Gastroenterology and Hepatology

Ascites Cirr

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12th leading cause of death in US is cirrhosis

Ascites is the most common complication of cirrhosis (Encephalopathy and bleeding the other 2)

50% of compensated cirrhosis will develop ascites in 10 years

Once develop ascites, mortality 15% in 1 year, upto 50% (2-5 years), if SBP, upto 50% in 1 year

Child’s C Alcoholic Liver Disease, if patient stop drinking (75% 3 year survival), if don’t (0%)

Once ascites refractory to routine medical therapy, mortality is 21% in 6 months


Approximately 1.5L needed before flanks become dull with percussion. If no flank dullness, < 10% chance of ascites


Consider DD of Ascites:

Cirrhosis (85%)

Alcoholic Hepatitis

Heart Failure



Nephrotic syndrome


Acute Liver Failure

Budd Chiari syndrome


Post op lymphatic leak


Risk of paracentesis:

Only 1% complication (usually hematoma) even when >70% have abnormal coagulopathy

Haemoperitoneum and bowel entry is <1 in 1000 procedures (<0.1%)

No concensus on correcting INR but if >2.5 may consider giving prophylactic FFP and tap without needing for repeat INR.

(Study of 1100 LVP, no bleeding even when platelet < 19k, INR 8.7 with no prophylaxis)

If clinical evidence of active bleeding, then prophylactic FFP may be useful.

Site is 3 cm cephalad and medial to ASIS

If tap is grossly hemorrhagic repeat quickly on the other side as this suggest existing haemoperitoneum and need to consider HCC rupture.


Ascitic Fluid Analysis

First Tap:

Cell count and differential


Total Protein

Culture (Blood culture bottle)




AFB culture



Repeated Tap:

Cell count and differential

Consider Culture and Albumin after clinical judgement

Note: CA 125 is elevated in ascites due to pressure on the mesothelial cells, so be careful when interpreting this result



Stop Alcohol

Na restriction (Daily 2g / 88mmol Na)

HypoNa is common but most of them still >125mmol/L (Only 1.2% < 120 and 5.7% < 125).




Weight loss target is 0.5kg daily if oedema has resolved. Otherwise 1kg.


Tense Ascites:

5L paracentesis is safe without needing post paracentesis colloid infusion (if renal fx is normal)

Larger volumes (>5L) will need 5-8g albumin for every litre ascites removed

Strict Na restriction



Refractory Ascites:

Unresponsive to 400mg spironolactone and 160mg frusemide or maximal tolerated diuretic dose

Ascites recurs rapidly after paracentesis

Rule out non compliance Na restriction and NSAIDs

Once ascites refractory to routine medical therapy, mortality is 21% in 6 months


edited 19th July 2010