Diagnosis, Evaluation, and Management of Ascites and Hepatorenal Syndrome

Patient Guideline Summary

Publication Date: May 2, 2021

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the American Association for the Study of Liver Diseases (AASLD) for diagnosis, evaluation, and management of ascites and hepatorenal syndrome. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Cirrhosis refers to scar tissue in an organ, commonly the liver.

Common causes of liver cirrhosis are long-standing alcohol intake, hepatitis and fatty liver disease.

Symptoms include ascites (fluid in the abdomen), decreased mental function and stomach bleeding.

The disease can lead to kidney failure, serious infections and death. Its mechanics are complex.

This patient summary focuses on management of the complications of liver cirrhosis.

Diagnosis

A complete evaluation of each patient is necessary – medical history, physical exam and laboratory testing.
Ascites is removed with a needle and tested for infection and chemical analysis.
- If infection is suspected, the fluid is cultured for bacteria.

Treatment

Ascites

A large amount of ascites can be removed through a needle.
Sodium restriction and diuretics are also used to reduce the amount of ascites.
- Albumin or baclofen may be used as well.
Fluid intake may be restricted.
Note: because blood flow through the scarred liver is restricted, back pressure forces ascitic fluid from veins into the abdomen. Consequently, re-routing blood flow around the liver helps relieve ascites. The recommended approach to this problem is a transjugular intrahepatic portosystemic shunt (TIPS), threading an instrument from the jugular vein in the neck into the liver and connecting a vein flowing into the liver with a vein flowing out of the liver.

General Management

The body may develop hyponatremia (too little sodium in the blood), requiring fluid adjustments and medications to restore balance.
Fluid may leak into the chest as well as the abdomen and need removal.
- Ascites (fluid leak into the abdomen) and hydrothorax (fluid leak into the chest) are prone to infection.
Changing fluid pressures may cause a hiatus hernia (part of the stomach in the chest) or other hernias (abdominal tissue protruding through the abdominal wall).
Liver failure may cause hepatorenal syndrome (kidney failure) and require dialysis.
Patients with recurring ascites should be evaluated for liver transplantation.

Medications

Antibiotics may be used to treat, and sometimes to prevent, infections.
Diuretics are used to improve fluid balance and reduce ascites.

Surgery

In addition to TIPS, hernia surgery may be needed.
Liver transplant may be needed in qualified patients.

Abbreviations

AASLD: American Association For The Study Of Liver Diseases
TIPS: Transjugular Intrahepatic Portosystemic Shunt

Source Citation

Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Aug;74(2):1014-1048. doi: 10.1002/hep.31884. PMID: 33942342.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.