Articles
Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore Throat Differential Diagnosis Dizziness Differential Diagnosis Peritonsillar Abscess/Quinsy Acute Tonsillitis Acute Mastoiditis Otitis Media Otitis Externa Extravasation of IV Amiodarone WoS Paediatric Drooling and Aspiration Guideline Palliative Care – How to Refer Eating Disorders Stroke Care Warfarin Anticoagulation for AF, DVT and PE Molnupiravir MyPsych Foundation Doctors Toolkit Paediatric Febrile Neutropenia Guidance PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN   Paediatric Diabetic Ketoacidosis (DKA) Guideline Child Protection Policies and Procedures (D&G) Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care Cancer of Unknown Primary Patients Returning from Interventional Cardiac Procedure Treatment of Malaria Discharging Patients on High Dose Steroids Sotrovimab Paediatric Ketone Correction Guideline Insulin Correction Factor Table (Paediatrics) Management of uncomplicated Henoch-Schonlein Purpura (HSP) in under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – Methadone/Buprenorphine Prescribing Advice on Admission – Corticosteroids Prescribing Advice on Admission – Items Not Prescribed by GP Prescribing Advice on Admission – Patients on Chemotherapy Regimes Prescribing Advice on Admission – Medication for Parkinson’s Disease Prescribing Advice on Admission – Insulin Prescribing Advice on Admission Medical Emergencies in Eating Disorders (MEED) Gentamicin & Vancomycin HIV Testing Guidelines Metabolic Syndrome Associated Fatty Liver Disease (MAFLD) Greener Inhaler Prescribing C4 Predischarge Beds Handover Safe and Secure Handling of Medicines Blood Glucose & Steroids IV Fentanyl & Morphine for Acute Pain in Adults Assessment & Management of Acute Pain Hospitalised and Has Coronavirus19 Infection (No suspected Viral Pneumonia Syndrome) Hospitalised Due to Coronavirus19 with Likely Viral Pneumonia Bi-Level NIV S/T Guidelines for CCU Phase Bi-Level NIV S/T Guidelines for ED Phase Adults With Incapacity Premenstrual Syndrome Pelvic USS Boarding Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 2, Management of women with previous VTE THROMBOPROPHYLAXIS IN PREGNANCY, LABOUR AND THE PUERPERIUM Orthopaedic VTE Risk Assessment Sodium Glucose Transporter 2 Inhibitors (SGLT2i) Cardiology Referrals Vascular Referrals ‘Watershed’ Conditions Myasthenia Gravis Gentamicin in Renal Replacement Therapy Vancomycin in Renal Replacement Therapy REDMAP Poster Realistic Conversations Summary Plan for Deteriorating Health Treatment Escalation Plans Ambulatory Care for Blood and/or Iron Infusion Principles for Light Touch Patients – B2 Clostridiodes difficile Infection Post Astra Zeneca Vaccine Headache Blood Culture Rhabdomyolysis Analgesia Acute Appendicitis Small Bowel Obstruction Elective Admission – Colorectal Surgery Trauma Admissions Post-operative Care Gallstone Disease Vasopressors and Inotropes/Chronotropes Shock Elective Admission – ERCP Elective Admission – Orthopaedics Laxatives Fat Embolism Compartment Syndrome Surgical Post-operative Complications Stoma Diverticular Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Coming Off Benzodiazepines and “Z” Drugs Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Acute Kidney Injury – Introduction Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired Pneumonia (CAP) Management of Urinary Symptoms Management of Acute Kidney Injury SSRI Poisoning Immobility Autopsies Indications for Echocardiography Bradycardia Suspected Meningitis Hypernatraemia Diarrhoea – ACP Suspected Meningitis – ACP Blood Transfusion Brain Tumours Newer Antidiabetic Drugs Parkinson’s Disease Major Haemorrhage Protocols (DGRI & GCH) Major Haemorrhage Stroke Thrombolysis Heart Failure – ACP Suspected Anaphylaxis Anaphylaxis – ACP The AMB Score – ACP Transient Loss of Consciousness (TLOC) – ACP Bell’s Palsy – ACP Suspected Sepsis Lumbar Puncture Hypokalaemia Gentamicin Dosing Transient Loss of Consciousness Urinary Tract Infection Urethral Catheterisation Vancomycin Dosing Hyponatraemia Narrow Complex Tachycardia Hypocalcaemia New Onset Type 1 Diabetes – ACP Paracentesis for Tense Ascites – ACP Idiopathic Intracranial Hypertension – ACP Other Funny Turns Hypoglycaemia Hypoglycaemia – ACP Management of Transfusion Reactions Hypercalcaemia Haematemesis – ACP Anti-Platelet Therapy in Coronary Heart Disease Unfractionated Heparin Infusion Anaemia (Investigation) – ACP Delirium Suspected Seizure – ACP Headache – ACP Community Acquired Pneumonia – ACP Cellulitis Dyspepsia Management of Acute AF Rhythm Control in AF Atrial Fibrillation Renal Transplants Massive Pulmonary Embolism Head and Neck Injury Diabetic Ketoacidosis Switching from VRII Insulin Pumps Diabetes Mellitus Aspirin Digoxin Poisoning Tricyclic Antidepressants Opiates Benzodiazepines Gut Decontamination Deliberate Self Harm Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Abdominal Aortic Aneurysms Malignant Spinal Cord Compression Post Splenectomy Sepsis Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C Symptom Control Suspected Variceal Bleeding Severe Headache Status Epilepsy in Adults Lower Gastrointestinal Bleeding Functional & Social Assessment Breathlessness with Abnormal CXR Polymyalgia Rheumatica Rheumatoid Arthritis Ureteric Colic & Renal Stones Intravascular Catheter Related Blood Stream Infection Care of Vascular Access Urinary Incontinence Peritoneal Dialysis Related Peritonitis The First Seizure Hypertension Ventricular Tachycardia Cardiogenic Shock Complicating Acute Coronary Syndrome Telemetry The Diabetic Foot Subcutaneous Insulin Diabetes and Acute Coronary Syndrome Hyperosmolar Hyperglycaemic State Multiple Sclerosis Coma
 
