Management of Adult Patients with Ascites Due to Cirrhosis
Publication Date: October 1, 2013
Last Updated: March 14, 2022
Recommendations and Rationales
Diagnostic abdominal paracentesis should be performed and ascitic fluid should be obtained from inpatients and outpatients with clinically apparent new-onset ascites. (CI)
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Since bleeding is sufficiently uncommon, the routine prophylactic use of fresh frozen plasma or platelets before paracentesis is not recommended. (CIII (harm))
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The initial laboratory investigation of ascitic fluid should include an ascitic fluid cell count and differential, ascitic fluid total protein, and serum-ascites albumin gradient (SAAG). (BI)
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If ascitic fluid infection is suspected, ascitic fluid should be cultured at the bedside in aerobic and anaerobic blood culture bottles prior to initiation of antibiotics. (BI)
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Other studies of ascitic fluid can be ordered based on the pretest probability of disease. (CIIa)
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Testing serum for CA125 is not helpful in the differential diagnosis of ascites. Its use is not recommended in patients with ascites of any type. (BIII (no benefit))
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Patients with ascites who are thought to have an alcohol component to their liver injury should abstain from alcohol consumption. (BI)
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Baclofen can be given to reduce alcohol craving and alcohol consumption in patients with ascites in the setting of alcoholic liver disease. (BIIb)
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First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2000 mg per day], diet education,) and diuretics (oral spironolactone with or without oral furosemide). (AIIa)
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Fluid restriction is not necessary unless serum sodium is less than 125 mmol/L. (CIII (no benefit))
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Vaptans may improve serum sodium in patients with cirrhosis and ascites. However their use does not currently appear justified in view of their expense, potential risks, and lack of evidence of efficacy in clinically meaningful outcomes. (AIII (harm))
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An initial therapeutic abdominal paracentesis should be performed in patients with tense ascites. Sodium restriction and oral diuretics should then be initiated. (CIIa)
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Diuretic-sensitive patients should preferably be treated with sodium restriction and oral diuretics rather than with serial paracenteses. (CIIa)
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Use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in patients with cirrhosis and ascites may be harmful, must be carefully considered in each patient, monitoring blood pressure and renal function. (CIII (harm))
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The use of nonsteroidal anti-inflammatory drugs should be avoided in patients with cirrhosis and ascites, except in special circumstances. (CIII (harm))
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Liver transplantation should be considered in patients with cirrhosis and ascites. (BI)
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The risks versus benefits of beta blockers must be carefully weighed in each patient with refractory ascites. Systemic hypotension often complicates their use. Consideration should be given to discontinuing or not initiating these drugs in this setting. (BIII (harm))
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The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided in patients refractory ascites. Systemic hypotension often complicates their use. (BIII (harm))
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Oral midodrine has been shown to improve clinical outcomes and survival in patients with refractory ascites; its use should be considered in this setting. (BIIa)
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Serial therapeutic paracenteses are a treatment option for patients with refractory ascites. (CI)
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Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. (CI)
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For large-volume paracenteses, an albumin infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended. (AIIa)
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Referral for liver transplantation should be expedited in patients with refractory ascites, if the patient is otherwise a candidate for transplantion. (CIIa)
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Transjugular intrahepatic portosystemic stent-shunt (TIPS) may be considered in appropriately selected patients who meet criteria similar to those of published randomized trials. (AI)
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Peritoneovenous shunt, performed by a surgeon or inteventional radiologist experienced with this technique, should be considered for patients with refractory ascites who are not candidates for paracenteses, transplant, or TIPS. (AIIb)
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Patients with ascites admitted to the hospital should undergo abdominal paracentesis. Paracentesis should be repeated in patients (whether in the hospital or not) who develop signs or symptoms or laboratory abnormalities suggestive of infection (e.g., abdominal pain or tenderness, fever, encephalopathy, renal failure, acidosis, or peripheral leukocytosis). (BI)
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Patients with ascitic fluid polymorphonuclear leukocyte (PMN) counts greater than or equal to 250 cells/mm3 (0.25 x 109 /L) in a community-acquired setting in the absence of recent β-lactam antibiotic exposure should receive empiric antibiotic therapy, e.g., an intravenous third-generation cephalosporin, preferably cefotaxime 2 g every 8 hours. (AI)
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Patients with ascitic fluid polymorphonuclear leukocyte (PMN) counts greater than or equal to 250 cells/mm3 (0.25 x 109 /L) in a nosocomial setting and/or in the presence of recent β-lactam antibiotic exposure should receive empiric antibiotic therapy based on local susceptibility testing of bacteria in patients with cirrhosis. (BIIa)
