COMMENTARY

Management of Ascites

Rowen K. Zetterman, MD

Disclosures

April 05, 2011

In This Article

Complications of Ascites

Spontaneous Bacterial Peritonitis

SBP occurs in approximately 10% of patients with cirrhosis and ascites,[12] and this complication can be asymptomatic. Paracentesis should be performed in all patients with new-onset ascites or those symptomatic with signs of infection, abdominal pain, encephalopathy, nausea or vomiting, or gastrointestinal bleeding. The diagnosis of SBP should be considered likely if ascitic fluid contains more than 250 polymorphonuclear leukocytes (PMNs)/µL. Bacteria in SBP are invariably aerobic or microaerophilic enteric organisms. Skin organisms such as staphylococci can be introduced by previous paracentesis. Up to 40% of patients with symptoms and signs of SBP will have negative ascites cultures,[13] but they should still be treated with antibiotics. Bacterascites can occur, evidenced by a positive bacterial culture in the absence of ascitic leukocytosis.[13] If the patient is asymptomatic, ascitic fluid should be recultured, and if the repeat culture is positive, the patient should be treated with antibiotics. If the repeat culture is negative, the patient can be observed.

SBP may follow an upper gastrointestinal (GI) bleed in patients with cirrhosis and ascites.[8] Administration of antibiotics such as oral fluoroquinolones or broad-spectrum antibiotics to patients with upper GI bleeding[14] can reduce the risk for SBP. Patients with low protein ascites and recurrent SBP might also benefit from antibiotic prophylaxis.

Refractory Ascites

Refractory ascites is defined as ascites that cannot be clinically mobilized by diuresis or ascites that recurs quickly despite appropriate diuretic doses or when complications of diuretics preclude their continuation.[15] Refractory ascites develops in up to 10% of patients with ascites and may be associated with type 2 hepatorenal syndrome.

Complications of Paracentesis

Paracentesis may result in a persisting ascitic leak at the site of needle puncture or infection with skin organisms. Thoracentesis of a hepatic hydrothorax that results in a pneumothorax can be life threatening because of massive fluid losses through the chest tube when negative pressure is used to re-expand the lung.[16]

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