Close Menu
 
 
In this section Close
In this section : Liver Disease
Metabolic Syndrome Associated Fatty Liver Disease (MAFLD) Decompensated Liver Disease Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C
Home | Articles | Liver Disease | Ascites in Cirrhosis

Ascites in Cirrhosis

Last updated 10th January 2024

Definitions

  • Uncomplicated Ascites
    • Grade 1 (mild) – only detectable by ultrasound
    • Grade 2 (moderate) – clinically detectable but not tense
    • Grade 3 (severe) – tense ascites
  • Refractory Ascites
    • Diuretic resistant ascites – refractory to salt restriction <100mmol/day and intensive diuretic therapy with Spironolactone up to 400mg/day and Frusemide up to 160mg/day
    • Diuretic intractable ascites – refractory due to diuretic induced complications that preclude use of effective diuretic dose

Investigations

  1. Important to determine cause – do not assume that the alcoholic patient with ascites necessarily has alcoholic liver disease
  2. All new and unwell patients should have urgent diagnostic tap requesting fluid albumin and protein (for serum ascites albumin gradient), WCC and culture
  3. Other tests should include routine bloods including LFTs and clotting screen, and abdominal ultrasound as per BSG/BASL Liver Bundle.

Ascitic Fluid Analysis

  1. Aspiration of ascitic fluid and its laboratory analysis is an essential step in the management of patients with newly diagnosed ascites.
  2. Request ascitic amylase if clinical suspicion of pancreatic disease.
    SA-AG>11g/LSA-AG<11g/L
    CirrhosisMalignancy
    Cardiac FailurePancreatitis
    Nephrotic SyndromeTuberculosis
  3. Request ascitic amylase if clinical suspicion of pancreatic disease.
  4. The ascitic fluid samples required from the diagnostic paracentesis summarised in figure below (amylase sometimes, BNP or adenosine deaminase rarely done) – always call BMS first, ext 33562 or via switchboard if out of hours.
    The ascitic fluid samples required from diagnostic paracentesis. *These investigations should be considered based on pretest probability of specific diagnosis. BNP, brain natriuretic peptide.

    Plain tube for biochemistry tests (albumin, amylase*, BNP*, adenosine deaminase)

    Plain tube for cytology*

    Plain tube for ascitic fluid microscopy and culture



    NOTE: separate bottles to be sent to each of the laboratories (biochemistry, cytology and microbiology)

    EDTA tube for Automated Cell Count (additional plain tube if microbiology cell count required)

    Standard blood culture bottles with ascitic fluid for culture and sensitivity.

