Management of adult patients with ascites due to cirrhosis

This is the authors' abstract. We don't add key points for this paper.

This guideline has been approved by the AASLD and represents the position of the Association. These recommendations provide a data-supported approach. They are based on the following: (1) formal review and analysis of the recently-published world literature on the topic (Medline search); (2) American College of Physicians Manual for Assessing Health Practices and Designing Practice Guidelines1; (3) guideline policies, including the AASLD Policy on the Development and Use of Practice Guidelines and the American Gastroenterological Association Policy Statement on Guidelines2; and (4) the author's decades of experience caring for patients with cirrhosis and ascites. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the quality of evidence supporting recommendations, the Practice Guidelines Committee of the AASLD requires a Class (reflecting benefit versus risk) and Level (assessing strength or certainty) of Evidence to be assigned and reported with each recommendation (Table 1, adapted from the American College of Cardiology and the American Heart Association Practice Guidelines3).4 These guidelines were developed for the care of adult patients with clinically detectable ascites. Although the general approach may be applicable to children, the pediatric database is much smaller and there may be unanticipated differences between adults and children. Patients with ascites detected only by imaging modalities but not yet clinically evident are excluded because of the lack of published information regarding the natural history of this entity. A Medline search from 1966 through 2007 was performed; search terms included ascites, hepatorenal syndrome, diet therapy, drug therapy, radiotherapy, surgery, and therapy. The search involved only articles published in English and involving humans. A manual search of the author's files and recent abstracts was also performed. The search yielded 2115 articles including 153 published since a similar search was performed in 2002 in preparation for writing the previous guideline on ascites. AASLD, American Association for the Study of Liver Diseases; LDH, lactate dehydrogenase; PMN, polymorphonuclear leukocyte; SAAG, serum-ascites albumin gradient; SBP, spontaneous bacterial peritonitis; TIPS, transjugular intrahepatic portasystemic stent-shunt. Cirrhosis was the twelfth leading cause of death in the United States, according to a 2006 Vital Statistics Report in which data were collected through 2004.5 Ascites is the most common of the three major complications of cirrhosis; the other complications are hepatic encephalopathy and variceal hemorrhage.6 Approximately 50% of patients with “compensated” cirrhosis, i.e., without having developed one of these complications, develop ascites during 10 years of observation.6 Ascites is the most common complication of cirrhosis that leads to hospital admission.7 The pathophysiology of ascites and hepatorenal syndrome have been reviewed elsewhere.8 Development of fluid retention in the setting of cirrhosis is an important landmark in the natural history of chronic liver disease: of patients with ascites in and in patients are for liver of ascites. patients with ascites in the United have cirrhosis (Table of patients with ascites, there is a cause of fluid is on an of the cause of not to therapy. 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This guideline was in with the AASLD Practice Guidelines of the AASLD Practice Guidelines Committee included and The is not for the or of supporting information by the be to the for the