Paracentesis
In those with severe (tense) 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. Surgery
Ascites that is refractory to medical therapy is considered an indication for liver transplantation. In the United States, the MELD score (online calculator) is used to prioritize people for transplantation. In a minority of people with advanced cirrhosis that have recurrent ascites, shunts may be used. Typical shunts used are portacaval shunt, peritoneovenous shunt, and the transjugular intrahepatic portosystemic shunt (TIPS). However, none of these shunts has been shown to extend life expectancy, and are considered to be bridged to liver transplantation. A meta-analysis of randomized controlled trials by the international Cochrane Collaboration concluded that "TIPS was more effective at removing ascites as compared with paracentesis...however, people with TIPS develop hepatic encephalopathy significantly more often".Another potential treatment option for patients with refractory/malignant ascites is the alfapump, (automated low flow ascites pump) which is an implantable device that removes ascites out of the peritoneal cavity and transports it via the pump into the bladder, where it passed naturally from the body through urination. Low SAAG ("exudative") ascites
Exudative 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. Society and culture
It has been suggested that ascites was seen as a punishment especially for oath-breakers among the Proto-Indo-Europeans.
People with ascites generally will complain of progressive abdominal heaviness and pressure as well as shortness of breath due to mechanical impingement on the diaphragm.Ascites is detected with physical examination of the abdomen by visible bulging of the flanks in the reclining person ("flank bulging"), "shifting dullness" (difference in percussion note in the flanks that shifts when the person is turned on the side), or in massive ascites, with a "fluid thrill" or "fluid wave" (tapping or pushing on one side will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen). Other signs of ascites may be present due to its underlying cause. For instance, in portal hypertension (perhaps due to cirrhosis or fibrosis of the liver) people may also complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy. Those with ascites due to cancer (peritoneal carcinomatosis) may complain of chronic fatigue or weight loss. Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance. Complications
Complications may include spontaneous bacterial peritonitis, hepatorenal syndrome, and thrombosis. Portal vein thrombosis and splenic vein thrombosis involve clotting of blood affects the hepatic portal vein or varices associated with splenic vein. This can lead to portal hypertension and a reduction in blood flow. When a person with liver cirrhosis has thrombosis, it is not possible to perform a liver transplant, unless the thrombosis is very minor.