Ascites in Cirrhosis (Adult)
New or worsening ascites in an adult with cirrhosis. Not for children or pregnancy.
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GastroenterologyManagement
Ascites Management in Cirrhosis (AASLD 2021)
Ascites Management in Cirrhosis (AASLD 2021): Ascites in Cirrhosis (Adult) → Diagnostic Paracentesis → Before Diuretics: Exclude SBP, AKI, Bleeding and ...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Diagnostic Paracentesis
For all new-onset ascites and every hospital admission with ascites. Do not delay for INR or platelet count.
- Cell count and differential: neutrophils ≥250 cells/mm³ (250 ×10⁶/L) = SBP
- Ascitic albumin (for SAAG) and total protein
- SAAG ≥11 g/L = portal hypertension; SAAG <11 g/L: look for another cause
- Culture: inoculate blood culture bottles at the bedside
- Cytology, amylase or adenosine deaminase only if another cause is suspected
03Warning Before Diuretics: Exclude SBP, AKI, Bleeding and Overt HE
Treat these first. Not for SAAG <11 g/L, children or pregnancy.
- SBP (neutrophils ≥250/mm³): start antibiotics and albumin now; use the SBP pathway
- AKI or rising creatinine: do not start or increase diuretics; stop NSAIDs and nephrotoxins
- GI bleeding, overt HE, sodium <125 mmol/L or abnormal potassium: correct first (raise sodium by no more than 8 mmol/L in 24 h); no diuretics in persistent overt HE
04Action Grade the Ascites
International Club of Ascites grade decides the next steps
- Grade 1 (mild): seen only on ultrasound
- Grade 2 (moderate): moderate symmetric distension
- Grade 3 (large): marked or tense distension
05Action Grade 3 Only (Large or Tense): Large-Volume Paracentesis (LVP) First
Grade 1-2: skip this step. Grade 3: drain the ascites, give albumin if more than 5 L is removed, then start salt restriction and diuretics.
- More than 5 L removed: albumin 20% IV, 6-8 g per litre removed
- Less than 5 L: consider albumin if AKI risk or acute-on-chronic liver failure
- Routine INR, platelet checks and blood products are not needed; avoid LVP in disseminated intravascular coagulation
- After drainage: check blood pressure and creatinine
06Action Salt Restriction and Start Diuretics
Grade 1 (ultrasound only): no evidence that diuretics help; restrict salt and monitor. Grade 2-3: start diuretics.
- Sodium about 2 g (88 mmol) per day: no added salt; avoid stricter limits (malnutrition risk)
- Spironolactone 100 mg oral daily, alone or with furosemide 40 mg oral daily
- Recurrent or grade 3 ascites: give both drugs from the start
- Fluid restriction (1-1.5 L/day) only if hypervolaemic and sodium <125 mmol/L
- Treat the cause: stop alcohol; treat hepatitis B or C
07Action Diuretic Titration With Stop Rules
Stop diuretics for AKI, sodium <125 mmol/L, worsening HE or severe cramps. Maximum weight loss 0.5 kg/day (1 kg/day with oedema).
- Stop spironolactone if potassium >6 mmol/L; stop furosemide if potassium <3 mmol/L
- If response is poor, increase every 3-5 days, keeping about 100 mg spironolactone to 40 mg furosemide
- Maximum oral doses: spironolactone 400 mg/day and furosemide 160 mg/day
- Check weight, sodium, potassium and creatinine often in the first weeks
- Avoid NSAIDs, ACE inhibitors, ARBs and alpha-1 blockers; avoid aminoglycosides
08Decision Response to Diuretics?
Review weight, symptoms, electrolytes and creatinine at each visit
- AKI or rising creatinine
09Action AKI on Diuretics: Stop Diuretics and Beta-Blockers, Treat the Cause
AKI: creatinine rise ≥26.5 µmol/L in 48 h or ≥50% from baseline within 7 days. Get hepatology advice now. Fluid overload or pulmonary oedema: no fluid or albumin bolus.
- Stop diuretics, beta-blockers, NSAIDs, vasodilators and nephrotoxins
- Look for and treat infection or bleeding; assess volume status and reassess often
- Fluid loss: balanced crystalloid. SBP or after LVP: albumin 20%. Give to volume status, not a fixed dose
- No response within 24 h and HRS-AKI criteria met: terlipressin with albumin (HRS-AKI pathway)
- Terlipressin: not if hypoxic, fluid overloaded or ongoing heart, gut or limb ischaemia; high risk if creatinine ≥442 µmol/L or ACLF grade 3
10Outcome Liver Transplant Assessment
Refer suitable patients to a liver transplant centre now. Do not wait for refractory ascites.
