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Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012 © 2012 The American Association for the Study of Liver Diseases, All rights reserved. rights All Diseases, Liver of Study the for Association American The 2012 © FORWARD REFERENCES FULL TEXT FULL RECOMMENDATIONS CONTENTS Jump to: Jump PRACTICE GUIDELINE PRACTICE Bruce A. Runyon A. Bruce Update 2012 Update with Ascites Due to Cirrhosis: Cirrhosis: to Due Ascites with Management of Adult Patients Patients Adult of Management AASLD Management of Adult Patients with Ascites PRACTICE GUIDELINE Due to Cirrhosis: Update 2012 CONTENTS RECOMMENDATIONS FULL TEXT REFERENCES WEB SITE Contents (click section title or page number) Recommendations and Rationales .......................... 3 Full-text Guideline ..................................... 56 Abbreviations ........................................ 57 Preamble ........................................... 58 Introduction ......................................... 58 Evaluation and Diagnosis ............................... 59 Ascitic Fluid Analysis ................................... 62 Differential Diagnosis ................................... 63 Treatment of Ascites ................................... 64 Refractory Ascites ..................................... 70 Spontaneous Bacterial Peritonitis .......................... 74 Prevention of SBP ..................................... 79 Hepatorenal Syndrome ................................. 81 Additional Considerations ................................ 84 Hepatic Hydrothorax ................................... 85 References .......................................... 87 USING, SEARCHING, AND PRINTING GUIDELINES This document was designed for use on a variety Use the top menu to return to the list. This file reflects of devices using Adobe Acrobat Reader.® Smaller the most recently approved language of the published screens should be held horizontally. You may search guideline. Your feedback is welcome on the design and or print using your PDF viewer. Menu hyperlinks allow usability and will help guide future publications. movement between sections and to the guidelines on Please email your comments the AASLD site. In Recommendations and Rationales, to [email protected] click on individual items to review specific rationales. or visit our social media pages. BACK 2 FORWARD © 2012 The American Association for the Study of Liver Diseases, All rights reserved. AASLD Management of Adult Patients with Ascites PRACTICE GUIDELINE Due to Cirrhosis: Update 2012 CONTENTS RECOMMENDATIONS FULL TEXT REFERENCES WEB SITE Recommendations and Rationales This guideline includes 49 specific recommendations. Please click on a recommendation to review the related ratio- nale and supporting evidence. See Table 1 for an explanation of the grading system for recommendations. 1. Diagnostic abdominal paracentesis should 9. First-line treatment of patients with be performed and ascitic fluid should be cirrhosis and ascites consists of sodium obtained from inpatients and outpatients restriction (88 mmol per day [2000 mg with clinically apparent new-onset ascites. per day], diet education,) and diuretics (Class I, Level C) (oral spironolactone with or without oral furosemide). (Class IIa, Level A) 2. Since bleeding is sufficiently uncommon, the routine prophylactic use of fresh frozen 10. Fluid restriction is not necessary unless plasma or platelets before paracentesis is serum sodium is less than 125 mmol/L. not recommended. (Class III, Level C) (Class III, Level C) 3. The initial laboratory investigation of ascitic 11. Vaptans may improve serum sodium in fluid should include an ascitic fluid cell patients with cirrhosis and ascites. However count and differential, ascitic fluid total their use does not currently appear justified protein, and serum-ascites albumin gradient. in view of their expense, potential risks, (Class I, Level B) and lack of evidence of efficacy in clinically meaningful outcomes. (Class III, Level A) 4. If ascitic fluid infection is suspected, ascitic fluid should be cultured at the bedside in 12. An initial therapeutic abdominal paracentesis aerobic and anaerobic blood culture bottles should be performed in patients with tense prior to initiation of antibiotics. (Class I, Level B) ascites. Sodium restriction and oral diuretics should then be initiated. (Class IIa, Level C) 5. Other studies of ascitic fluid can be ordered based on the pretest probability of disease 13. Diuretic-sensitive patients should preferably (Table 3). (Class IIa, Level C) be treated with sodium restriction and oral diuretics rather than with serial 6. Testing serum for CA125 is not helpful in the paracenteses. (Class IIa, Level C) differential diagnosis of ascites. Its use is not recommended in patients with ascites of 14. Use of