Treatment of Uncomplicated Ascites

  1. Sodium restriction, no added salt diet – will decrease sodium intake to around 100mmol/day
  2. First line drug treatment of ascites should be Spironolactone 100 mg/day with Frusemide added in if the patient has leg oedema at 40mg/day, aiming for weight loss not greater than 0.5kg/day
  3. Increase doses of spironolactone or both drugs every 3-5 days to a maximum of Spiro 400mg and Frusemide 160mg if necessary and if tolerated both clinically and biochemically.
  4. Large volume paracentesis (LVP) is the standard of care for managing large volume ascites if the patient’s respiration is compromised, but has the risk of introducing infection which is life threatening because patients with decompensated liver disease are immunocompromised. Strict sodium restriction and additional fluid restriction is preferable in most cases. Paracentesis relieves symptoms of a tense abdomen and can also be used in the management of refractory ascites, when diuretics become ineffective or the side effects preclude their continued use, but TIPSS should be considered.
  5. Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) – consider for refractory ascites in patients with preserved liver function (bilirubin <60micromol/L) and no encephalopathy, who require frequent therapeutic paracentesis (blood bypassing the liver means that less toxins get cleared through the liver).
  6. Consider liver transplant in all suitable patients once cirrhotic ascites develops as therapeutic paracentesis and TIPS do not improve long term survival

 

What to do if Develops Hyponatraemia

  1. Sodium 126–135 mmol/l, normal creatinine. Continue diuretic therapy but observe serum electrolytes. Do not water restrict.
  2. Sodium 121–125 mmol/l, normal creatinine. BSG advises to stop diuretic therapy or adopt a more cautious approach.
  3. Sodium 121–125 mmol/l, creatinine >150 mmol/l or >120 mmol/l and rising. Stop diuretics and volume expand (in hepatorenal syndrome use albumin).
  4. Sodium <=120 mmol/l, stop diuretics. Risk of seizures. Always needs discussion with consultant. Be aware of development of central pontine myelinolysis if corrected too quickly. If encephalopathic then patient might require hypertonic saline and ICU admission.

Therapeutic Paracentesis

  1. Indicated for tense or refractory ascites if the patient has compromised respiration.
  2. Be aware of the high risk of introducing infection which is life threatening in these immunocompromised patients. Use very strict (theatre type) sterile technique.
  3. The “Bonano” suprapubic catheter is ideal for this purpose.
  4. Check clotting and platelets before the procedure. Bleeding is uncommon but discuss if INR>2 or platelets <50,000.
  5. Best site for drainage is usually right ileac fossa (on the left there can be a very lage spleen) 2 finger breath above and medial to anterior superior iliac spine – avoids liver, spleen, bladder, and the inferior epigastric arteries which run 5cm either side of the midline.
  6. Insert aseptically and drain completely over up to 6 hours – use 100ml bottle of albumin 20% infused over 30 minutes for every 2 litres ascites drained.
  7. Remove drain asap and certainly at 6 hours or earlier to limit risk of infection & fluid leak –patient can move and be turned onto the drain side towards end of procedure to maximise drainage. After removing, nurse patient on opposite side for 30-60 mins to minimise leak with occlusive dressing.
  8. If leaks at drainage site, use stitches as soon as possible to minimise risk of infection (iatrogenic bacterial peritonitis) which is life threatening.
  9. Give more albumin (100 ml 20 %) if patient becomes hypotensive.
  10. Refer to the Edinburgh Royal Infirmary Liver Unit if may be candidate for TIPSS

Outcome

  1. The development of ascites is associated with a mortality of 50% within 1 years of diagnosis and all patients with ascites should be considered for liver transplant.
  2. Once ascites becomes refractory to medical therapy, 50% die within six months, therefore, at its onset, suitability of liver transplantation should be considered and assessed as a priority.
  3. Particular risks for death include spontaneous (or iatrogenic) bacterial peritonitis and hepatorenal syndrome.

