Ascites treatment can be divided into many regimens which either can be used in usual or refractory ascites which most common causes is liver cirrhosis
This treatment can be divided into the following items

As in case of ascites there is salt like sodium and fluid or water retention so the patient need to restricted dietary salt as sodium intake in the diet and also restricted water intake especially in case associated with hyponatremia

Patients with  liver cirrhosis often can not excreted more than 50 mEq of sodium per day so dietary sodium is usually restricted to 50 mEq (1 gram sodium equal to 3 gram salt) so if serum sodium is low less than 130 mEq|l fluid restriction to 1000ml|day 

As in ascites there is more or excessive body fluid so patients need drugs to decrease this fluid and excreted it outside the body these drugs are called diuretics drugs which excreted fluid through the kidney into the urine and patient feel increased the number of micturation in each time micturated fluid excreted outside the body as urine
Diuretic therapy is better used in combination to avoid decreased serum potassium  (hypokalemia)  or  increased serum potassium( hyperkalemia ) if one drug alone also to give better results
These diuretic drugs combination such as spironolactone in initial dose 100 mg combined with furosemide in initial dose 40 mg or bumetanide in initial dose 1 mg which inhibit sodium absorption so increased its secretion in urine
The dose of these drugs spironolactone and furosemide can be increased gradually in multiples 50 and 40 mg four to five times untill a diuresis is obtained
It should be known that an increased urine output of 500 ml|day correspond to a weight loss of 1 pound per day
It is also should be considered that the large diuretic may result in decreased renal perfusion and high level of nitrogen contaninig compounds such as urea and creatinine (azotemia ) so
At least during the initial diuretic treatment it is important to determine serum electrolytes like sodium and potassium urea nitrogen and serum creatinine
The dose of diuretic should be adjusted to a lower maintenance dosage  known by the patient weight become dry  this to prevent decreased plasma volume and hyponatremia

In some patient during treatment of ascites there is may be no response to treatment can occurred and this is known as refractory ascites
 Definition of refractory ascitis  as it is intraaddominal fluid which not respond to sodium restriction and high dose of diuretic therapy or early recurrence of ascites after therapeutic aspiration of the ascitic fluid (paracentesis ) that cannot be prevented by sodium restriction and diuretic therapy which need special treatment such as

Treatment of refractory ascites

There are many options for treatment of refractory ascites such as
  • Therapeutic aspiration or paracentesis of ascitic fluid
  • Transjugular intrahepatic portasystemic stent-shunt TIPS
  • Peritoneovenous shunt
  • Liver transplantation
Theraputic paracentesis
This can be done by repeated aspiration of  large volume of the ascitic fluid by paracentesis up to 4-6 litre at a time this procedure can be done by using 18 gauge needle with plastic catheter is placed in the left lower abdomen and the fluid drained by plastic catheter into 1 litre vacutainer bottles 
It may give the patient salt poor or free albumin during paracentesis to decreased changes in electrolytes plasma renin and serum creatinine
Repeated paracentesis with maintenance diuretic helps control of ascites and the patient feel comfortable

It is has good result with high successful rate in reducing portal pressure and preventing recurrent bleeding from esophageal and gastric varices and reduced ascites

The procedure consists of the placement of a self expanding metallic stent (Wallstent)  between the hepatic vein and the portal vein under radiological screening with patient under mild sedation have good success rate in most of major  medical centres

Effective by increasing intravascular volume and decreasing ascites and allow to used lower dose of diuretic to control ascites but it is rare used nowadays because it has major and fatal complications
Chronic liver disease complicated by refractory ascites is a good indication for liver transplantation


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