The treatment of ascites largely depends on the underlying cause. For example, peritoneal carcinomatosis or malignant ascites may be treated by surgical resection of the cancer and chemotherapy, while management of ascites related to heart failure is directed toward treating heart failure with medical management and dietary restrictions.
Cirrhosis of the liver is the main cause of ascites, and related treatment involves:
Managing ascites in patients with cirrhosis typically involves limiting dietary sodium intake and the use of diuretics (water pills). Restricting dietary sodium (salt) intake to less than 2 grams per day is very practical, successful, and widely recommended for patients with ascites. In majority of cases, this approach needs to be combined with the use of diuretics as salt restriction alone is generally not an effective way to treat ascites. Consultation with a nutrition expert in regards to daily salt restriction can be very helpful for patients with ascites.
Diuretics increase water and salt excretion from the kidneys. The recommended diuretic regimen in the setting of liver related ascites is a combination of spironolactone (Aldactone) and furosemide (Lasix). Single daily dose of 100 milligrams of spironolactone and 40 milligrams of furosemide is the usual recommended initial dosage. This can be gradually increased to obtain appropriate response to the maximum dosage of 400 milligrams of spironolactone and 160 milligrams of furosemide, as long as the patient can tolerate the dose increase without any side effects. Taking these medications together in the morning is typically advised to prevent frequent urination during the night.
For patients who do not respond well to or cannot tolerate the above regimen, frequent therapeutic paracentesis (a needle carefully is placed into the abdominal area, under sterile conditions) can be performed to remove large amounts of fluids. A few liters (up to 4 to 5 liters) of fluid can be removed safely by this procedure each time. For patients with malignant ascites, this procedure may also be more effective than diuretic use.
For more refractory cases, surgical procedures may be necessary to control the ascites. Transjugular intrahepatic portosystemic shunts (TIPS) is a procedure done through the internal jugular vein (the main vein in the neck) under local anesthesia by an interventional radiologist. A shunt is placed between the portal venous system and the systemic venous system (veins returning blood back to the heart), thereby reducing the portal pressure. This procedure is reserved for patients who have minimal response to aggressive medical treatment. It has been shown to reduce ascites and either limit or eliminate the use of diuretics in a majority of cases performed. However, it is associated with significant complications such as hepatic encephalopathy (confusion) and even death.
More traditional shunt placements (peritoneovenous shunt and systemic portosystemic shunt) have been essentially abandoned due to their high rate of complications.
Finally, liver transplantation for advanced cirrhosis may be considered a treatment for ascites due to liver failure. Liver transplant involves a very complicated and prolonged process, and it requires very close monitoring and management by transplant specialists.
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