Management of ascites in patients with end-stage liver disease

Ascites is the most common complication in patients with decompensated cirrhosis. Approximately 50% of patients with compensated cirrhosis will develop ascites over a 10-year period. This occurrence is an important milestone in the natural history of end-stage liver disease because only 50% of patients survive 2 to 5 years (depending on the cause of cirrhosis) after its onset. Salt restriction and diuretics are the mainstays of therapy, and these measures are effective in approximately 90% of patients. Large-volume paracentesis or transjugular intrahepatic portosystemic shunt can be used in patients with refractory ascites as either a bridge to transplant or as palliation. Cirrhotic patients with ascites should be carefully monitored for the development of bacterial peritonitis, and those at greatest risk should receive antibiotic prophylaxis. When spontaneous bacterial peritonitis is suspected, prompt diagnostic paracentesis followed by broad-spectrum antibiotics and albumin infusion can be life saving. Orthotopic liver transplantation should be considered in all patients with decompensated liver disease with or without ascites.