Ascites Management in Cirrhosis (AASLD 2021)

Algorithm Steps

1. ▶

   Start

   New-Onset Ascites

   First presentation of ascites in patient with liver disease

   1. ●

      Action

      Diagnostic Paracentesis

      Required for all new-onset ascites

      • Cell count + differential
      • Albumin (calculate SAAG)
      • Total protein
      • Culture if infection suspected
      • SAAG ≥1.1 = portal hypertension
      1. ◆

         Decision

         Classify Ascites Grade

         International Ascites Club classification

         • Grade 1: Only detectable by ultrasound
         • Grade 2: Moderate, symmetric distension
         • Grade 3: Large/tense ascites
         1. ●

            Action

            Grade 1-2 (Uncomplicated)

            Medical management first-line

            • Sodium restriction: 2g/day (88 mmol)
            • No fluid restriction unless Na <125
            • Start spironolactone 100mg daily
            • May add furosemide 40mg if needed
            1. ●

               Action

               Diuretic Titration

               Goal: 0.5 kg/day weight loss (1 kg if edema)

               • Maintain 100:40 ratio (spironolactone:furosemide)
               • Increase every 3-5 days if inadequate response
               • Max: spironolactone 400mg + furosemide 160mg
               • Monitor K+, Cr, Na
               1. ◆

                  Decision

                  Assess Response

                  After 2 weeks of therapy

                  1. ●

                     Action

                     Diuretic-Responsive Ascites

                     Continue current regimen

                     • Maintain sodium restriction
                     • Titrate diuretics to minimum effective dose
                     • Monitor electrolytes, renal function
                     • SBP prophylaxis if indicated
                     1. ✓

                        Outcome

                        Ascites Controlled

                        Continue medical management, monitor for complications

                  2. ⚠

                     Warning

                     Refractory Ascites

                     Diuretic-resistant or diuretic-intractable

                     • Cannot be mobilized despite max diuretics
                     • OR diuretics cause complications (HE, Cr rise, hyponatremia)
                     • Poor prognosis - 6-month mortality ~50%
                     1. ◆

                        Decision

                        Refractory Ascites Options

                        Serial LVP vs TIPS

                        1. ●

                           Action

                           Serial Large Volume Paracentesis

                           Every 2-4 weeks as needed

                           • Albumin 8g/L for volumes >5L
                           • Continue diuretics if tolerated
                           • Quality of life consideration
                           1. ✓

                              Outcome

                              Liver Transplant Evaluation

                              Refractory ascites = decompensated cirrhosis, MELD exception

                        2. ●

                           Action

                           TIPS (Transjugular Intrahepatic Portosystemic Shunt)

                           Consider if frequent LVP needed

                           • Better ascites control than serial LVP
                           • Contraindications: severe HE, bilirubin >5, MELD >18-20
                           • Covered stents preferred
                           • Risk: encephalopathy in 30-50%
         2. ●

            Action

            Grade 3 (Large/Tense)

            Large volume paracentesis (LVP)

            • LVP with albumin replacement
            • Albumin 8g per liter removed (if >5L)
            • Then start/optimize diuretics
            • Can remove any volume safely with albumin