Ascites and refractory ascites

Causes and initial assessment. Cirrhosis with portal hypertension accounts for about 80%; other causes are malignancy (peritoneal carcinomatosis), heart failure, tuberculosis, nephrotic syndrome and pancreatitis. Perform a diagnostic paracentesis in every patient with new-onset ascites — send cell count and differential, albumin, total protein, culture inoculated into blood culture bottles at the bedside, and cytology and adenosine deaminase where indicated. Neutrophils ≥250/mm³ diagnoses spontaneous bacterial peritonitis.

Serum-ascites albumin gradient (SAAG). SAAG ≥1.1 g/dL indicates portal hypertension (cirrhosis, cardiac ascites — cardiac ascites has an ascitic protein >2.5 g/dL, cirrhotic <2.5). SAAG <1.1 g/dL indicates non-portal causes — malignancy, tuberculosis, pancreatic or nephrotic ascites.

Grading. Grade 1 detectable only on ultrasound; Grade 2 moderate, with symmetrical abdominal distension; Grade 3 large or tense ascites.

First-line management. Sodium restriction to 5–6 g of salt (about 2 g sodium) per day; fluid restriction only if serum sodium is below 125 mmol/L. Spironolactone 100 mg with furosemide 40 mg daily, maintaining the 100:40 ratio, increased stepwise to maxima of 400 mg and 160 mg. Target weight loss of 0.5 kg/day without oedema and up to 1 kg/day with oedema. Monitor weight, sodium, potassium and creatinine, and stop NSAIDs, ACE inhibitors and ARBs.

Definition of refractory ascites. Ascites that cannot be mobilised or that recurs early and cannot be prevented, and is either diuretic-resistant (no response to maximal diuretic doses with salt restriction) or diuretic-intractable (diuretic-induced complications — encephalopathy, creatinine rise above 2 mg/dL, sodium below 125 mmol/L, or potassium disturbance — preventing the use of effective doses). It occurs in about 10% and carries a 1-year survival of only 50%.

Management of refractory ascites. Serial large-volume paracentesis with albumin 8 g per litre removed whenever more than 5 litres is drained (to prevent post-paracentesis circulatory dysfunction). TIPS for patients needing repeated paracenteses — contraindicated with recurrent encephalopathy, age over 70, Child-Pugh >13 or cardiac dysfunction. Discontinue beta-blockers if systolic BP falls below 90 mmHg, or with hyponatraemia or AKI. Consider indwelling tunnelled peritoneal drains or an alfapump for palliation, and refer for liver transplantation. Watch for SBP, hepatorenal syndrome, hyponatraemia, umbilical hernia and hepatic hydrothorax.

Baveno VII plus recent trial evidence — TIPS with covered stents should now be considered earlier, in patients requiring three or more large-volume paracenteses per year, irrespective of the presence of varices or previous variceal bleeding, as this improves transplant-free survival compared with repeated paracentesis. In addition, the ANSWER trial (Lancet 2018) and subsequent data support long-term weekly albumin infusion in uncomplicated cirrhotic ascites, which improved survival and reduced complications; this is now standard in some countries, although confirmatory evidence remains debated and cost limits its use in Indian practice.