What are the guideline sources, guidelines and references for Ascites ?
Guideline sources The following summarized guidelines for the evaluation and management of ascites are prepared by our editorial team based on guidelines from the British Association for the Study of the Liver (BASL/BSG 2021), the American Association for the Study of Liver Diseases (AASLD 2021; 2014), and the European Association for the Study of the Liver (EASL 2018). 1 2 3 4 5 6 6 6 Definition Ascites is a pathologic accumulation of fluid within the peritoneal cavity that usually develops as a result of liver disease, congestive HF, or nephrotic syndrome. 5 Epidemiology Ascites is most frequently caused by portal hypertension occurring in the setting of cirrhosis. Other causes are broadly divided into pre-hepatic (portal vein thrombosis, lymphoma, abdominal lymphatic injury or obstruction, bowel perforation, renal failure, pancreatitis, peritoneal tuberculosis or malignancy with peritoneal implants) and post-hepatic (congestive HF, constrictive pericarditis, Budd-Chiari syndrome, and stricture/web formation in the IVC) causes. 6 https://web.pathway.md/diseases/recs0e0JJ5V8pmQoN 1/8 6/23/23, 3:10 AM Ascites Pathway Disease course Ascites causes clinical manifestations of abdominal distention, abdominal fullness, discomfort, shortness of breath, early satiation, and a sense of reduced mobility. 6 Prognosis and risk of recurrence Ascites is associated with a 1-year mortality of 40%. Refractory ascites has a median survival rate of 6 months. 6 Calculator Calculator Child Pugh score for mortality in Mumtaz readmission risk score i Guidelines 1. Diagnostic investigations Initial evaluation: Obtain the following as part of the initial evaluation of patients with ascites: history and physical examination abdominal ultrasound laboratory assessment of liver and renal functions, serum and urine electrolytes ascitic fluid analysis. Use contrast media cautiously and implement appropriate preventive measures for renal impairment, B although the use of contrast media does not appear to be associated with an increased risk of renal impairment in patients with ascites and preserved renal function. B 2. Diagnostic procedures Diagnostic paracentesis: As per AASLD 2021 guidelines, perform diagnostic paracentesis in all patients with new-onset ascites accessible for sampling. E Show 5 more As per BSG 2021 guidelines, perform diagnostic paracentesis in all patients with new-onset ascites. B Show 6 more As per EASL 2018 guidelines, perform diagnostic paracentesis in all patients with new-onset grade 2 or 3 ascites, and in hospitalized patients with worsening ascites or any complication of https://web.pathway.md/diseases/recs0e0JJ5V8pmQoN 2/8 6/23/23, 3:10 AM Ascites Pathway cirrhosis. B Show 6 more 3. Medical management General principles: Control and treat gastrointestinal hemorrhage, renal impairment, hepatic encephalopathy, hyponatremia, or alterations in serum potassium concentration before initiating diuretic therapy. Be cautious when initiating diuretic therapy and obtain frequent clinical and biochemical assessments. B Identify and treat etiological factors in patients with decompensated cirrhosis, particularly alcohol consumption and hepatitis B or C virus infection. B Diuretic therapy: As per AASLD 2021 guidelines: Initiate diuretics (spironolactone with or without furosemide), along with moderate sodium restriction (2 g or 90 mmol/day), as first-line therapy in patients with cirrhosis and grade 2 ascites. E Attempt to taper the diuretics to the lowest dose necessary to maintain minimal or no ascites to prevent the development of adverse effects after ascites is adequately mobilized. E As per BSG 2021 guidelines, consider initiating spironolactone monotherapy (starting dose 100 mg, increased to 400 mg) in patients with the first presentation of moderate ascites. B Show 6 more As per EASL 2018 guidelines, initiate spironolactone (starting at 100 mg/day PO, with stepwise increases every 72 hours to a maximum of 400 mg/day if there is no response to lower doses) in patients with a first episode of grade 2 ascites. A Show 4 more Intravenous albumin: As per AASLD 2021 guidelines: Consider administering human albumin solution (20-40 g/week) in patients with severe muscle cramps. E Insufficient evidence to support the routine long-term infusion of human albumin solution in patients with cirrhosis and diuretic-responsive ascites. I As per BSG 2021 guidelines, administer albumin (20% or 25% solution) after paracentesis of > 5 L is completed at a dose of 8 g albumin/L of ascites removed. A Show 2 more Other agents: As per AASLD 2021 guidelines, consider administering baclofen (10 mg/day, with a weekly increase of 10 mg/day, up to 30 mg/day) in patients with severe muscle cramps. E https://web.pathway.md/diseases/recs0e0JJ5V8pmQoN 3/8 6/23/23, 3:10 AM Ascites Pathway As per EASL 2018 guidelines, insufficient evidence to support adding clonidine or midodrine to improve the efficacy of diuretic treatment. I Medications