Management of adult patients with ascites due to cirrhosis†

SAAG, serum-ascites albumin gradient; PMN, polymorphonuclear leukocyte; TIPS, transjugular intrahepatic portasystemic stent-shunt; SBP, spontaneous bacterial peritonitis. 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) the American College of Physicians' Manual for Assessing Health Practices and Designing Practice Guidelines1; (3) policy guidelines, including the American Association for the Study of Liver Diseases' Policy Statement on Development and Use of Practice Guidelines and the American Gastroenterological Association's Policy Statement on the Use of Medical Practice Guidelines,2, 3; and (4) the author's 22 years of experience in the clinical and laboratory investigation of, and care of patients with, this problem, including 7 years' experience in a liver unit in which approximately 60% of patients have ascites. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventative aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. Cost-effectiveness and cost-benefit data should be incorporated in the appropriate setting. In an attempt to characterize the quality of evidence supporting recommendations, the Practice Guidelines Committee of the American Association for the Study of Liver Diseases requires a grade to be assigned and reported with each recommendation (Table 1). 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 data base is much smaller and there may be unanticipated differences between adults and children. Patients with ascites that is detected by imaging modalities but is not yet clinically evident are not included because of the lack of published information regarding the natural history of this entity. Cirrhosis was the tenth leading cause of death in the United States, according to a 2000 Vital Statistics Report, in which data was collected through 1998.4 Ascites is the most common of the 3 major complications of cirrhosis; the other complications are hepatic encephalopathy and variceal hemorrhage.5 Approximately 50% of patients with “compensated” cirrhosis, i.e., without having developed one of these complications, develop ascites during 10 years of observation.5 Development of fluid retention in the setting of cirrhosis is an important landmark in the natural history of chronic liver disease: approximately 50% of patients with ascites succumb in 2 years.6 Many patients are referred for liver transplantation after development of ascites. A Medline search from 1966 through 2002 was performed; search terms included ascites, diet therapy, drug therapy, radiotherapy, surgery, and therapy. The search involved only papers published in English and involving humans. A manual search of the author's files was also performed. The search yielded 1,867 papers including 411 published since a similar search was performed in 1997 in preparation for writing the previous guideline on ascites.7 Most patients (approximately 85%) with ascites in the United States have cirrhosis.8 In about 15% of patients with ascites, there is a nonhepatic cause of fluid retention. Successful treatment is dependent on an accurate diagnosis of the cause of ascites; e.g., peritoneal carcinomatosis does not respond to diuretic therapy. Patients with ascites should be questioned about risk factors for liver disease. Those who lack an apparent cause for cirrhosis should also be questioned about lifetime body weight; nonalcoholic steatohepatitis has been concluded to be causative in many of these patients.9 Past history of cancer, heart failure, or tuberculosis is also relevant. Hemophagocytic syndrome can masquerade as cirrhosis with ascites.10 These patients have fever, jaundice, and hepatosplenomegaly, usually in the setting of lymphoma or leukemia.10 The presence of a full, bulging abdomen should lead to percussion of the flanks. If the amount of flank dullness is greater than usual (i.e., if the percussed air-fluid level is higher than normally found on the lateral aspect of the abdomen with the patient supine), one should test for “shifting.” Approximately 1,500 mL of fluid must be present before flank dullness is detected.11 If no flank dullness is present, the patient has less than a 10% chance of having ascites.11 The fluid wave and puddle sign are not useful.11 Ascites due to alcoholic cardiomyopathy can mimic that due to alcoholic cirrhosis. Jugular venous distension is present in the former but not in the latter. The physical examination for detecting ascites in the obese patient is problematic. An abdominal ultrasound may be required to determine with certainty if fluid is present. The diagnosis of new-onset ascites is suspected on the basis of the history and physical examinationand usually confirmed by successful abdominal paracentesis and/or ultrasound. The diagnosis of the cause of ascites formation is based on the results of the history, physical, and fluid In other are the liver is with to for and hepatic paracentesis with appropriate fluid analysis is the most and of the cause of due to can be from fluid due to other in of the of fluid the of to the an may