Management of ascites. Paracentesis as a guide

All patients with new-onset ascites or with known ascites and any change in their condition, such as the appearance of fever, abdominal pain, renal insufficiency, or encephalopathy, should undergo diagnostic paracentesis to characterize the ascitic fluid, detect infection, and aid differential diagnosis. A serum-ascites albumin gradient greater than 1.1 g/dL indicates portal hypertension. Spontaneous bacterial peritonitis is a common and serious complication of ascites and is best diagnosed by the number of neutrophils in the ascitic fluid. Patients with the condition should be treated with parenteral antibiotics, and response to therapy should be assessed with repeated paracentesis. Hospitalized patients with low-protein ascites should receive antibiotic prophylaxis. Sodium restriction and diuretics are the cornerstones of therapy for ascites. In refractory cases, alternative forms of therapy, such as large-volume paracentesis, peritoneovenous shunting, or transjugular intrahepatic portosystemic shunting, may be of benefit. Patients with refractory ascites should be considered for liver transplantation.