Guidelines on the management of ascites in cirrhosis

Abstract

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the ‘Grading of Recommendations Assessment, Development and Evaluation (GRADE)’ system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years’ time.

Management of Cirrhotic Ascites under the Add-on Administration of Tolvaptan

“…We summarized the mechanisms underlying the development of ascites in cirrhosis, and the management of ascites with diuretics other than tolvaptan, according to textbooks and cirrhosis management guidelines [ 2 , 3 , 6 , 7 , 8 , 9 ]. We found articles investigating the effect of tolvaptan in cirrhotic ascites via Pubmed, using these search terms: ‘cirrhosis x tolvaptan’, ‘cirrhosis ascites tolvaptan’, and ‘cirrhosis x hyponatremia x tolvaptan’.…”

“…The first step of ascites management is nutritional support, especially dietary salt restriction [ 9 , 20 ]. However, if salt restriction is too strict (e.g., <5 g/day), then this may result in hyponatremia and related renal impairment [ 21 ].…”

Albumin for cirrhosis‐related complications

“…Table 1 provides a description of recommendations from commonly cited clinical practice guidelines for the use of albumin in patients with cirrhosis‐related complications and a recently published guideline for critically ill patients with acute liver disease requiring resuscitation 8–11 . All of the complications listed may accelerate liver disease progression as recognized by signs of overt disease (e.g., ascites, encephalopathy) in patients with decompensated cirrhosis 12 .…”

Fontan-Associated Liver Disease: Pathophysiology, Staging, and Management

“…Ascites is a late manifestation of cirrhosis and is associated with decreased survival and poor quality of life. 54 Its prevalence in Fontan patients ranges from 4 to 17%. 29,55 In FALD, several causes of ascites can coexist: systemic venous hypertension due to failure of the Fontan circulation (arrhythmias, thrombosis/stenosis of the Fontan conduit, ventricular dysfunction, or pulmonary thromboembolism), hypoalbuminemia (protein-losing enteropathy and nephropathy, malnutrition, or liver insufficiency), and sinusoidal portal hypertension (severe liver fibrosis).…”