Although published reported a and were for regarding paracentesis complications in patients with ascites no or by the were reported in only about of patients the that of the patients an Although complications or by the paracentesis are that should not of this is the of to and/or before paracentesis in patients with policy is not The and of the In the the was usually as the for the abdominal in the 2 and 2 to the has been to be and with a of fluid than the If the fluid is to by examination because of can be are to should paracentesis only there is clinically evident or clinically evident These in less than is no data-supported of which paracentesis should be paracentesis should be performed and fluid should be from and with clinically apparent new-onset ascites. is the use of or before paracentesis is not are required to determine the an approach to a of on most If ascites is only and albumin and are performed on the If the results of these are can be performed on fluid many an of fluid for a this fluid can be if the has been since most are with ascites, no be in the of If fluid is suspected abdominal or bacterial in should be performed. Use of a to in fluid only to 2 if confirmed by other this may a of of has been to be the is and may the manual e.g., and to in spontaneous from bacterial can be performed on the based on clinical An fluid greater than or fluid greater than has also been to be accurate in detecting The serum-ascites albumin has been in to ascites than the and than fluid the the albumin of and fluid on the and the fluid from the If the is greater than or to the patient has with approximately Patients who have a cause for ascites formation also have a greater than or to Patients should be only for and has detected of spontaneous bacterial in approximately in a paracentesis in 2 years of ascites, is not in patients The most are the and and for these should be only there is a of of the The fluid is only in the setting of peritoneal The of in detecting peritoneal carcinomatosis is if 3 are and the is in and of 2 is in In this mL of fluid were to the laboratory for Patients with peritoneal carcinomatosis usually have a history of a or The of for is approximately the of fluid for is approximately patients risk for from an or should have for on the fluid with and of are the most and accurate of peritonitis. have that bacterial in only about 50% of fluid with a polymorphonuclear greater than or to is by as to approximately if the fluid is the The laboratory investigation of fluid should an fluid and fluid and If fluid is fluid should be the in can be based on of (Table Although cirrhosis is the cause of ascites formation in most approximately 15% have a cause other than liver including cancer, heart failure, or Approximately of patients with ascites have 2 or of ascites i.e., these patients have cirrhosis other e.g., peritoneal carcinomatosis or peritoneal Many patients with ascites are found to have 2 or 3 for ascites formation heart failure, and cirrhosis due to nonalcoholic In this the of factors to and retention each not be to cause fluid treatment of patients with ascites on the cause of fluid retention. can be as as in regarding Patients with ascites usually not have with the of not respond to and In patients with a have and usually are to these The of this guideline is applicable only to patients with cirrhosis as the cause of ascites. in the of patients with ascites on successful treatment of the liver is the most cause of liver that to albumin of the most important in ascites in this setting is to the liver by the patient to In a of can in in the of alcoholic liver disease. that patients who have cirrhosis due to and who have an approximately but who to in 3 Ascites may or to with and liver are less by the ascites is present, these patients may be for liver transplantation than therapy. 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with to diet may Development of ascites as a of cirrhosis is with a approximately a 50% Liver transplantation should be in the treatment for these Patients with ascites who are to have an to liver should from treatment of patients with cirrhosis and ascites of and and is not is less than An abdominal paracentesis should be performed in patients with ascites. and should be patients should be with and than with Liver transplantation should be in patients with cirrhosis and ascites. ascites is as fluid that (1) is to diet and diuretic treatment of and or (2) after as can in patients with cirrhosis and can These can patients from to and should be in this setting. of diuretic may be by (1) to no with or (2) development of clinically complications of e.g., greater than less than or greater than have that less than 10% of ascites patients are to for patients to (1) liver transjugular intrahepatic portasystemic and are in ascites. has been since the of the only recently have the of this approach been in patients with no performed approximately every 2 of paracentesis the of with the The of fluid is approximately to that of in these A paracentesis of A paracentesis Patients of approximately 10 