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Oral ofloxacin (400 mg twice per day) can be considered a substitute for intravenous cefotaxime in inpatients without prior exposure to quinolones, vomiting, shock, grade II (or higher) hepatic encephalopathy, or serum creatinine greater than 3 mg/dL. (BIIa)
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Patients with ascitic fluid polymorphonuclear leukocyte (PMN) counts less than 250 cells/mm3 (0.25 x 109 /L) and signs or symptoms of infection (temperature >100° F or abdominal pain or tenderness) should also receive empiric antibiotic therapy, e.g., intravenous cefotaxime 2 g every 8 hours, while awaiting results of cultures. (BI)
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When the ascitic fluid of a patient with cirrhosis is found to have a polymorphonuclear leukocyte (PMN) count greater than or equal to 250 cells/mm3 (0.25 x 109 /L) and there is high suspicion of secondary peritonitis, it should also be tested for protein, LDH, glucose, Gram’s stain, carcinoembryonic antigen, and alkaline phosphatase to assist with the distinction of spontaneous bacterial peritonitis (SBP) from secondary peritonitis. Computed tomographic scanning should also be performed. (BIIa)
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Patients with ascitic fluid polymorphonuclear leukocyte (PMN) counts greater than or equal to 250 cells/mm3 (0.25 x 109 /L) in a nosocomial setting and/or in the presence of recent Β-lactam antibiotic exposure and/or culture an atypical organism(s) or have an atypical clinical response to treatment, should undergo a follow-up paracentesis after 48 hrs of treatment to assess the response in PMN count and culture. (CIIa)
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Patients with ascitic fluid polymorphonuclear leukocyte (PMN) counts greater than or equal to 250 cells/mm3 (0.25 x 109 /L) and clinical suspicion of SBP, who also have a serum creatinine >1 mg/dL, blood urea nitrogen >30 mg/dL, or total bilirubin >4 mg/dL should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3. (BIIa)
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Intravenous ceftriaxone for 7 days or twice daily norfloxacin for 7 days should be given to prevent bacterial infections in patients with cirrhosis and gastrointestinal hemorrhage. (AI)
Perhaps parenteral antibiotic, while the patient is bleeding and oral antibiotic after oral intake is resumed, for a total of 7 days, is a practical treatment regimen.
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Patients who have survived an episode of spontaneous bacterial peritonitis (SBP) should receive long-term prophylaxis with daily norfloxacin (or trimethoprim/sulfamethoxazole). (AI)
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In patients with cirrhosis and ascites, longterm use of norfloxacin (or trimethoprim/sulfamethasoxazole) can be justified if the ascitic fluid protein <1.5 g/dL along with impaired renal function (creatinine ≥1.2, BUN ≥25 or serum Na ≤130) or liver failure (Child score ≥9 and bilirubin ≥3). (AI)
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Intermittent dosing of antibiotics to prevent bacterial infections may be inferior to daily dosing due to the development of bacterial resistance) and thus daily dosing should preferentially be used. (CIIb)
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Urinary biomarkers such as neutrophil gelatinase associated lipocalin may assist in the differential diagnosis of azotemia in patients with cirrhosis. (BIIa)
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Albumin infusion plus administration of vasoactive drugs such as octreotide and midodrine should be considered in the treatment of type I hepatorenal syndrome. (BIIa)
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Albumin infusion plus administration of norepinephrine should also be considered in the treatment of type I hepatorenal syndrome, when the patient is in the intensive care unit. (AIIa)
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Patients with cirrhosis, ascites, and type I or type II hepatorenal syndrome should have an expedited referral for liver transplantation. (BI)
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The risks versus benefits of hernia repair must be weighed carefully in patients with cirrhosis and ascites. Elective repair can be performed during or after liver transplantation. (CIIa)
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Elective repair of a hernia in a patient with cirrhosis is best performed after ascites has been controlled by medical treatment, the patient’s overall condtion has been optimized, and a multidisciplinary approach with consideration of perioperative TIPS is utilized. (CIIa)
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Emergent repair of a strangulated or perforated umbilical hernia is best performed by a surgeon who is experienced in the care of patients with cirrhosis. (CIIa)
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Chest tube insertion is contraindicated in patients with hepatic hydrothorax. (BIII (harm))
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First-line therapy of hepatic hydrothorax consists of dietary sodium restriction and diuretics. (BIIa)
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TIPS can be considered as second-line treatment for hepatic hydrothorax, once it becomes refractory. (BIIb)
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Cellulitis can explain pain and fever in patients with cirrhosis and ascites and should be treated with diuretics and antibiotic(s). (BIIb)
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Percutaneous endoscopic gastrostomy should be avoided in patients with cirrhosis and ascites. (BIIb)
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Recommendation Grading
Overview
Title
Management of Adult Patients with Ascites Due to Cirrhosis
Authoring Organization
American Association for the Study of Liver Diseases
Publication Month/Year
October 1, 2013
Last Updated Month/Year
January 18, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline includes 49 specific recommendations on management of Adult Patients with Ascites Due to Cirrhosis:
Target Patient Population
Patients with ascites due to cirrhosis
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D008107 - Liver Diseases, D008099 - Liver, D008103 - Liver Cirrhosis, D001201 - Ascites
Keywords
cirrhosis, liver disease, ascites