Ascites - Diagnosis and Management Summary
Paracentesis studies: cell count + differential, albumin, protein, culture
• Serum-ascites-albumin-gradient (SAAG): > 1.1 g/dL suggests portal hypertensive source
• SBP: PMN count (WBC x PMN%) > 250 cells
• Secondary Peritonitis: 2+ of following: protein > 1g/dL, glucose < 50mg/dL, LDH > ULN
• Protein: level < 1-1.5g/dL suggests higher SBP risk. If > 2.5 g/dL, consider cardiac ascites
1) Sodium restriction
<2g (88mmol) Na per day
Not recommended to restrict Na intake more than above as this may lead to reduced overall caloric intake
2) Diuretic therapy
Initial: spironolactone +/- furosemide
Ratio: 100:40 (maintains K+ balance)
Titrate: q3-5 days at start
Diuretic resistance: inadequate diuresis at max doses
Diuretic intolerance: limited by side effects ( severe AKI or ↓Na+)
3) Large-volume paracentesis
Consider in: Large, tense ascites, Diuretic-resistance/intolerance
Administer albumin to ↓ PPCD:
• If LVP > 5L: 25% albumin, 6-8g/L removed
• If AKI/CKD: give regardless of amount removed
4) TIPS - Consider in carefully selected patients with diuretic resistance/intolerance
Compared to LVP: ↑ Control of ascites, ↑Risk of encephalopathy, ? Impact on survival depends on appropriate patient selection
5) Other
• Midodrine: can increase response in diuretic-resistant
• Medications to avoid: NSAIDs, ACE inhibitors, Angiotensin receptor blocker (ARBs), ? Beta-blockers (in ascites w/ ↓ BP)
- Dr. Hersh Shroff @HershShroff
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