in and no a of a paracentesis 10 of and a paracentesis approximately of in patients with no Patients with should less Patients of approximately 10 than every 2 are not with the In paracentesis has that may the and of regarding paracentesis is that of In one patients with ascites were to albumin of fluid no after to diuretic treatment was not a for this in of patients not The that no albumin developed in and than the albumin but no clinical or Although has that the of patients who develop a in after paracentesis have there has been no to in patients no to patients albumin after the in that can paracentesis may not be to a albumin albumin and albumin is In a performed years of albumin was for by and a 15% in albumin to a in albumin in has been to albumin The is a of in the United of the of Health on albumin no fluid after of less than and as a and albumin as a for In of the of also should albumin is after are is not to for greater than have between and 10 of albumin of fluid has as and have been also without of a can and cause in patients without liver of the regarding to are in that as the in patients with ascites. should be for the 10% of patients who diuretic patients may from albumin after are are risk factors that of the of patients who are higher risk of Liver transplantation should be in the treatment of patients with ascites. patients to therapy, 50% and should not be in patients with ascites. is a that is by an usually in is by is in higher in the to the but this was and in experience with this to paracentesis have been (Table of these are and The is and has been published only in of these of ascites in the no by analysis but a for the by of syndrome but with higher in the there were similar of encephalopathy but hepatic encephalopathy in the no with a or encephalopathy in the and no on quality of is the to provide a of for for The of the patient with cirrhosis is usually greater than An of greater than 60% may be appropriate as an for a since patients with an between 50% and 60% may have a higher risk of heart The of the a in the with similar and encephalopathy a has been developed that has than the of the in a there is a for Liver to after of these were before this was and have after usually patients after and the to is the experience with and the level of of patient and the of the the results of may be than are results are before the of in the of treatment of patients with ascites can be e.g., or was in the as a treatment of ascites. has been in to the of the of and the of complications, and no to in have to of this and formation can liver transplantation should be for patients who are not for or who are not for of abdominal or from a to and of experience in by the may also be a in results in the patient who is to this have reported the of a without the of a are also for and have to develop a that fluid the of these have been in the results of before these may be performed in patients with ascites. albumin may not be for a paracentesis of less than to an albumin of to 10 of fluid can be for liver transplantation should be in patients with ascites. should be in patients who similar to of published should be for patients with ascites who are not for or (1) chronic or liver with (2) greater than or less than mL (3) of bacterial treatment with or or fluid (4) no in diuretic and of with of and less than and no evidence of or of syndrome have been is by in as by a of the to a level greater that or a 50% of the to a level that mL in less that 2 does not have a is to and before liver Many patients for a after during is a common without transplantation is one reported no of less but requires the of a In a that patients with cirrhosis and ascites and included an for patients with was not to in a not be this was performed before the of syndrome were Many including that are not in the United States, have been with or without are followed by a of the from the literature without of a a with results is have been much successful for without is the drug that has been The drug with albumin that has been reported from but is also in the United States is and In one patients 10 to of albumin for with a of 3 and to a of 3 to an in of were to of patients with and can be of an care unit and can be Many liver in the United States are with this this one of in this treatment requires that the patient be in an care An in the United also with has also been reported to be in syndrome in an of 7 is for these be in patients with syndrome to be are are has been for years that liver transplantation is an treatment for this be in a of as and should be in the treatment of Patients with cirrhosis, ascites, and syndrome should have an for liver fluid is common the of of a patient with cirrhosis and ascites to a The diagnosis of spontaneous bacterial is there is a fluid bacterial and an fluid (i.e., without an evident of An abdominal paracentesis must be performed and fluid must be before a diagnosis of fluid can be A of fluid without a paracentesis is not of fluid and may of this Patients with fluid greater than or to in a clinical with fluid should An fluid