Ascites medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]


The mainstays of first-line treatment of patients with cirrhosis and ascites include (1) education regarding dietary sodium restriction (2000 mg per day [88 mmol per day]) and (2) oral diuretics. Medical therapy is based on different grades of ascites. Medical therapy would inhibit different processes in pathophysiology of ascites. First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2000 mg per day], diet education), and diuretics (oral spironolactone with or without oral furosemide).

Ascites Treatment Recommendations (DO NOT EDIT)

Recommendations for the treatment of Ascites[1]

Recommendations for the treatment of Refractory Ascites[1]

Medical Therapy

  • The mainstays of first-line treatment of patients with cirrhosis and ascites include:[1]
    • Education regarding dietary sodium restriction (2000 mg per day [88 mmol per day])
    • Oral diuretics
  • Medical therapy is based on different grades of ascites.[2]
Grade Description Therapy
Grade I Mild fluid accumulation, only detectable with ultrasonography No treatment
Grade II Moderate fluid accumulation, detectable by physical examination Sodium intake restriction and diuretics
Grade III Severe fluid accumulation, detectable by inspection of flanks bulging Large volume paracentesis followed by sodium intake restriction and diuretics
Portal hypertension
Vasodilator release
Splanchnic arteriolar vasodilation
Splancnic hypertension
Beta blockers
Hypovolemia and Arterial hypotension
Sympathetic nerve activation
Renin-angiotensin-aldosterone system activation
Aldosterone antagonists
Vasopressin activation
Increased lymph formation
Sodium and water retention
Loop diuretics
Plasma volume expansion

Dietary salt and water intake restriction

  • Limitation of daily sodium intake results in negative sodium balance and also redistribution of fluid retention.
  • Daily avoidance of prepared foods along with no added salt diet would lead to suitable sodium restriction (80–120 mMol, corresponded to 4.6–6.9 grams of salt/day).
  • Water restriction is the absolute therapy for fluid accumulation in uncomplicated ascites. However, decreasing water input to <1 L/day is almost impossible in some patients.[4]


  • 1 Grade I
    • No treatment is needed.
  • 2 Grade II
    • 2.1 Adult
    • The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema and no more than 0.5 kg/day for patients with ascites alone.[5]
    • 2.2 Pediatric[6]
      • Preferred regimen (1): Spironolactone 2-3 mg/kg PO as a single morning dose (max. dose 2 mg/kg every 5-7 days)
      • Preferred regimen (2): Furosemide up to 1 mg/kg PO daily (max. dose 40 mg)
      • Preferred regimen (3): Albumin 25% up to 1 g/kg IV daily, up to q8h (until plasma level > 2.5 g/dL)


  1. 1.0 1.1 1.2 Runyon, BA. "Management of adult patients with ascites due to cirrhosis: update 2012" (PDF).
  2. "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J. Hepatol. 53 (3): 397–417. 2010. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.
  3. Pedersen JS, Bendtsen F, Møller S (2015). "Management of cirrhotic ascites". Ther Adv Chronic Dis. 6 (3): 124–37. doi:10.1177/2040622315580069. PMC 4416972. PMID 25954497.
  4. Ginès P, Cárdenas A (2008). "The management of ascites and hyponatremia in cirrhosis". Semin. Liver Dis. 28 (1): 43–58. doi:10.1055/s-2008-1040320. PMID 18293276.
  5. Shear L, Ching S, Gabuzda GJ (1970). "Compartmentalization of ascites and edema in patients with hepatic cirrhosis". N. Engl. J. Med. 282 (25): 1391–6. PMID 4910836.
  6. Giefer, Matthew J; Murray, Karen F; Colletti, Richard B (2011). "Pathophysiology, Diagnosis, and Management of Pediatric Ascites". Journal of Pediatric Gastroenterology and Nutrition. 52 (5): 503–513. doi:10.1097/MPG.0b013e318213f9f6. ISSN 0277-2116.

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