous albumin should be infused to reduce the likelihood of the patient developing postparacentesis circulatory dysfunction. Transjugular intrahepatic portosystemic shunt (TIPS) placement effectively eliminates ascites; however, there is no convincing evidence that the shunt improves mortality. Furthermore, it is associated with frequent complications of encephalopathy and shunt malfunction. We feel TIPS should be reserved for patients requiring extremely frequent paracentesis, those who develop significant postparacentesis circulatory dysfunction, or those with hepatic hydrothorax. Patients who have evidence of SBP should be treated with antibiotics and intravenous albumin infusion. Patients who have had a previous episode of SBP or an ascitic fluid protein level of less than 1.0 should receive prophylactic antibiotics. Overall, the prognosis for patients with refractory ascites remains grim, and liver transplantation is the only definitive therapy. Appropriate candidates should be identified promptly and referred for transplant evaluation.


Ascitic Fluid Spontaneous Bacterial Peritonitis Refractory Ascites Contraindication Hypersensitivity Hepatic Hydrothorax 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Moreau R, Delegue P, Pessione F, et al.: Clinical characteristics and outcome of patients with cirrhosis and refractory ascites. Liver Int 2004, 24:457–464.PubMedCrossRefGoogle Scholar
  2. 2.
    Runyon BA: Management of adult patients with ascites due to cirrhosis. Hepatology 2004, 39:841–856. A complete American Association for the Study of Liver Diseases practice guideline published in 2004 for management of ascites due to portal hypertension that includes a section on treatment of refractory ascites.PubMedCrossRefGoogle Scholar
  3. 3.
    Moore K, Wong F, Gines P: The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 2003, 38:258–266. This article summarizes recommendations from the Consensus Conference of the International Ascites Club on the management of ascites.PubMedCrossRefGoogle Scholar
  4. 4.
    Arroyo V, Gines P, Gerbes AL, et al.: Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996, 23:164–176.PubMedCrossRefGoogle Scholar
  5. 5.
    Cardenas A, Kelleher T, Chopra S: Review article: hepatic hydrothorax. Aliment Pharmacol Ther 2004, 20:271–279.PubMedCrossRefGoogle Scholar
  6. 6.
    Liu LU, Haddadin HA, Bodian CA, et al.: Outcome analysis of cirrhotic patients undergoing chest tube placement. Chest 2004, 126:142–148.PubMedCrossRefGoogle Scholar
  7. 7.
    Cardenas A, Gines P: Management of refractory ascites. Clin Gastroenterol Hepatol 2005, 3:1187–1191.PubMedCrossRefGoogle Scholar
  8. 8.
    Albillos A, Banares R, Gonzalez M, et al.: A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. J Hepatol 2005, 43:990–996. A meta-analysis of the five randomized trials published between 1989 and 2005 comparing TIPS and paracentesis in the management of refractory ascites.PubMedCrossRefGoogle Scholar
  9. 9.
    Deltenre P, Mathurin P, Dharancy S, et al.: Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis. Liver Int 2005, 25:349–356.PubMedCrossRefGoogle Scholar
  10. 10.
    Sanyal AJ, Genning C, Reddy KR, et al.: The North American Study for the Treatment of Refractory Ascites. Gastroenterology 2003, 124:634–641.PubMedCrossRefGoogle Scholar
  11. 11.
    Allard J, Chau J, Sandokji K: Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites. Am J Gastroenterol 2001, 96:2442–2447.PubMedCrossRefGoogle Scholar
  12. 12.
    Campbell MS, Brensinger CM, Sanyal AJ: Quality of life in refractory ascites: transjugular intrahepatic portalsystemic shunting versus medical therapy. Hepatology 2005, 42:635–640.PubMedCrossRefGoogle Scholar
  13. 13.
    Gines P, Uriz J, Calahorra B, et al.: Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002, 123:1839–1847.PubMedCrossRefGoogle Scholar
  14. 14.
    Sakai H, Sheer TA, Mendler MH, et al.: Choosing the location for non-image guided abdominal paracentesis. Liver Int 2005, 25:984–986.PubMedCrossRefGoogle Scholar
  15. 15.
    Evans LT, Kim WR, Poterucha JJ, et al.: Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology 2003, 37:897–901.PubMedCrossRefGoogle Scholar
  16. 16.
    Dudley F: Management of refractory ascites. J Gastroenterol Hepatol 2004, 19(Suppl):S194-S199.CrossRefGoogle Scholar
  17. 17.
    Cardenas A, Arroyo V: Refractory ascites. Dig Dis 2005, 23:30–38.PubMedCrossRefGoogle Scholar
  18. 18.
    Boyer TD, Haskal ZJ: The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005, 41:386–400.PubMedCrossRefGoogle Scholar
  19. 19.
    Montgomery A, Ferral H, Vasan R, Postoak DW: MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol 2005, 28:307–312.PubMedCrossRefGoogle Scholar
  20. 20.
    Russo MW, Sood A, Jacobson IM, et al.: Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality. Am J Gastroenterol 2003, 98:2521–2527.PubMedCrossRefGoogle Scholar
  21. 21.
    Bureau C, Garcia-Pagan JC, Otal P, et al.: Improved clinical outcome using polyetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004, 126:469–475.PubMedCrossRefGoogle Scholar
  22. 22.
    D’Amico G, Luca A, Morabito A: Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology 2005, 129:1282–1293.PubMedCrossRefGoogle Scholar
  23. 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.PubMedCrossRefGoogle Scholar
  24. 24.
    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 2003, 37:1147–1153.PubMedCrossRefGoogle Scholar
  25. 25.
    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.PubMedCrossRefGoogle Scholar
  26. 26.
    Orsi F, Grasso RF, Bonomo G, et al.: Percutaneous peritoneovenous shunt positioning: technique and preliminary results. Eur Radiol 2002, 12:1188–1192.PubMedCrossRefGoogle Scholar
  27. 27.
    Rosenblum DI, Geisinger MA, Newman JS, et al.: Use of subcutaneous venous access ports to treat refractory ascites. J Vasc Interv Radiol 2001, 12:1343–1346.PubMedCrossRefGoogle Scholar
  28. 28.
    Gerbes AL, Gulberg V, Gines P, et al.: Therapy of hyponatremia in cirrhosis with a vasopressin receptor antagonist: a randomized double-blind multicenter trial. Gastroenterology 2003, 124:933–939.PubMedCrossRefGoogle Scholar
  29. 29.
    Wong F, Blei AT, Blendis LM, et al.: A vasopressin receptor antagonist (VPA-985) improves serum sodium concentration in patients with hyponatremia: a multi-center, randomized, placebo-controlled trial. Hepatology 2003, 37:182–191.PubMedCrossRefGoogle Scholar
  30. 30.
    Gerbes AL, Gulberg V: Progress in treatment of massive ascites and hepatorenal syndrome. World J Gastroenterol 2006, 12:516–519.PubMedGoogle Scholar
  31. 31.
    Guardiola J, Baliellas C, Xiol X, et al.: External validation of a prognostic model for predicting survival of cirrhotic patients with refractory ascites. Am J Gastroenterol 2002, 97:2374–2378.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  • Praveena G. Velamati
  • H. Franklin Herlong
    • 1
  1. 1.Division of Digestive DiseasesJohns Hopkins Bayview Medical CenterBaltimoreUSA

Personalised recommendations