to avoid: As per AASLD 2021 guidelines: Avoid using NSAIDs, ACEIs and ARBs in patients with cirrhosis and ascites. D Avoid using aminoglycosides for the treatment of bacterial infections, whenever possible. D As per EASL 2018 guidelines: Avoid NSAIDs in patients with ascites because of the high risk of developing further sodium retention, hyponatremia, and AKI. D Avoid ACEIs, ARBs, or alpha-1 receptor blockers in most patients with ascites, as these drugs have been associated with an increased risk of renal impairment. D Management of hyponatremia: obtain monitoring and advise water restriction in patients with mild hyponatremia (126-135 mEq/L) without symptoms. E Show 6 more 4. Nonpharmacologic interventions Salt restriction: As per AASLD 2021 guidelines, advise moderate sodium restriction (2 g or 90 mmol/day) in patients with cirrhosis and grade 2 ascites. E As per BSG 2021 guidelines: Advise moderate salt restriction with daily salt intake of 5-6.5 g (87-113 mmol sodium), meaning no added salt diet with avoidance of precooked meals, in patients with cirrhosis and ascites. B Provide nutritional counseling on the sodium content in the diet in patients with cirrhosis and ascites. B As per EASL 2018 guidelines, advise moderate restriction of sodium intake (80-120 mmol/day, corresponding to 4.6-6.9 g of salt) in patients with moderate, uncomplicated ascites. A Fluid restriction: do not advise fluid restriction for ascites management unless there is concomitant moderate or severe hyponatremia (serum sodium 125 mmol/L). D Physical activity: insufficient evidence to support prolonged bed rest for the treatment of ascites. I 5. Therapeutic procedures Therapeutic paracentesis: As per AASLD 2021 guidelines, perform large-volume paracentesis as first-line therapy in patients with grade 3 ascites. Advise sodium restriction and initiate diuretics after paracentesis. E https://web.pathway.md/diseases/recs0e0JJ5V8pmQoN 4/8 6/23/23, 3:10 AM Ascites Pathway As per BSG 2021 guidelines: Consider using ultrasound guidance when available during large-volume paracentesis to reduce the risk of adverse events. C Do not obtain routine measurement of the PT and platelet count before therapeutic or diagnostic paracentesis and infusion of blood products. D As per EASL 2018 guidelines, perform large-volume paracentesis, removing ascites completely in a single session, as first-line therapy in patients with large ascites (grade 3 ascites), followed by plasma volume expansion to prevent post-paracentesis circulatory dysfunction. A Show 4 more Transjugular intrahepatic portosystemic shunt: As per BSG 2021 guidelines: Consider performing TIPS placement in patients with refractory ascites. B Be cautious when considering TIPS placement in patients with: age > 70 years serum bilirubin > 50 mcmol/L platelet count < 75 10 /L MELD score 18 current hepatic encephalopathy active infection or hepatorenal syndrome. B As per EASL 2018 guidelines, evaluate patients with refractory or recurrent ascites for TIPS insertion. A Show 5 more Implantable peritoneal pump: As per BSG 2021 guidelines, consider placing an automated low-flow ascites pump only in special circumstances with robust arrangements of clinical governance, audit or research. C As per EASL 2018 guidelines, consider placing an implantable peritoneal pump in experienced centers in patients with refractory ascites not amenable to transhepatic intrajugular portosystemic shunt insertion. Obtain close monitoring because of the high risk of adverse events including renal dysfunction and technical difficulties. B 6. Surgical interventions Liver transplantation: As per AASLD 2021 guidelines, consider referring patients with grade 2 or 3 ascites for evaluation for liver transplantation. E As per EASL 2018 guidelines, evaluate patients with refractory ascites or hydrothorax for liver transplantation. B Show 10 more As per AASLD 2014 guidelines: https://web.pathway.md/diseases/recs0e0JJ5V8pmQoN 5/8 6/23/23, 3:10 AM Ascites Pathway Consider evaluating for liver transplantation once a patient with cirrhosis has experienced an index complication, such as ascites, hepatic encephalopathy, or variceal hemorrhage, or hepatocellular dysfunction results in a MELD score 15. B Treat potentially treatable etiologies and components of hepatic decompensation in liver transplant candidates, such as ascites, hepatic encephalopathy, or variceal hemorrhage. B Elective hernia repair: As per AASLD 2021 guidelines: Perform elective hernia repair in patients with cirrhosis through a multidisciplinary approach after ascites has been controlled and the patient's overall condition, including nutritional status, has been optimized. E Consider performing TIPS placement before elective hernia repair or after an emergent surgery in patients with cirrhosis and uncontrolled ascites. E As per BSG 2021 guidelines, discuss the suitability and timing of surgical repair of umbilical hernia with the patient and multidisciplinary team involving physicians, surgeons, and anesthesiologists. B 