see also gastroenterology, cirrhosis

• usually transudative due to either:
  • elevated portal venous pressures
  • hypoalbuminaemia
  • enhanced renal retention of sodium
• uncommonly, it is exudative as in:
  • spontaneous bacterial peritonitis (SBP)
  • neoplasia / cancer / tumours such as:
    • hepatocellular carcinoma
    • peritoneal carcinomatosis
    • ovarian tumours
  • rarely, mesenteric panniculitis (MP) / sclerosing mesenteritis

• Rx underlying liver disease if possible
• Rx precipitants such as infections
• avoid salt in diet
• avoid drugs that:
  • promote sodium retention (eg. non-steroidal anti-inflammatory drugs (NSAIDs))
  • contain large amounts of sodium (eg. antacids, aspirin (acetylsalicylic acid), effervescent preparations)
  • ensure adequate protein intake unless hepatic encephalopathy
• if symptomatic (eg. discomfort, distension):
  • spironolactone 50-100mg o mane

• as for mild, plus,
• consider admission to hospital for RIB, daily weighs, monitoring fluid balance, urine output, renal function.
• send ascitic fluid to exclude spontaneous bacterial peritonitis (SBP)
• spironolactone 100mg o mane, increase dose by 100mg/day every 4-7 days prn to max. 400mg/d
• if ascites prominent or refractory to above, add:
  • frusemide / furosemide / Lasix 40mg o mane
  • can use higher doses but may ppt hypokalaemia or aggravate renal impairment
• if tense ascites or refractory, consider paracentesis over 1-3hrs to drain ascitic fluid:
  • if > 5L removed then infuse albumin 6-8g per L ascites removed

• requires specialised care with consideration of:
  • repeated paracentesis
  • reduction in portal pressure via:
    • operative portosystemic shunt
    • percutaneous insertion of shunt between hepatic & portal vein
      • transjugular intrahepatic portosystemic shunt (TIPS)
  • peritoneovenous shunt to drain ascites from peritoneum into SVC (Le Veen shunt)
  • liver transplantation