Summary of AASLD Practice Guidelines on Cirrhotic Ascites – Paracentesis Indicated for all Hospitalized Patients

According to AASLD Practice Guidelines, all patients with cirrhotic ascites admitted to the hospital should have a diagnostic paracentesis to rule out spontaneous bacterial peritonitis (SBP). Treatment of SBP requires cefotaxime plus albumin 1.5 gm/kg on the first day and 1 gm/kg on the third day. The addition of albumin leads to decreased mortality from 29% to 10%. A recent study suggests albumin is only necessary when serum creatinine is greater than 1 mg/dL, BUN is greater than 30 mg/dL, or Total bilirubin is greater than 4 mg/dL. Once SBP is diagnosed lifelong antibiotic prophylaxis is crucial. Alternatively, levofloxacin can be given to patients with a PCN allergy.  If a patient has a history of or is at risk of SBP then a proton pump inhibitor should be withheld.

Other guidelines include:

  • Fluid restriction is not necessary in treating most patient with ascites unless [Na]<125 mmol/L
  • Diuretics should be stopped for uncontrolled hepatic encephalopathy, [Na]<120 mmol/L, or creatinine>2 mg/dL
  • Avoid ACEI, ARB, propranolol, NSAIDS and ASA in patients with moderate-large ascites
  • Serial therapeutic paracentesis or Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure for diuretic-resistant ascites
  • All appropriate candidates with cirrhotic ascites should be referred for consideration of liver transplantation

Sigal SH, et al. Restricted use of albumin for spontaneous bacterial peritonitis. Gut 2007; 56: 597

Dever JB, et al. Review article: spontaneous bacterial peritonitis—bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015 Jun;41(11):1116-31.

Read all articles in Cardiovascular diseases, Featured Procedure, Infections, Medical General, medical procedures, Paracentesis
Tags: Cirrhotic ascites, featured procedure, Guidlelines, HPC updates, paracentesis, SBP, spontaneous bacterial peritonitis

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