Ascites is generally treated while its cause is determined in order to prevent complications, relieve symptoms and prevent further progression. In patients with mild ascites, therapy is usually as an outpatient. The goal is weight loss of no more than 2 lbs. (1 kg) per day for patients with both ascites and peripheral edema and no more than 1 lb. (0.5 kg) per day for patients with ascites alone. In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis.
Treatment for Patients with High SAAG Results: Salt restriction: Salt restriction is the initial treatment, which increases the production of urine. Since the patient now has more fluid than salt concentration. Salt restriction is effective in about 15% of patients.
Diuretics: Since salt restriction is the basic concept in treatment, and aldosterone is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be sought. Spironolactone (or other diuretics such as triamterene or amiloride) is the drug of choice since they block the aldosterone receptor. Diuretics for ascites should be dosed once per day. 40% of patients will respond to spironolactone. For non-responders, a loop diuretic such as furosemide (Lasix) may also be added. Serum potassium level and renal function should be monitored closely while on these medications.
Monitoring diuresis: Diuresis (urine production) can be monitored by weighing the patient daily. The goal is weight loss of no more than 2 lbs. (1 kg)/day for patients with both ascites and peripheral edema and no more than 1 lb. (0.5 kg)/day for patients with ascites alone. If daily weights cannot be obtained, diuretics can also be guided by the urinary sodium concentration. Dosage is increased until a negative sodium balance occurs.
Diuretic resistance: If a patient exhibits a resistance to or poor response to diuretic therapy, filtering their blood through a special machine (ultrafiltration or aquapheresis) may be needed to achieve adequate control of ascitic fluid. The use of such mechanical methods of fluid removal may restore responsiveness to conventional doses of diuretics in patients with diuretic resistance.
Water restriction:Water restriction is needed if hyponatremia develops.
Paracentesis: In those with severe ascites, therapeutic paracentesis may be needed in addition to medical treatments listed above. As this may deplete serum albumin levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed.
Liver transplantation: Ascites that is resistant to therapy is considered an indication for liver transplantation. In the United States, the MELD score is used to prioritize patients for transplantation.
Shunting:In some patients with advanced cirrhosis that have recurrent ascites, Transjugular Intrahepatic Portosystemic Shunts (TIPS) may be used. However, TIPS has NOT been shown to extend life expectancy, and is considered to be a bridge to liver transplantation. An analysis of controlled trials concluded: "TIPS was more effective at removing ascites as compared with paracentesis...however, TIPS patients develop hepatic encephalopathy significantly more often"
Treatment for Patients with Low SAAG Results: Mild ascites generally does not respond to manipulation of the salt balance or diuretic therapy. Repeated paracentesis and treatment of the underlying cause is the mainstay of treatment.