- Responding
11Action Responding: Keep the Lowest Effective Dose
Ascites controlled without diuretic complications
- Once ascites has largely resolved, reduce diuretics to the lowest effective dose
- Keep salt restriction; check sodium, potassium and creatinine regularly
- After an SBP episode: long-term antibiotic prophylaxis
- Ascites means decompensated cirrhosis: discuss transplant referral with hepatology
12Outcome Ascites Controlled
Continue treatment and follow-up; watch for SBP, AKI, hyponatraemia and HE
- Refractory
13Warning Refractory Ascites: Refer for Transplant Assessment
Median survival about 6 months. On a beta-blocker: reduce or stop it if systolic BP <90 mmHg, sodium <130 mmol/L or AKI.
- Resistant: no response to spironolactone 400 mg + furosemide 160 mg daily for ≥1 week with salt restriction
- Intractable: HE, AKI, sodium <125 mmol/L or potassium <3 or >6 mmol/L prevent effective doses
- Also refractory: grade 2-3 ascites returns within 4 weeks of drainage
14Decision Suitable for TIPS?
Decide with hepatology and interventional radiology
- If Yes
15Action TIPS Suitable: Covered TIPS in a Specialist Centre
Not for severe heart failure, severe tricuspid regurgitation, pulmonary hypertension, active infection or overt HE.
- Caution if bilirubin >50 µmol/L, platelets <75 ×10⁹/L, MELD ≥18, age >70 years or HRS
- Better ascites control than serial LVP; survival benefit in recurrent ascites
- Use small-diameter PTFE-covered stents
- Continue salt restriction and diuretics until ascites resolves; watch for new HE
- Path rejoins step 10Shared downstream outcome
If No16Action TIPS Not Suitable: Serial LVP With Albumin
Repeat large-volume paracentesis when needed. Avoid LVP in disseminated intravascular coagulation.
- More than 5 L removed: albumin 20% IV, 6-8 g per litre removed
- Continue diuretics only if urine sodium >30 mmol/day and no complications
- Not a transplant candidate: offer palliative care referral
- Long-term indwelling drains: palliative care setting only (infection risk)
- Path rejoins step 10Shared downstream outcome
Guideline Source
AASLD 2021 Practice Guidance: Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome (Biggins et al., Hepatology 2021;74:1014-1048)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with ascites from cirrhosis (SAAG ≥11 g/L) only; not for malignant, TB, pancreatic or cardiac ascites.
- SBP, HRS-AKI and severe hyponatraemia need their own pathways and urgent hepatology input.
- Guidelines differ on salt target, albumin dose per litre and primary SBP prophylaxis; follow local protocol.
- TIPS, NSBB and transplant decisions need a specialist hepatology team.
Contraindicated Populations
ChildrenPregnancyAscites not due to portal hypertension (SAAG <11 g/L)
Applicable Regions
AUUSEUUKGlobal
AU: GESA 2026 portal hypertension guideline: no-added-salt diet (up to 2300 mg sodium per day); primary SBP prophylaxis no longer recommended; secondary prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole; albumin 20 g for every 2 L drained when LVP is over 5 L; long-term drains only in palliative care.
EU: EASL 2018: spironolactone alone for a first grade 2 episode; albumin 8 g per litre after LVP of more than 5 L.
UK: BSG 2020: salt 5-6.5 g per day (87-113 mmol sodium); albumin 8 g per litre after LVP of more than 5 L.
US: AASLD 2021: sodium 2 g (88 mmol) per day; albumin 6-8 g per litre after LVP of more than 5 L.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Ascites Management in Cirrhosis (AASLD 2021)?
The Ascites Management in Cirrhosis (AASLD 2021) is a management clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on AASLD 2021 Practice Guidance: Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome (Biggins et al., Hepatology 2021;74:1014-1048).
What guideline is the Ascites Management in Cirrhosis (AASLD 2021) based on?
This algorithm is based on AASLD 2021 Practice Guidance: Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome (Biggins et al., Hepatology 2021;74:1014-1048) (DOI: 10.1002/hep.31884).
What are the limitations of the Ascites Management in Cirrhosis (AASLD 2021)?
Known limitations include: Adults with ascites from cirrhosis (SAAG ≥11 g/L) only; not for malignant, TB, pancreatic or cardiac ascites.; SBP, HRS-AKI and severe hyponatraemia need their own pathways and urgent hepatology input.; Guidelines differ on salt target, albumin dose per litre and primary SBP prophylaxis; follow local protocol.; TIPS, NSBB and transplant decisions need a specialist hepatology team.. Individual patient factors may require deviation from these recommendations.
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