Spontaneous Bacterial Peritonitis (SBP)

  1. Ascitic fluid infection that occurs in patients with advanced cirrhosis spontaneously (without prior tap, drain nor surgery) and patients have a high risk of developing hepatorenal syndrome (HRS).
  2. May be asymptomatic but can also present with local (abdominal pain or rebound tenderness) or systemic (signs of sepsis) symptoms or signs.
  3. Diagnostic paracentesis indicated in all new onset ascites and in cirrhotic patients with ascites who become ill. However, if there is suspicion of SBP (e.g. rebound tenderness in a cirrhotic patient with known ascites or shifting dullness) treat before the diagnosis is confirmed because of the high mortality if not treated in time. Every hour delay in treatment begin increases the mortality!
  4. Send ascitic fluid to lab in white topped universal bottles and into blood culture bottles. This increases chances of detecting bacteria (many infections go undetected – see work on bacterascites done in Glasgow)
  5. Diagnosis confirmed if polymorph nuclear (PMN) cell count > 250 mm3. Culture may be negative in up to 60% of cases. If high percentage of lymphocytes (rather than PMN cells) then tuberculosis has to be considered. Please discuss with the labs and your consultant further tests (ZN stain, Quantiferon Gold).
  6. Treat empirically while awaiting culture results with Cefotaxime 2 g eight hourly for 5 days. Could also use Co-amoxiclav 1.2g tds IV or Ciprofloxacin 400mg bd IV. If sepsis confirmed in these immunocompromised patients consider escalation (tazocin, meropenem, antifungals) Any delay increases mortality.
  7. Long term secondary prophylaxis with co-trimoxazole oral 960mg once daily (first line) or ciprofloxacin oral 500mg once daily (second line).
  8. In 2016 the National Institute for Health and Care Excellence (NICE) recommended offering prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites and no history of SBP with an ascitic protein of ≤15 g/L (1.5 g/dL), until the ascites has resolved.

Hepatorenal Syndrome (HRS)

Note that urea as well as creatinine is often low in these patients who have muscle wasting and are malnourished. Even an increase in creatinine within the normal range is a sign of renal failure in these patients. Early diagnosis and referral to to the liver team / transfer to ward C5 is vital because of the poor prognosis.

  1. Renal failure that occurs in patients with cirrhosis and ascites in the absence of shock or nephrotoxic drugs. Bacterial infection used to exclude HRS but is now considered a precipitating cause.
  2. Type 1 HRS characterised by doubling SC to >260µmol/l in < 2 weeks, often developing in association with SBP. Median survival 2 weeks.
  3. Type 2 HRS typically associated with use of diuretics for refractory ascites. Median survival 6 months.
  4. As a general rule the kidneys do not recover until the liver recovers, which it often does not (therefore, renal replacement therapy is futile and not recommended).
  5. For type 1 HRS (not Type 2) Rx 20% albumin (20 g per 100 ml, do not use 5 % unless severely intravascularly dry) 1 g/kg/day up to 100 g on first day then 20-40 g/day together with terlipressin 5-2 (typical starting dose is 1 mg qds) mg every 4 hours initially, reviewing the renal function and increasing as clinically indicated in discussion with the liver team. Terlipressin is contraindicated in ischaemic heart disease / peripheral vascular disease and arrhythmias. Note the risk of peripheral necrosis.

Differential Diagnosis of Ascites

  1. Cirrhosis with portal hypertension and hypoalbuminaemia – in Scotland often related to alcohol related liver disease, as above.
  2. Malignancy – see below.
  3. Venous thrombosis: portal vein (most common), splenic or hepatic vein (Budd Chiari syndrome, less common, consider thrombophilia disorders)
  4. Cardiac causes eg severe right heart failure or constricted pericarditis – uncommon (if chronic can cause cardiac cirrhosis).
  5. Others eg cancer (relatively common: gastric, gynaecological), TB, pancreatitis, malnutrition, nephrotic syndrome, myxoedema – less common.

Malignant Ascites

  1. Commonly seen with ovarian, breast, gastric, colonic and hepatocellular carcinoma.
  2. Calculate serum albumin ascites gradient (SAAG) by subtracting fluid protein concentration from serum albumin (see SAAG Calculator (MDCalc)).
  3. SAAG <11g/litre (exudate) when cause is diffuse peritoneal cancer – paracentesis is treatment of choice (send as much ascites off for cytology as possible), repeat as necessary. No evidence that albumin infusion improves outcome.
  4. Less commonly SAAG >11g/litre (transudate) when cause is portal hypertension – these patients may respond to spironolactone (see above).
  5. Prognosis generally poor – median survival is 3 months unless ovarian cancer responsive to chemotherapy.

Links

Content by Dr Mathis Heydtmann & Dr Moawad Mahgoub