7. Specific circumstances Pediatric patients: obtain a comprehensive evaluation of clinical history, physical examination, and diagnostic testing including abdominal ultrasound for the diagnosis of ascites and its cause in pediatric patients. E Show 6 more Patients with bacterascites: Initiate antibiotics in patients with bacterascites (neutrophil count < 250/mm but positive bacterial culture) exhibiting signs of systemic inflammation or infection. B Perform a second paracentesis in patients with bacterascites as an alternative strategy to antibiotic therapy. Initiate treatment if the culture results come back positive again regardless of the neutrophil count. B Patients with hepatic hydrothorax: As per AASLD 2021 guidelines, advise dietary sodium restriction and initiate diuretics plus thoracentesis as required as first-line therapy in patients with hepatic hydrothorax. E Show 3 more As per BSG 2021 guidelines: Consider performing TIPS placement in patients with hepatic hydrothorax, after discussion with the multidisciplinary team. B Consider offering alternative palliative interventions in patients with hepatic hydrothorax not undergoing TIPS placement and/or liver transplant evaluation. B As per EASL 2018 guidelines, exclude cardiopulmonary and primary pleural disease before diagnosing hepatic hydrothorax. B Show 6 more https://web.pathway.md/diseases/recs0e0JJ5V8pmQoN 6/8 6/23/23, 3:10 AM Ascites Pathway 8. Follow-up and surveillance Serial clinical and laboratory assessment: As per AASLD 2021 guidelines, monitor body weight and serum creatinine and sodium regularly to assess response and to detect the development of adverse effects in patients receiving diuretics. E As per EASL 2018 guidelines, advise a maximum weight loss of 0.5 kg/day in patients without edema and 1 kg/day in patients with edema during diuretic therapy. B Show 2 more Post-TIPS care: Continue diuretics and salt restriction after TIPS insertion up to the resolution of ascites. B Continue close clinical follow-up after TIPS insertion. B Management of inadequate response: Initiate the combination of a mineralocorticoid receptor antagonist and furosemide in patients with long-standing or recurrent ascites, increasing the doses sequentially according to clinical response. A Consider initiating torasemide in patients exhibiting a weak response to furosemide. B Management of refractory ascites: As per AASLD 2021 guidelines, advise continued dietary sodium restriction (< 2 g/day) in patients with refractory ascites to reduce the rate of ascites accumulation. E Show 10 more As per BSG 2021 guidelines, do not view refractory ascites as a contraindication to nonselective -blockers. D Show 2 more As per EASL 2018 guidelines, diagnose refractory ascites based on the assessment of the response of ascites to diuretic therapy and salt restriction in stable patients without associated complications, such as bleeding or infection, after ascertaining patient compliance with treatment. B Show 6 more Likelihood Ratios Pertinent positives The following findings increase the probability of ascites in adults. 1 1 Finding LR+ Value Positive fluid wave sign 5.3 (2.9-9.5) History of recent increase in abdominal girth 4.1 (2.3-4.7) History of recent weight gain 3.2 (1.7-6.2) History of ankle swelling 2.8 (1.8-4.3) https://web.pathway.md/diseases/recs0e0JJ5V8pmQoN 7/8 6/23/23, 3:10 AM Ascites Pathway Show 3 more Pertinent negatives The following findings decrease the probability of ascites in adults. 1 1 Finding LR- Value Absence of flank dullness 0.1 No history of ankle swelling 0.10 (0.01-0.67) No history of recent increase in abdominal girth 0.17 (0.05-0.62) No history of recent weight gain 0.42 (0.20-0.87) Show 1 more References 1. Guruprasad P Aithal, Naaventhan Palaniyappan, Louise China et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021 Jan;70 1 9 29. Open 2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69 2 406 460. Open 3. Scott W Biggins, Paulo Angeli, Guadalupe Garcia-Tsao et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Aug;74 2 1014 1048. Open 4. Paul Martin, Andrea DiMartini, Sandy Feng et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014 Mar;59 3 1144 65. Open 5. Ming-Huei Cheng, Ming-Shyen Yen, Kuan-Chong Chao et al. Differential diagnosis of gynecologic organ- related diseases in women presenting with ascites. 2008 Dec;47 4 384 90.2008 Dec;47 4 384 90. Open 6. Christopher M Moore, David H Van Thiel. Cirrhotic ascites review: Pathophysiology, diagnosis and management. 2013 May 27;5 5 251 63.2013 May 27;5 5 251 63. Open 7. de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015 Sep;63 3 743 52. Open 8. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010 Sep;53 3 397 417. Open 9. Runyon BA, AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013 Apr;57 4 1651 3. Open 10. D L Simel, R A Halvorsen Jr, J R Feussner. Quantitating bedside diagnosis: clinical evaluation of ascites. J Gen Intern Med. Sep-Oct 1988;3 5 423 8. 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