evidence of of the of the peritoneal to Most of the bacterial of these fluid if (1) the fluid is in (2) there has been no and (3) there is no other for an e.g., ascites, peritoneal or peritoneal The patients who the but have have been with a diagnosis of The for this diagnosis was have this to Patients with ascites have similar and as patients with and A in which 2 were performed in (approximately before of has that only of patients with fluid with an The of patients with ascites bacterial and are in before of The of patients with ascites with this of fluid analysis are in before of The fluid is than the and to be accurate in who treatment the fluid may in the death of the patient from In is detected the before there is a i.e., less than this has been Most in one the without and without a Patients with who not the and who to have or of the of the paracentesis that patients with cirrhosis and ascites who have or of abdominal or should treatment the results are of the in The patient with alcoholic a case. These patients may have fever, and abdominal that can masquerade as In can develop These patients not develop fluid because of an must be to treatment fluid of patients with alcoholic who have and/or can be after if and no bacterial is in patients with suspected fluid the results of are a has been to be to in a or a similar to be the treatment of for suspected of the including the 3 most common and (Table of 2 every has been to in fluid after are the of can usually be A involving patients has that of treatment is as as 10 in the treatment of patients with has been reported in a to be as as in the treatment of in patients without grade hepatic or greater than 3 of patients with treatment was in patients with to albumin body of and on A in from to 10% was is the reported in a of of a of cirrhosis is is is is to albumin in this in this setting. bacterial i.e., fluid by a can masquerade as can be 2 with of a and with in the of and not patients who of from who have and only In the fluid analysis and the to treatment can with this important The analysis in the setting of is greater than or to many on and and of the greater than greater than the of for and less than is to an fluid and in patients with cirrhosis and ascites and an fluid greater than or to These have been to have but only in detecting in a An fluid greater than or fluid greater than has also been to be accurate in detecting fluid with a of and of these not be to be in Patients who of for should and contrast of the and 22 The and are only 50% in detecting the after of treatment in detecting these The is the in an appropriate is in the treatment in Patients to have or should in to a and should The of with and is similar to that of with A fluid analysis is not in patients with The of patients have in the setting (i.e., with fluid analysis less that the of for and greater than or to a and a clinical paracentesis can be performed to of and in in patients with is not In if the or are paracentesis can be in the of and and Patients with ascites to the should abdominal should be in patients in the or who develop or or laboratory of abdominal or fever, failure, or Patients with fluid greater than or to should therapy, e.g., 2 every Patients with fluid less than and or of or abdominal or should also therapy, e.g., 2 every results of the fluid of a patient with cirrhosis is found to have a greater than or to should also be for and to with the of from peritonitis. can be a for in without grade hepatic or greater than 3 Patients with fluid greater than or to and clinical of should albumin body of and on The of risk factors for development of fluid less than variceal and of has to of has been reported to in (1) patients with ascites and (2) patients with for 7 in patients with variceal An can be the patient is has been for this of has also been reported to be in in patients with cirrhosis and may of this drug may be than with or has not been to in in these were not designed to a A of in patients with cirrhosis and has a of in the does which can cause spontaneous that are to are usually to A from a in which has been in patients for many years a in the of bacterial with a of to a of in the is cause for and the of to patients with or in patients with or fluid does to be in which patients with fluid or greater than were to or to that to patients a higher risk of develop on the is to (1) to who these with of the drug the of or (2) to patients who these In a of liver one risk for was with are no published of in in patients liver Use of in this setting in the of is not to not to be based on a is the that to be the risk for not has be less to be of in the setting of should be to bacterial in patients with cirrhosis and a can be the patient is Patients who have an of should with because this is the most data-supported for In patients with cirrhosis and ascites but no or use of can be the fluid is less than or to or greater than guideline was and by the American Association for the Study of Liver Diseases and the of the was in with the Practice Guidelines of the Practice Guidelines Committee and