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Medical Author:

Benjamin Wedro, MD, FACEP, FAAEM

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Excess fluid in the abdominal cavity can cause significant discomfort and shortness of breath. The method of treatment depends upon the reason for the ascites accumulation, how quickly the fluid has accumulated, whether it is a first occurrence or a repeated event, and how significantly the symptoms affect the patient.

For patients with cirrhosis, the initial therapy for ascites begins with dietary salt restriction and medications to assist the body in ridding itself of excess salt and fluid. Spironolactone (Aldactone) is a first line diuretic medication that helps block the chemical aldosterone which is responsible for salt retention in the body. Furosemide (Lasix) and metolazone (Zaroxolyn) may also be added. This treatment is effective in controlling ascites fluid in the vast majority of patients.

Body weight is used as a measurement of ascites control. The goal for diuretic therapy is to lose between one to two pounds of weight per day depending upon underlying medical conditions. Once most of the ascites fluid is gone, medication dosing will be individualized to the patient's needs.

Water restriction may be considered if hyponatremia, (low serum sodium) is present.

• Paracentesis: If diuretics and diet fail, paracentesis may be the next step in the treatment offered. Under sterile conditions, a needle is placed into the peritoneal space and fluid is withdrawn. Paracentesis may be considered as a first step if the ascites fluid accumulates quickly and the abdominal distension causes pain or shortness of breath. Because the peritoneal fluid contains albumin, if large amounts of fluid (more than 5 liters) are withdrawn, an albumin transfusion may be needed.

Paracentesis may be done more than once, but if it becomes a frequent necessity for symptom control, other options may be considered.

The complications of paracentesis include infection, bleeding, electrolyte disturbances, and perforating an organ such as the intestine. However, in tense ascites, the benefits outweigh the risks in providing relief to the patient.

• Transjugular intrahepatic portosystemic shunt (TIPS): TIPS diverts fluid from the portal vein into the central blood circulation, thus decreasing pressure in the liver and decreasing ascites formation. An interventional radiologist is able to thread a catheter or stent underneath the skin from the internal jugular vein to the hepatic vein while the patient is sedated.
  
  
• Liver transplant: Patients who have cirrhosis and ascites should be considered as candidates for potential liver transplantation.
  
  
• Cancer: In patients with ascites from cancer, diet restrictions and diuretics are not effective. Paracentesis may be the first-line treatment. If needed, the catheter maybe left in place to drain, so that fluid can be removed as needed and the patient does not need to undergo repeated procedures.
  
  
• Peritoneovenous shunting: Peritoneovenous shunting is a surgical operation that may increase short-term survival in cancer patients who are not candidates for, or who have failed treatment with, paracentesis. Shunting may be also considered for patients who have refractory ascites and are not candidates for paracentesis, liver transplant, or a TIPS procedure.

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