angiotensin converting enzyme any type. (Class III, Level B) inhibitors and angiotensin receptor blockers in patients with cirrhosis and ascites may 7. Patients with ascites who are thought be harmful, must be carefully considered in to have an alcohol component to their each patient, monitoring blood pressure and liver injury should abstain from alcohol renal function. (Class III, Level C) consumption. (Class I, Level B) 15. The use of nonsteroidal anti-inflammatory 8. Baclofen can be given to reduce alcohol drugs should be avoided in patients with craving and alcohol consumption in patients cirrhosis and ascites, except in special with ascites in the setting of alcoholic liver circumstances. (Class III, Level C) disease. (Class IIb, Level C) BACK 3 FORWARD © 2012 The American Association for the Study of Liver Diseases, All rights reserved. AASLD Management of Adult Patients with Ascites PRACTICE GUIDELINE Due to Cirrhosis: Update 2012 CONTENTS RECOMMENDATIONS FULL TEXT REFERENCES WEB SITE 16. Liver transplantation should be considered 25. Peritoneovenous shunt, performed by in patients with cirrhosis and ascites. a surgeon or inteventional radiologist (Class I, Level B) experienced with this technique, should be considered for patients with refractory 17. The risks versus benefits of beta blockers ascites who are not candidates for must be carefully weighed in each paracenteses, transplant, or TIPS. patient with refractory ascites. Systemic (Class IIb, Level A) hypotension often complicates their use. Consideration should be given to 26. Patients with ascites admitted to the hospital discontinuing or not initiating these drugs in should undergo abdominal paracentesis. this setting. (Class III, Level B) Paracentesis should be repeated in patients (whether in the hospital or not) who 18. The use of angiotensin converting enzyme develop signs or symptoms or laboratory inhibitors and angiotensin receptor blockers abnormalities suggestive of infection should be avoided in patients refractory (e.g., abdominal pain or tenderness, fever, ascites. Systemic hypotension often encephalopathy, renal failure, acidosis, or complicates their use. (Class III, Level B) peripheral leukocytosis). (Class I, Level B) 19. Oral midodrine has been shown to improve 27. Patients with ascitic fluid polymorphonuclear clinical outcomes and survival in patients leukocyte counts greater than or equal with refractory ascites; its use should be to 250 cells/mm3 (0.25 x 109/L) in a considered in this setting. (Class IIa, Level B) community-acquired setting in the absence 20. Serial therapeutic paracenteses are a of recent Β-lactam antibiotic exposure treatment option for patients with refractory should receive empiric antibiotic therapy, ascites. (Class I, Level C) e.g., an intravenous third-generation cephalosporin, preferably cefotaxime 2 g 21. Post-paracentesis albumin infusion may not every 8 hours. (Class I, Level A) be necessary for a single paracentesis of less than 4 to 5 L. (Class I, Level C) 28. Patients with ascitic fluid polymorphonuclear leukocyte counts greater than or equal 22. For large-volume paracenteses, an to 250 cells/mm3 (0.25 x 109/L) in a albumin infusion of 6-8 g per liter of fluid nosocomial setting and/or in the presence removed appears to improve survival and is of recent Β-lactam antibiotic exposure recommended. (Class IIa, Level A) should receive empiric antibiotic therapy based on local susceptibility testing of 23. Referral for liver transplantation should be bacteria in patients with cirrhosis. expedited in patients with refractory ascites, (Class IIa, Level B) if the patient is otherwise a candidate for transplantion. (Class IIa, Level C) 29. Oral ofloxacin (400 mg twice per day) can be considered a substitute for intravenous 24. Transjugular intrahepatic portosystemic cefotaxime in inpatients without prior stent-shunt (TIPS) may be considered exposure to quinolones, vomiting, shock, in appropriately selected patients who grade II (or higher) hepatic encephalopathy, meet criteria similar to those of published or serum creatinine greater than 3 mg/dL. randomized trials. (Class I, Level A) (Class IIa, Level B) BACK 4 FORWARD © 2012 The American Association for the Study of Liver Diseases, All rights reserved. AASLD Management of Adult Patients with Ascites PRACTICE GUIDELINE Due to Cirrhosis: Update 2012 CONTENTS RECOMMENDATIONS FULL TEXT REFERENCES WEB SITE 30. Patients with ascitic fluid polymorphonuclear 34. Intravenous ceftriaxone for 7 days or leukocyte counts less than 250 cells/mm3 twicedaily norfloxacin for 7 days should (0.25 x 109/L) and signs or symptoms of be given to prevent bacterial infections in infection (temperature >100° F or abdominal patients with cirrhosis and gastrointestinal pain or tenderness) should also receive
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